So you're considering Breast Reconstruction.  You're probably wondering what's next?

The Consultation
The success and safety of your breast reconstruction procedure depends on your complete candidness during your initial consultation with Dr. Gray. Cynthia will ask a number of questions about your health, surgery objectives and lifestyle.

Be prepared to discuss:

• Why you want the surgery, your expectations and desired outcome

• Medical conditions, drug allergies and medical treatments

• Use of current medications, vitamins, herbal supplements, alcohol, tobacco and drugs

• Previous surgeries

• The options available in breast reconstruction surgery

• The likely outcomes of breast reconstruction and any risks or potential complications

• The course of treatment recommended by Cynthia, including procedures to achieve breast symmetry

If you decide to have Dr. Gray perform your Breast Reconstruction, she will:

• Evaluate your general health status and any pre-existing health conditions or risk factors

• Examine your breasts, and take detailed measurements of their size and shape, skin quality, and placement of nipples and areolae

• Take photographs for your medical record

• Ask you to complete required paperwork for your medical records.
  

Although breast reconstruction can rebuild your breast, the results are highly variable:

• A reconstructed breast will not have the same sensation and feel as the breast it replaces.

• Visible incision lines will always be present on the breast, whether from reconstruction or mastectomy.

• Certain surgical techniques will leave incision lines at the donor site, commonly located in less exposed areas of the body such as the back, abdomen or buttocks

A note about symmetry: If only one breast is affected, it alone may be reconstructed. In addition, a breast lift, breast reduction or breast augmentation may be recommended for the opposite breast to improve symmetry of the size and position of both breasts.

Prior to your surgical procedure
You may be asked to:

• Get lab testing or allow additional medical evaluation

• Take certain medications or adjust your current medications

• Stop smoking well in advance of surgery

• Avoid taking aspirin, anti-inflammatory drugs and herbal supplements as they can increase bleeding

Special instructions you receive will cover:

• What to do on the day of surgery

• The use of anesthesia during your breast reconstruction

• Post-operative care and follow-up

• Breast implant registry documents (when necessary) with advisories regarding radiation treatments and MRI's. 

If you choose to have Dr. Gray perform your breast reconstruction, she will also discuss which accredited hospital in which your procedure will be performed.

What will happen during your Breast Reconstruction surgery?

Anesthesia

Medications are administered for your comfort during the surgical procedure. The choices include intravenous sedation and general anesthesia. Dr. Gray will recommend the best choice for you.

Immediate breast reconstruction is done at the same time as the mastectomy. An advantage to this is that the chest tissues are not damaged by radiation therapy or scarring. This often means that the final result looks better. Also, immediate reconstruction means less surgery.

After the first surgery, there still may be a number of steps that are needed to complete the immediate reconstruction process. If you are planning to have immediate reconstruction, be sure to ask what will need to be done afterward and how long it will take.

Delayed breast reconstruction means that the rebuilding is started later. This may be a better choice for some women who need radiation to the chest area after the mastectomy. Radiation therapy given after breast reconstruction surgery can cause problems.

Decisions about reconstructive surgery also depend on many personal factors such as:

• your overall health
• the stage of your breast cancer
• the size of your natural breast
• the amount of tissue available (for example, very thin women may not have enough extra body tissue to make flap grafts)
• whether you want reconstructive surgery on both breasts
• your insurance coverage for the unaffected breast and related costs
• the type of procedure you are thinking about
• the size of implant or reconstructed breast
• your desire to match the look of the other breast

Other important things to think about

• Some women do not want to think about reconstruction while coping with a diagnosis of cancer. If this is the case, you may choose to wait until after your breast cancer surgery to decide about reconstruction.

• You may not want to have any more surgery than needed.

• Scarring is a natural outcome of any surgery, but cell death (called necrosis) of the breast skin, the flap, or transplanted fat can happen. Immediate reconstruction may be more likely to result in necrosis. If this happens, more surgery is needed to fix the problem and can deform the new breast shape.

• Not all surgery is a total success, and you may not like the way it looks.

• You may be concerned if you tend to bleed or scar.

• Healing may be affected by previous surgery, chemotherapy, radiation, smoking, alcohol use, diabetes, some medicines, and other factors.

• Would you prefer to have reconstruction before or after you complete your cancer treatment?

• Breast reconstruction restores the shape, but not feeling, in the breast. With time, the skin on the reconstructed breast can become more sensitive, but it will not feel the same as it did before your mastectomy.

