To Reconstruct or Not: A Woman’s Choices When Faced With Mastectomy

 On July 18, 2000 , Diane Campbell was diagnosed with invasive ductal lobular carcinoma in her left breast. “My first thought was, ‘Take both of my breasts. Get rid of them,’” the 34-year-old Campbell says.

Campbell ’s doctors discussed her options with her, and the Massachusetts resident took some time to think about what she wanted to do. She sought a second opinion and decided on her course of treatment. Then Campbell also decided that she wanted to have breast reconstruction to rebuild the breast she would lose in a mastectomy.

Campbell says of her oncology team, “They presented it to me by saying, ‘This is an option. You can do this if you want to reconstruct the breast. But it’s a decision you really need to take the time to look into.’”

The Breast Reconstruction Basics

Jo Ann Garofalo, RN, in the Division of Plastic and Reconstructive Surgery at Duke University Medical Center, is a certified plastic surgery nurse with a special interest in breast reconstruction. She has worked with many women who have breast cancer.

Garofalo says there are many reasons to consider reconstruction. “Reconstruction is done, in part, to restore the person’s body image after mastectomy,” says Garofalo, “to enable her to wear her clothing and feel as comfortable as she did before.”

Garofalo explains the two basic types of reconstruction. “You can use your body’s own tissue or use an implant. Each of those choices has various approaches.”

Michael Zenn, MD, assistant professor of plastic surgery, Division of Plastic and Reconstructive Surgery at Duke University Medical Center, performs about 100 breast reconstructions each year. Zenn describes different types of reconstruction using the body’s own tissue.

“A microsurgeon can take tissue from anywhere on the body. Tissue can come from the back, leg, or buttock area,” Zenn says. However, he notes that an ideal option is a procedure called a transverse rectus abdominis muscle (TRAM) flap, which takes tissue from the tummy or lower abdomen.

 “The TRAM flap can be performed by keeping tissue attached to the rectus muscle and tunneling it to the chest to recreate a breast,” explains Zenn. Or the surgeon can detach it from the body and use microsurgery to transfer it. You are basically doing a tummy tuck and hiding the scar beautifully. And it doesn’t affect function.”

If you use an implant, instead of your body’s own tissue, you may have the option of a saline or silicone implant. The U.S. Food and Drug Administration (FDA) mandates that women getting silicone implants must be part of an approved study.

An implant reconstruction requires 1 or 2 surgeries. The standard approach is 2 procedures to build a mound. The surgeon places a tissue expander in the breast area at the time of the mastectomy, according to Garofalo. In a second operation, usually 3 or more months after the expander has been inserted, the woman can have surgery to place the implant. The implant procedure can also be done in one stage if muscle is borrowed from the back at the same time.

Zenn said that women often wonder which is the better reconstruction. ”But neither one is better than the other,” says Zenn. “It really is a personal decision.”

Both the American Cancer Society and the American Society of Plastic Surgeons (ASPS) say that most women who have had their cancer treated through mastectomies are candidates for breast reconstruction. Factors such as health, extent of the cancer, and the treatment plan may delay a woman’s reconstruction so that she is not able to have it at the time of her mastectomy. In some cases, these factors may be reason for an oncologist or plastic surgeon to suggest that a woman not have reconstruction.

Breast reconstruction may not be recommended in certain situations. If the breast cancer is very advanced locally or the pathology suggests a high risk of local recurrence, reconstruction would not be recommended. Also, if you smoke, are obese, have heart or lung disease, or have diabetes, you may not be a good candidate for reconstruction. It’s also important to know that the complications after flap reconstruction are more common when women have had radiation therapy.

If you are considering reconstruction, talk with your oncologist and plastic surgeon about the benefits and risks of the procedure. Any surgery, including reconstruction, carries with it certain risks. It’s up to you to make an informed decision based on these factors. Fortunately, most complications such as infection, bleeding, or scarring are minor but may require a follow-up surgery. You may also want a follow-up surgery if the cosmetic results don’t match your desires.

