With breast cancer, women are usually looking out one of three options: either (a) they do not need surgery, (b) they are able to have breast-conserving surgery, or (c) they have to have a mastectomy. Women who have to have a mastectomy have many decisions to make. 

The first decision to make is whether to have one breast removed or both. In many cases, it may be necessary to remove only one breast; however, because of risk of recurrence the patient and doctor may agree that it is best removed both breasts. One she decides what type of mastectomy to have, she then must decide if she wants the option to have breast reconstruction. Some women know for sure that they do want breast reconstruction surgery; some women know for sure they do not, and others do not want to deal with it until after their cancer is passed. If she decides she does want reconstruction surgery, she must then choose a surgeon, and then she must decide what category and then what type of reconstruction surgery to have. Her last two decisions will be whether to get her nipples reconstructed, and whether to get them tattooed to have color. Without tattooing, they are the same color as the surrounding skin.

So let us go through this step-by-step, in detail. The first thing a woman needs to do, regardless of if she thinks she may or may not want reconstruction surgery, is to speak with a plastic surgeon before her mastectomy about her reconstruction options. She wants to choose a plastic surgeon that has good experience with breast cancer reconstructions. She also wants choose one whose personalities she finds agreeable. She will be spending a lot of time with this doctor, so it is important that the two of them get along. By seeing what she looks like before the mastectomy, if she chooses to proceed with reconstruction, it will be easier for the doctor to know what she should look like after reconstruction to get a look that is as close to her original appearance is possible, if that is what she desires. If the doctor does not see her pre-mastectomy, it will be very difficult to get her back close to the same size.

Once a doctor is found, the next step is deciding what category of surgery to have. There are two options: implants and tissue flap procedures. If she chooses to have an implant procedure, she must decide if she wants to receive saline filled implants or silicone gel filled implants. If she decides to get implants, she has two timing options. One, she can choose to having implants done at the same time as her mastectomy, or, to, she can have a two-stage reconstruction, which is where she will have a second surgery to have her implants placed. If she chooses a two-stage reconstruction, they will implant a tissue expander under the skin and chest muscle after the mastectomy that will be slowly inflated with saline water at regular intervals to expand the skin until it is large enough to hold the implants of her desired size. This typically takes 4 to 6 months some women choose to keep their expanders as their final implants, other women have their expanders removed and the permanent implants put in. Although immediate reconstruction has less psychological impact, the implants are not advised if radiation treatments are part of your treatment plan. Radiation can cause scarring of the skin, as well as hardening of the implant, which can lead to a less than aesthetically pleasing appearance. If you are going to have radiation, it is best to separate the procedures into two separate surgeries.

The other option is tissue flap procedures, which offers five options, three of which are relatively new. There is the transverse rectus abdominis muscle flap, or TRAM flap. In the TRAM flap, in fact blood vessels and muscle tissue is removed from the lower abdomen to the chest to re-create the breast(s). For women who have excess body fat, this is an excellent solution and creates a tummy tuck effect. The TRAM flap is not an option for women who have had abdominal tissue removed in prior surgeries, or for women who have very little body fat on their lower abdomen. There must be enough fat and tissue available to create the breast for this to be a viable method. The second option is the latissimus dorsi flap, which moves muscle and skin from your shoulder blade and tunnels at around to the front of the chest, creating a pocket for breast implant, if desired, for greater fullness. 

The newer procedures include the third option, which is the deep inferior epigastric artery perforator flap, DIEP flap. This procedure is very similar to the Tram flap; however, it does not relocate muscle, only skin, fat, and blood vessels. The fourth option is the gluteal free flap, or GAP. This procedure uses skin, fat, blood vessels, and muscle from the butt to re-create the breast(s). This procedure is recommended for women who cannot take tissue from the abdomen for various reasons. The final option is the transverse upper gracilis flap, or TUG, which uses muscle, skin, fat, and blood vessels from the inner thigh, extending from the fold of the buttock out. This procedure is ideal for women who only want small to medium-size breasts, and who currently have inner thighs that touch. Women with thin to medium-size legs generally do not have enough tissue for this procedure.

Once the decisions have been made about what kind of surgeries to have the when to have them the final decisions are whether to have nipples reconstructed, which is optional, and if they are reconstructed, whether to get them tattooed after they are fully healed. The nipple reconstruction is done in an independent procedure and can be done under local or general anesthesia. It is done using a skin graft, and the grafted skin can come from several donor sites on the body. Because nipples are reconstructed from her regular skin, they have no color to them. Once they have fully healed, she has the option of getting them colored in to have a more natural appearance by mimicking the areola pigmentation. This can be done by a traditional tattoo artist or a medical tattoo artist. With many tattoo shops, once they find out is a cancer reconstruction related tattoo, they will do it at a reduced rate. Finding a shop that has experience doing nipple reconstruction tattoos will usually mean finding one that has a license to purchase the numbing gel to anesthetize the area so you do not feel the pain as much. Be advised, this gel will cost extra, but it is not outrageously expensive. Depending on how the nerves healed after surgery, the breasts may still be numb enough then anesthetizing the area will not be necessary.

It takes one surgery to remove the breast, and two to four procedures to get new breasts that look real, well, almost real. If a good surgeon and a good tattoo artist are chosen, the new set may look better than the originals.

Photo courtesy of Kristopher Radder