• Dr. Gray may suggest you wait for one reason or another, especially if you smoke or have other health problems. Many surgeons say that you must quit smoking at least 2 months before reconstructive surgery to allow for better healing. You may not be able to have reconstruction at all if you are obese, too thin, or have blood circulation problems.

• Dr. Gray may recommend surgery to reshape the remaining breast to match the reconstructed breast. This could include reducing or enlarging the size of the breast, or even surgically lifting the breast.

• Knowing your reconstruction options before surgery can help you prepare for a mastectomy with a more realistic outlook for the future.

Types of breast reconstruction

Several types of operations can be done to reconstruct your breast. You can have a newly shaped breast with the use of a breast implant, your own tissue flap, or a combination of the two. (A tissue flap is a section of your own skin, fat, and muscle which is moved from your tummy, back, or other area of your body to the chest area.)

Implant procedures

The most common implant is a saline-filled implant. It is a silicone shell filled with salt water (sterile saline). Silicone gel-filled implants are another option for breast reconstruction. They are not used as often as they were in the past because of concerns that silicone leakage might cause immune system diseases. But most of the recent studies show that silicone implants do not increase the risk of immune system problems. Also, alternative breast implants that have different shells and are filled with different materials are being studied, but you can only get them in clinical trials.

One-stage immediate breast reconstruction may be done at the same time as mastectomy. After the general surgeon removes the breast tissue, Dr. Gray places a breast implant where the breast tissue was removed to form the breast contour.

Two-stage reconstruction or two-stage delayed reconstruction is done if your skin and chest wall tissues are tight and flat. An implanted tissue expander, which is like a balloon, is put under the skin and chest muscle. Through a tiny valve under the skin, Dr. Gray injects a salt-water solution at regular intervals to fill the expander over time (about 4 to 6 months). After the skin over the breast area has stretched enough, a second surgery is done to remove the expander and put in the permanent implant. Some expanders are left in place as the final implant.

The two-stage reconstruction is sometimes called delayed-immediate reconstruction because it allows options. If the surgical biopsies show that radiation is needed, the next steps may be delayed until after radiation treatment is complete. If radiation is not needed, the surgeon can start right away with the tissue expander and second surgery.

There are some important factors for you to keep in mind if you are thinking about having implants:

• Implants may not last a lifetime. You may need more surgery to replace them later.

• You can have problems with breast implants. They can break (rupture) or cause infection or pain. Scar tissue may form around the implant (capsular contracture), or you may not like the way the implant looks.

Tissue flap procedures

These procedures use tissue from your tummy, back, thighs, or buttocks to rebuild the breast. The 2 most common types of tissue flap surgeries are the TRAM flap (or transverse rectus abdominis muscle flap), which uses tissue from the tummy area, and the latissimus dorsi flap, which uses tissue from the upper back.

These operations leave 2 surgical sites and scars -- one where the tissue was taken and one on the reconstructed breast. The scars fade over time, but they will never go away completely. There can also be problems at the donor sites, such as abdominal hernias and muscle damage or weakness. There can also be differences in the size and shape of the breasts. Because healthy blood vessels are needed for the tissue's blood supply, flap procedures are not usually offered to women with diabetes, connective tissue or vascular disease, or to smokers.

In general, flap procedures behave more like the rest of your body tissue. For instance, they may enlarge or shrink as you gain or lose weight. There is also no worry about replacement or rupture.

TRAM (transverse rectus abdominis muscle) flap

The TRAM flap procedure uses tissue and muscle from the tummy (the lower abdominal wall). The tissue from this area alone is often enough to shape the breast, and an implant may not be needed. The skin, fat, blood vessels, and at least one abdominal muscle are moved from the belly (abdomen) to the chest. The TRAM flap can decrease the strength in your belly, and may not be possible in women who have had abdominal tissue removed in previous surgeries. The procedure also results in a tightening of the lower belly, or a "tummy tuck."

There are 2 types of TRAM flaps:

• A pedicle flap leaves the flap attached to its original blood supply and tunnels it under the skin to the breast area.

• In a free flap, Dr. Gray cuts the flap of skin, fat, blood vessels, and muscle for the implant free from its original location and then attaches it to blood vessels in the chest. This requires the use of a microscope (microsurgery) to connect the tiny vessels and takes longer than a pedicle flap. The free flap is not done as often as the pedicle flap, but some doctors think that it can result in a more natural shape.

