Deciding whether or not to have a breast rebuilt is a very personal choice. Take the time you need to learn about how breast reconstruction might affect you, both emotionally and physically, before you decide to have the surgery. There are two main categories of reconstruction:
- implant reconstruction, which uses a saline or silicone implant to create a breast shape
- autologous or flap reconstruction, which takes tissue from another area of your body to create a breast form
In some cases, an implant and flap may be used together.
Also consider whether you’re open to not having reconstruction. This could be your most flexible option — you can go breast-free, use a pop-in breast form, or change your mind and get breast reconstruction in the future. When considering this idea, keep in mind that reconstruction at the time of mastectomy generally produces better cosmetic results than a reconstruction done much later. Still, having reconstruction much later on is possible if you’re just not ready to make decisions right now.
Talk to all of your cancer doctors and your plastic surgeon about the best options for your unique situation. A plastic surgeon who's experienced in the options you're considering may offer you the most complete review of all your choices. Since plastic surgeons tend to specialize in different reconstructive techniques, you may need to talk to more than one surgeon to get the full picture.
Talking to other women who have had breast reconstruction can give you more personal opinions about your options. There’s nothing like hearing from other women who’ve had it done — and they may even be willing to share photos. Some great places to go are the Breastcancer.org Discussion Board forums called Breast Reconstruction and Living Without Reconstruction After a Mastectomy, where women share experiences and support each other. The site BreastFree is devoted to sharing stories, photos, and other information about opting to have no reconstruction after mastectomy. Many women call this "going flat."
Here are some things you might want to consider while you're making a decision about breast reconstruction:
- Is it important to you to have a permanent breast shape? Some women prefer to use a prosthesis (a wearable artificial breast shape) instead of having reconstruction. Other women feel that a reconstructed breast is more convenient than wearing, removing, and taking care of a prosthetic breast.
- If you’re having a mastectomy on one breast, is it important to you that your breasts look balanced when wearing a bra or bathing suit? After mastectomy, many women want their breasts to have a natural, balanced appearance in bras, bathing suits, and other garments with low necklines. Though you’ll be able to see some difference between the rebuilt breast and your other breast when you're naked, reconstruction usually looks very natural when you're wearing a bra or bathing suit.
- In your unique situation, will breast reconstruction involve several surgeries over a long period of time? For many women, the answer is yes. Talk to your plastic surgeon about what needs to be done, both immediately and later, as you consider your options. For example, if you have very large breasts, the reconstruction might create a smaller breast. In this case, you might have the affected breast reconstructed, followed by reduction surgery on the other breast. Some time later, you'd have the opportunity to get nipple reconstruction on the rebuilt breast.
- How important is it that you be able to resume your normal activities as soon as possible? In most cases, women who choose no reconstruction are able to resume their daily activities more quickly than women who choose reconstruction.
- Are you an athlete, or do you have a physically demanding job? If so, full range of motion after reconstruction naturally will be very important to you. Some women find that implants, which are placed under or over the chest muscle, can limit comfort and range of motion, especially if the area hardens over time (a complication called capsular contracture). On the other hand, certain flap procedures actually cut through muscle in the back or lower abdomen, which can cause weakness or loss of function. Newer “perforator flap” techniques, such as the DIEP and SIEA flaps, lower this risk by preserving the muscle structure at the donor site; surgeons only remove the tissue that is needed to rebuild the breast. (You can read all about this in Types of Breast Reconstruction.) These are important things to consider as you weigh your options.
- Is the cost of reconstruction surgery a concern for you? Generally, cost will only be an issue if you do not have health insurance or if your plan does not cover mastectomy. Federal law requires that insurers who cover mastectomy also cover breast reconstruction, including any procedures needed to achieve a balanced appearance between the two breasts. You may have to prove to your insurance company that reconstruction is necessary. If this happens, your doctors’ support, including a letter and other documentation, is often needed. If you don’t have insurance coverage, a prosthesis will likely be your most affordable option. If you decide to pay for surgery out of pocket or if you have an insurance plan that requires you to cover a portion of the cost, work with your plastic surgeon to figure out the most affordable option.
- Did you have a lumpectomy that gave your breast a very different shape than it originally had? Many women who have lumpectomies are happy with their breast's appearance and don't choose reconstruction. However, if you had a large portion of tissue removed during a lumpectomy, you might want reconstruction to restore a more balanced look. One study found that about 10%-30% of women who have a lumpectomy aren't satisfied with the way their breast looks after the procedure. Also, many women find that within a couple of years after lumpectomy, the breast can look disfigured, especially if they’ve had radiation therapy. The treated breast is often smaller than the other breast or obviously distorted by comparison. Reconstruction may be the best option, sometimes with surgery on the opposite breast — such as a reduction or breast lift — to bring them back into balance. (This is a situation in which health insurance coverage may become an issue, since technically no mastectomy has been performed. For more information, visit the Paying for Reconstruction Procedures page.)
- Do you have any other medical conditions that might affect your ability to heal after surgery? If you have diabetes, circulatory problems, or a bleeding disorder, it may take your body longer to heal from reconstruction surgery than it will for someone who doesn't have these conditions. Heavy smoking and drinking also can affect your ability to heal. All surgery leaves some scars, but the skin cells along your incision may die (a condition called necrosis) if your ability to heal is reduced. If you smoke, you may be required to quit smoking for a period of time before reconstruction surgery so your body is better able to heal.
Dr. Marisa Weiss, chief medical officer of Breastcancer.org, has found that most of her patients prioritize reconstruction goals in the order below when making decisions:
- receiving the most effective anti-cancer therapy above and beyond anything else, including reconstruction
- the ability to function fully and comfortably after recovering from the reconstruction procedure
- aesthetics: the way the reconstructed breast feels and looks as far as size, shape, and symmetry with the other breast
- practical considerations: timing, cost, availability, length of recovery
It's also important to know that while breast reconstruction rebuilds the shape of the breast, it doesn't restore sensation to the breast or the nipple. Over time, the skin over the reconstructed breast can become more sensitive to touch, but it won't be exactly the same as it was before surgery.