Choosing Not to Have Reconstruction

Garofalo says there may be reasons to not choose reconstruction or to delay a decision until all other treatments have been completed. You may feel you have too many decisions to make regarding the cancer and would prefer to decide later about reconstruction. Or you may find that you don’t want additional scars or the risks of another surgery.

Linda Ellerbee, the award-winning TV news reporter, writer, producer, and breast cancer survivor, describes her decision not to reconstruct after a double mastectomy.

“We live in a breast-conscious society, breast-obsessed, some might say. But I have come to understand that I do not judge my femininity or my sexuality by body parts. And happily, neither does the man with whom I have shared my life for the past 14 years. And that is a good lesson to learn,” Ellerbee says.

Melanie Smith elected to have both of her breasts removed when cancer was diagnosed in one of them. “I asked my surgeon to remove my other breast, too,” Smith says. “I think of it as breast ‘deconstruction,’ as well as an extra preventive measure against recurrence.”

Smith also chose not to reconstruct. “I really, really disliked having an operation at all, so having even more surgery seemed like torture to me,” she says. “Recovery from the ‘deconstructive’ surgery didn’t take any extra time. Now, having both breasts gone means I don’t have to balance one side with the other.”

According to Smith, “I can wear my prostheses when I feel like it, and I can easily go up a size if I choose. Best of all, I’ve found that this is my chance to never have to wear a bra again.”

A woman who opts for no reconstruction has several options. “There is always the option for women to utilize an external prosthesis or even nothing at all,” Garofalo says.

You can get more information about a prosthesis from your doctor or nurse. Ask about where you can get fitted and how long you should wait after surgery to begin wearing one. A prosthesis requires that a woman wear a mastectomy bra, which is designed to hold the prosthesis in place.

Also, women have the option of initially choosing no reconstruction and then, years later, deciding to have the surgery. “We have women come to us 5 and 10 years later to talk about reconstruction. At the time of diagnosis, it’s too much to think about for some women,” Garofalo notes.

Delayed Reconstruction

Linda Mitchell, a Hodgkin’s disease survivor, was diagnosed with breast cancer in November 1991. The retired college professor said waking up after her mastectomy was difficult. Always a large-breasted woman, Mitchell felt a loss for the breast that was removed. In addition, she says she felt off-balance.

“The discomfort was the primary thing,” recalls Mitchell. “And because I was very large-breasted, I found it hard finding a prosthesis that would fit. It was also hard just having to spend part of my life lopsided. In the evening, when I took the prosthesis off, I still had only one breast.”

In 1992, Mitchell’s oncologist talked with her about reconstruction. “The doctors discussed taking part of my body to rebuild the breast. They told me they could do the TRAM flap surgery and use that to fill the breast,” she says. At the time of her reconstruction, Mitchell’s plastic surgeon also decreased the size of her remaining breast by about one-half.

Mitchell, like Garofalo, believes the decisions about reconstruction are personal ones. However, she says, “I would advise anyone who can to have it done at the same time as mastectomy,” she says.

Waking Up After Mastectomy and Reconstruction

“When I woke up and looked, I was like, ‘Wow!’ The only thing that’s different from before is that there wasn’t a nipple,” Dianne Campbell remembers.  Campbell ’s surgeon will eventually tattoo and “pucker” her skin to rebuild a nipple.

The 34-year-old mother said the major side effects of her surgery were numbness and back pain. “I really felt more numbness than pain. After the surgery, I was up and moving the next day. I’m very determined, and I believe that you can’t keep a good woman down. But I was hunched over because of the incision in my stomach, and that caused some back spasms, which was the only pain I really had.”

Three weeks after her surgery, Campbell was able to return to work. However, she still experienced numbness several weeks later, when she began to get feeling in her arm and her breast.

“I have to say that this was not a tragic or traumatic experience for me,” Campbell says. Campbell is also pleased because she believes her new breast is “settling.”

“It has the exact same droop as the other one. The skin is still firm though, so if it doesn’t drop anymore, they may not be identical,” she says.

Campbell is happy with her decision to have reconstruction at the time of mastectomy. However, she also stresses that it is a woman’s own personal decision.