Latissimus dorsi flap

The latissimus dorsi flap moves muscle and skin from your upper back when extra tissue is needed. The flap is made up of skin, fat, muscle, and blood vessels. It is tunneled under the skin to the front of the chest. This creates a pocket for an implant, which can be used for added fullness to the reconstructed breast. Though it is not common, some women may have weakness in their back, shoulder, or arm after this surgery.

DIEP (deep inferior epigastric artery perforator) flap

A newer type of flap procedure, the DIEP flap, uses fat and skin from the same area as in the TRAM flap but does not use the muscle to form the breast mound. This results in less skin and fat in the lower belly (abdomen), or a "tummy tuck." This method uses a free flap, meaning that the tissue is completely cut free from the tummy and then moved to the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels. The procedure takes longer than the TRAM pedicle flap discussed above.

Gluteal free flap

The gluteal free flap or SGAP (superior gluteal artery perforator) flap is newer type of surgery that uses tissue from the buttocks, including the gluteal muscle, to create the breast shape. It is an option for women who cannot or do not wish to use the tummy sites due to thinness, incisions, failed tummy flap, or other reasons. The method is much like the free TRAM flap mentioned above. The skin, fat, blood vessels, and muscle are cut out of the buttocks and then moved to the chest area. A microscope (microsurgery) is needed to connect the tiny vessels.

New methods of tissue support

These surgeries move sections of tissue to new places, or add fairly heavy implants, and some tissues need support to keep them in place as they heal. Doctors use synthetic mesh and other methods for this. More recently, doctors are trying a new product made of donated human skin (AlloDerm). It is regulated by the U.S. Food and Drug Administration (FDA) as a human tissue used for transplant. But it has had the human cells removed (is acellular), which reduces any risk that it carries diseases or the body will reject it. It is used to extend and support natural tissues and help them grow and heal. In breast reconstruction it may be used with expanders and implants. It has also been used in nipple reconstruction.

This product is fairly new in breast reconstruction, Studies that look at outcomes are still in progress, but have been promising. AlloDerm is not used by every plastic surgeon, but is becoming more widely available.

Nipple and areola reconstruction

You can decide if you want to have your nipple and the dark area around the nipple (areola) reconstructed. Nipple and areola reconstructions are optional and usually the final phase of breast reconstruction. This is a separate surgery that is done to make the reconstructed breast look more like the original breast. It can be done as an outpatient after drugs are used to make the area numb (under local anesthesia). It is usually done after the new breast has had time to heal (about 3 to 4 months after surgery).

The ideal nipple and areola reconstruction requires that the position, size, shape, texture, color, and projection of the new nipple match the natural one. Tissue used to rebuild the nipple and areola also is taken from your body, such as from the newly created breast, opposite nipple, ear, eyelid, groin, upper inner thigh, or buttocks. A tattoo may be used to match the color of the nipple of the other breast and to create the areola.

Nipple-sparing procedures

In a newer procedure called nipple-sparing mastectomy, the nipple and areola are left in place while the breast tissue under them is removed. Women who have a small early stage cancer near the outer part of the breast, with no signs of cancer in the skin or near the nipple, may be able to have nipple-sparing surgery. (Cancers that are larger or nearby may mean that cancer cells are hidden in the nipple.) Some doctors give the nipple tissue a dose of radiation during or after the surgery to try and reduce the risk of the cancer coming back.

There are still some problems with nipple-sparing surgeries. Afterward, the nipple does not have a good blood supply, so sometimes it can wither away or become deformed. Because the nerves are also cut, there is little or no feeling left in the nipple. In some cases, the nipple may look out of place later, mostly in women with larger breasts. This type of surgery is not yet widely available.

Saving the nipple from the breast that has been removed to use it later (called nipple saving or nipple banking) is no longer favored by most surgeons. The tissue can be injured by the way it is stored or preserved, and there have been other problems with this surgery.

Choosing your plastic surgeon

Once you decide to have breast reconstruction, you will need to find a board-certified plastic surgeon with experience in breast reconstruction.

To find out if a surgeon is board certified, contact the American Society of Plastic Surgeons (ASPS). This organization has a Plastic Surgery Information Service that provides a list of ASPS members in a caller's area who are certified by the American Board of Plastic Surgery.

