By Liz Galst

In 1998, when Carolyn Charkey was diagnosed with ductal carcinoma in situ of the breast, a precancerous condition, she knew right away she wanted a mastectomy. “Just take it off,” she told her doctor after he delivered the bad news.

And just as simply, Charkey knew she didn’t want breast reconstruction—not with an implant and not with her own tissue. “I was in my late 50s at the time, married to a man who was supportive of my decision, and I was not apt to be running around in a bikini,” says the Wellington, Colorado, freelance writer matter-of-factly. For Charkey the choices are an external prosthesis in many sizes, shapes, and weights that fit in her bra or, in some cases, directly onto her chest wall with adhesive.

For many women, though, breast reconstruction after a mastectomy feels like a necessity, or at least an important option worth considering. “Emotionally, I couldn’t handle not having a breast,” explains breast cancer advocate Rhonda Berry of Trenton, New Jersey. An earlier lumpectomy left her feeling “incomplete,” she says.

For the nearly 95,000 American women who will lose their breasts to cancer and related conditions this year, reconstruction options are increasing—immediate reconstruction, which combines mastectomy and reconstruction in one procedure, is available, as is delayed reconstruction, often helpful for women who are undecided or who need radiation treatment after surgery. Saline and silicone implants are both options. Likewise, autologous reconstruction, which uses a woman’s own tissue to build a new breast, comes in at least three different varieties: an abdominal or TRAM (transverse rectus abdominus muscle) flap, a latissimus flap, which uses tissue from a woman’s back muscles, and buttock crease transfer, which uses tissue from the buttock.

Women considering reconstruction should at the outset do research to find a plastic surgeon who has extensive experience with reconstruction, is willing to show before and after photos of former patients, and is current on the latest technology.

Indeed, the options for women who want reconstruction are significantly better than those available even a decade ago, says Mia Talmor, MD, assistant professor of surgery, Weill Medical College of Cornell University, New York. “Ten years ago, our aim was to achieve reconstruction that appeared symmetric in a bra. We now aim to create a reconstructed breast that truly looks and feels the same as the contralateral breast.”

Reconstruction is often first discussed when doctors talk with patients about the possibility of mastectomy. “My surgeon mentioned the benefits of immediate reconstruction,” remembers Gail Richardson, a sales office coordinator from Piscataway, New Jersey.

Such timely discussions should be standard procedure, explains Edward Luce, MD, chief of plastic surgery at the University Hospitals of Cleveland and a past president of the American Society of Plastic Surgeons. “In the initial discussions about treatment, the patient should be offered a consultation with a plastic surgeon.” That consultation should take place soon after diagnosis, he notes.

For those choosing reconstruction, immediate and delayed reconstruction are both options. Both procedures are similar; only the timing differs. For some, immediate reconstruction is preferred. “I didn’t want to come out of the surgery without a breast,” says Berry. But for others, such as psychotherapist and author Kathlyn Conway, the diagnosis is overwhelming, making the patient unable to fully consider the possibilities. “There were too many decisions to make at the time,” recalls the New Yorker, who regrets her decision to have immediate reconstruction. “Nobody was saying, ‘Maybe you want to think about it.’ There was this presumption from the doctors that ‘you’ll be glad you did this.’”

Immediate reconstruction combines mastectomy and plastic surgery in one procedure. Often, two surgeons work in tandem, one removing the breast tissue, the other harvesting tissue to be used in reconstruction. The current standard of care for immediate reconstruction is the skin-sparing mastectomy (see sidebar), which leaves the breast skin intact and removes the interior tissue as well as the nipple area.

“That creates an envelope for the plastic surgeon to fill,” explains Eva Singletary, MD, professor of surgical oncology, M. D. Anderson Cancer Center, Houston. Dr. Singletary adds that in the case of delayed reconstruction, a skin-sparing mastectomy can’t be used.

If a woman chooses implants, as Richardson did, so-called tissue expanders are placed under the pectoral muscles. Every week or two, for approximately six months after the initial surgery, these balloon-like pouches are filled with additional saline solution, stretching the overlying tissue and making a place for the implant, which will be inserted in a second, outpatient procedure. In total, the immediate expander reconstruction adds about “an hour to an hour and a half” to the length of the mastectomy, says Dr. Talmor. That compares with four to 10 additional hours for autologous reconstruction.

Women often choose implants over autologous reconstruction for a number of reasons. Richardson was concerned that if muscle tissue were removed from her abdomen or back, as happens in autologous reconstruction, “I wouldn’t be able to exercise.”

Carol Erlbach, a staffer at the Y-ME National Breast Cancer Organization in Chicago, was concerned about autologous reconstruction because she had a history of herniated discs in her back. “I didn’t like the idea that my back or stomach muscles would be cut,” she recalls. “And I didn’t want to be on the operating table for that long.”

Implants are often a better choice for smokers and/or women who are more than 100 pounds overweight, says Dr. Talmor, as these women frequently have vascular and circulatory problems that can impair healing and, with autologous reconstruction, can increase the incidence of hernia after surgery. The recovery time for implant surgery is also significantly shorter than for autologous reconstruction.

Dr. Talmor says both saline and silicone implants are good options. Silicone has a more natural feel, but in the event it leaks, silicone deposits can form in the lymph nodes. “That can be difficult for a breast cancer patient, because every lump and bump needs to be checked out,” she notes. Saline, on the other hand, is mere salt water; should a saline-filled implant leak, the liquid is absorbed quickly into the body. But saline implants are more likely to cause rippling on the skin’s surface, Dr. Talmor says.

Autologous reconstruction involves tunneling muscle, fat, and sometimes skin to the site of the breast from other parts of the body. In the event not enough tissue exists, an implant can be used as a supplement. Of the TRAM flap, Dr. Luce says, “It’s a more cosmetic result than the implant. It droops more like a natural breast. It’s more natural feeling. And the tummy tuck [which results from channeling abdominal fat up to the breast site] is a fringe benefit.” Rhonda Berry agrees. “I love my TRAM flap!” she enthuses. “I was amazed it looked so good.”
Dr. Luce says all three autologous reconstruction procedures are equally well tolerated. “We’ve found that when women are tested for activities of daily living, the results are the same.”

Many women are happy with their reconstruction, but the procedure can have its drawbacks. Women who undergo autologous reconstruction can suffer from poor healing, which can lead to bad results and additional surgeries. Likewise, Erlbach had to have a number of additional surgeries after her implant ruptured. Her chest now has “plenty of ridges and craters,” she says, opting now for a prosthesis rather than undergoing additional surgeries.

To women considering reconstruction, Richardson offers this advice: Make sure your plastic surgeon shows you pictures of both good and bad outcomes, and whenever possible, talk to women who have undergone different procedures and those who have opted against reconstruction entirely.

“That way,” she says, “you’ll know bad outcomes are possible. And when you make a decision, you’ll be comfortable with it.”