Decisions, Decisions, Decisions: Choosing Breast Reconstruction

I’ve spent the last several months researching my surgical options and I want to share with you what I learned and what I decided on. I hope you find this helpful in understanding what I’m going through and perhaps it will help you or someone you love in making a similar decision.

Which Breast Surgery?

In 2013, when I was first diagnosed with breast cancer, the tumor was small and isolated in the right breast so I had a lumpectomy. This procedure is considered breast-conserving since most of the breast is left alone. The goal is to be the least invasive as possible with the hope of removing all the cancer and preventing a recurrence. In my case, the result of the surgery was almost unnoticeable. If a patient is a good candidate for breast-conserving surgery, this is a great place to start and hope that is all you need.

Well, that didn’t quite work for me. My cancer came back in the right breast and is now in the left breast, too. The good news is that it is still a very common, manageable, and hopefully contained cancer, so I am opting for a bilateral mastectomy (also called a double mastectomy).

This surgery removes all of the breast tissue, leaving the skin in place. Mastectomies can be nipple-sparing, in which the nipple stays intact, but in my case, I will have both nipples removed as well. This decision usually depends on where in the breast the tumor is located. If it is near the nipple, it has to go, and mine is.

Reconstruction – Yes or No? When?

The next decision is whether or not to have reconstruction. There are three options, 1) choose not to have reconstruction at all, 2) choose to have the mastectomy and then do reconstruction at a later time (delayed reconstruction), or 3) do reconstruction at the same time as the mastectomy (immediate reconstruction).

It was not a hard decision for me to choose reconstruction. This is a very personal decision and every woman has the right to choose whatever she wants to do. Some women choose not to do reconstruction and to wear a prosthetic breast or nothing at all. If you’re super athletic, maybe it will be a nice change to not have to wear a sports bra. There are a million different factors, both physical and psychological, and everyone has to choose what’s right for them.

I am also choosing to do immediate reconstruction because I’m a “get it done” kind of person, I’d rather just jump in and take care of things. Others may choose delayed reconstruction to give themselves more time to heal or make decisions. Again, whatever works for you.

Types of Breast Reconstruction Surgery

The next decision is what type of breast reconstruction surgery to have. There is a choice between implant reconstruction or tissue flap reconstruction. Implant reconstruction uses a silicone or saline implant to rebuild the breast while tissue flap uses your own body tissue taken from another part of your body. You can also opt to do a combination of both.

There are pros and cons to both implant and tissue flap surgery. Implant only surgery is usually faster and easier to recover from, while tissue flap is much more involved and requires surgery on two sites of your body. The biggest benefit for me is that because tissue flap surgery uses your own tissue the breasts feel and look more natural and they expand and shrink with you as you gain or lose weight. Also, implants can rupture and they have a shelf life, usually requiring replacement in 10 to 15 years.

If you choose implant surgery, your procedure might involve removing the breast tissue and immediately putting in the final implant, or the surgeon may insert an expander implant, which is then inflated slowly over several months and eventually replaced with the permanent implant.

Now here’s where it gets tricky. If you’ve already had radiation, like in my case, the skin may not be able to stretch enough to accommodate the implant. In this case, you would need a combo flap and implant surgery. The first surgical team I met with recommended Latissimus Dorsi Flap (lat flap) surgery. In this procedure fat, skin and muscle are moved from the upper back and tunneled under the skin around to the chest to create the breast. An implant can also be added for size. Apparently, this is a short surgery with a relatively easy recovery period, but any surgery involving muscle can cause loss of strength and when implants are inserted under the muscle, the muscle can spasm, causing quite a bit of pain and discomfort. I said thanks, but no thanks and I did some more research.

Another type of flap surgery is the TRAM (transverse rectus abdominus muscle) flap. Similar to the lat flap surgery fat, skin and muscle are moved, this time from the abdomen, to the chest to recreate the breast. An implant can also be used to achieve the desired size. This one has the added risk of potentially causing a hernia since the abdominal muscles are disturbed. No thanks.

Another note, both the lat flap and the TRAM flap surgeries are called pedicle flap surgeries, meaning that the blood supply to the tissue is left intact since the muscle is tunneled under the skin into the new position. There is another type of flap surgery called free flap, where skin and fat but no muscle are moved from a location on your body to the chest. In this case, the blood supply has to be reconnected via microsurgery to feed the tissue flap in the new location. Have I completely lost you yet?

Free flap surgery can harvest skin and fat from either your abdomen or your glutes, giving you the added benefit of getting either a tummy tuck or a butt lift at the same time. OK, now we’re talking!

I’ve never had any negative feelings about my derriere but I swear I’ve been cultivating my abdominal fat for years just for this purpose! I am going with what is called DIEP (deep inferior epigastric perforator) flap surgery. Skin and fat will be removed from my abdomen (just like a legit tummy tuck!) and moved to my chest to build the breasts. I will have a low incision across my abdomen and they will recreate my navel. My plastic surgeon is also a microsurgeon who specializes in this type of free flap surgery, he will reconnect the blood supply to the tissue in my chest then if I’m not the size I want to be, we go back later and do liposuction/body sculpting from anywhere on my body and use that fat to enlarge the breasts. SCORE!

Yes, this is a longer, more involved surgery and one of the risks with any free flap surgery is that the blood supply may fail and the flaps could die, but it is a very low risk and they will monitor me closely in the hospital until they are sure that everything is fine. I will be meeting with both of my surgeons next week to get even more specific details about how long the surgery will be and how long they expect me to be in the hospital. I will be happy to share those details as soon as I have them.

So that is what I’ve been working on for the last few months, but I’m very pleased with my decision and my team. It is absolutely worth it to take your time, ask a lot of questions and do your research when making this kind of a decision. And please know, if you are faced with something like this, it is your decision and no one else’s. DO NOT let anyone tell you what you should or should not do, you have the right to make this decision on your own. Ask for help and advice, but ultimately, trust your gut and do what you feel is right for you.