Questions to ask Dr. Gray

It is very important that you get all of your questions answered by Dr. Gray before having breast reconstruction. If you don't understand something, ask Dr. Gray about it. Here is a list of questions to get you started. Write down other questions as you think of them. You may want to take notes. Some people bring a friend or family member with them to their consultation to help remember what was said. The answers to these questions may help you make your decisions.

• Can I have breast reconstruction?
• When can I have reconstruction done?
• What types of reconstruction could I have?
• What is the average cost of each type? Will my insurance cover them?
• What type of reconstruction do you think would be best for me? Why?
• How many of these procedures have you (plastic surgeon) done?
• What results can I expect?
• Will the reconstructed breast match my other breast?
• How will my reconstructed breast feel to the touch?
• Will I have any feeling in my reconstructed breast?
• What possible problems should I know about?
• How much discomfort or pain will I feel?
• How long will I be in the hospital?
• Will I need blood transfusions? If so, can I donate my own blood?
• How long it take for me to recover?
• What will I need to do at home to care for my incisions (surgical wounds)?
• Will I have a drain (tube that lets fluid out) when I go home?
• How much help will I need at home to take care of my drain and wound?
• When can I start my exercises?
• How much activity can I do at home?
• What do I do if my arm swells (this is called lymphedema)?
• When will I be able to go back to normal activity such as driving and working?
• Can I talk with other women who have had the same surgery?
• Will reconstruction interfere with chemotherapy?
• Will reconstruction interfere with radiation therapy?
• How long will the implant last?
• What kinds of changes to the breast can I expect over time?
• How will aging affect the reconstructed breast?
• What happens if I gain or lose weight?
• Are there any new reconstruction options that I should know about?

It is common to get a second opinion before having any surgery. Breast reconstruction is not an emergency procedure. It is more important for you to make the right decisions based on the correct information than to act quickly before you know all your options.

Before surgery

Planning your surgery

You can start talking about reconstruction as soon as you know you have breast cancer. You will want your breast surgeon and Dr. Gray to work together to come up with the best possible plan for reconstruction.

After reviewing your medical history and overall health, Dr. Gray will explain which reconstructive options are best for you based on your age, health, body type, lifestyle, and goals. Talk with Dr. Gray openly about what you expect. Dr. Gray will be frank with you when explaining the risks and benefits of each option.

Breast reconstruction after a mastectomy can make you feel better about how you look and renew your self-confidence. But keep in mind that the reconstructed breast will not be a perfect match or substitute for your natural breast. If tissue from your tummy, shoulder, or buttocks will be used, those areas will also look different after surgery. Talk with Dr. Gray about surgical scars and changes in shape or contour. Ask where they will be, and how they will look and feel after they heal.

Dr. Gray will also explain the details of your surgery, including:

• the drugs (anesthesia) that will be used to make you sleep through the surgery
• where the surgery will be done
• what to expect after surgery
• the plan for follow-up
• costs

Health insurance policies often cover most or all of the cost of reconstruction after a mastectomy. Check your policy to make sure you are covered. Also, see if there are any limits on what types of reconstruction are covered.

Make sure your insurance companies will not deny breast reconstruction costs if you have already submitted claims for a form that fits into your bra (an external breast prosthesis).

Getting ready for surgery

Dr. Gray will give you clear instructions on how to prepare for surgery. These will likely include:

• guidelines on eating and drinking
• tips to quit smoking
• instructions to take or avoid certain vitamins and medicines for a period of time before your surgery

Plan to have someone drive you home after your surgery or your time in the hospital and help you out for a few days.

Where your surgery will be done

Breast reconstruction often involves more than one operation. The first stage creates the breast mound. This may be done at the same time as the mastectomy or later on. It is usually done in a hospital.

Follow-up procedures, such as creating the nipple and areola, may also be done in the hospital or in an outpatient facility. This decision depends on how much surgery is needed and what Dr. Gray prefers, so you will need to ask about this.

What kinds of anesthesia are used?

The first stage of reconstruction is almost always done using general anesthesia. This means you'll be given drugs to make you sleep and not feel pain during the surgery.

Follow-up procedures may only need a local anesthesia. This means that only the area Dr. Gray is working on will be made numb. A drug called a sedative may also be used to make you sleepy. You'll be relaxed but awake, and you may feel some discomfort.

Possible risks

Almost any woman who must have her breast removed because of cancer can have reconstructive surgery. Certain risks go along with any surgery, and reconstruction may have certain unique problems for some people.

Some risks of reconstruction surgery are:

• bleeding
• fluid build-up with swelling and pain
• growth of scar tissue
• infection
• tissue death (necrosis) of all or part of the flap, skin, or fat
• problems at the donor site (this can happen right away and later on)
• loss of or changes in nipple and breast sensation
• extreme tiredness (fatigue)
• the need for more surgery to fix problems that come up
• changes in the affected arm
• problems with the drugs (anesthesia)

Risks of smoking

Using tobacco causes the blood vessels to tighten (constrict) and reduces the supply of nutrients and oxygen to tissues. As with any surgery, smoking can delay healing. This can cause more noticeable scars and a longer recovery time. Sometimes these problems are bad enough that a second operation is needed to fix them. You may be asked to quit smoking a few weeks or months before surgery to reduce these risks.

Risks of infection

Infection can happen with any surgery, usually in the first 2 weeks after surgery. If an implant has been used, it may have to be removed until the infection clears. A new implant can be put in later. If you have a tissue flap, surgery may be needed to clean the wound.

Risks of capsular contracture

The most common problem with breast implants is capsular contracture. This happens when the scar (or capsule) around the implant tightens and starts to squeeze the soft implant. It can make the breast feel very hard. Capsular contracture can be treated. Sometimes surgery can remove the scar tissue, or the implant may be removed or replaced.

After breast reconstruction surgery

What to expect

You are likely to feel tired and sore for a week or 2 after implants, and longer after flap procedures. Dr. Gray can give you medicines to control pain and other discomfort.

Depending on the type of surgery, you should go home from the hospital in 1 to 6 days. You may be discharged with a drain in place. The drain is an open tube that is left in place to remove extra fluid from the surgery site while it heals. Follow Dr. Gray's instructions on wound and drain care. Also be sure to ask what kind of support garments you should wear. If you have any concerns or questions, call Dr. Gray.

Getting back to normal

You should be up and around in 6 to 8 weeks. If implants are used without flaps, your recovery time may be shorter. Some things to keep in mind:

• Reconstruction does not restore normal feeling to your breast, but some feeling may return.

• It may take up to about 8 weeks for bruising and swelling to go away. Try to be patient as you wait to see the final result.

• It may take as long as 1 to 2 years for tissues to heal and scars to fade, but the scars never totally go away.

• Ask when you can go back to wearing regular bras. Underwires and lace may not be comfortable.

• Follow Dr. Gray's advice on when to begin stretching exercises and normal activities. As a rule, you'll want to avoid any overhead lifting, strenuous sports, and sex for 4 to 6 weeks after reconstruction.

• Women who have reconstruction months or years after a mastectomy may go through a period of emotional readjustment once they have their breast reconstructed. Just as it takes time to get used to the loss of a breast, you may feel anxious and confused as you begin to think of the reconstructed breast as your own. Talking with other women who have had breast reconstruction might be helpful. Talking with a mental health professional may also help you sort out these feelings.

• Silicone gel implants may open up or leak inside the body without causing symptoms. Some surgeons will recommend that regular MRIs of the implant be done to make sure it isn't leaking. You will likely have your first MRI about 1 year after your implant surgery and every 2 years from then on. Your insurance may not cover this. Talk to Dr. Gray about long-term follow-up.

Can breast reconstruction hide cancer, or cause it to come back?

Studies show that reconstruction does not make breast cancer come back. If the cancer does come back, reconstructed breasts should not cause problems with chemotherapy or radiation treatment.

If you are thinking about breast reconstruction, either with an implant or flap, you need to know that reconstruction rarely, if ever, hides a return of breast cancer. You should not consider this a big risk when deciding to have breast reconstruction after mastectomy.

Talk to your doctors about mammograms

It is important to have regular mammograms on your other breast at a facility with technologists experienced in taking and reading mammograms. If your reconstruction involves an implant, be sure to get your mammograms done at a facility with technologists trained in moving the implant to get the best possible images of the rest of the breast. Pictures can sometimes be impaired by implants, more so by silicone than saline-filled.

Mammograms can be done with tissue flap breast reconstructions. But reconstructed breasts can look fatty, and surgical clips and scars may show up on the mammogram. Still, breast changes or abnormalities can be seen. Talk to Dr. Gray and your oncologist about this.

Breast self-examinations

After breast reconstruction, you may choose to keep doing breast self-examination (BSE). Check both the remaining breast and the reconstructed breast at the same time. This will help you learn what is normal for you so that you can find any changes in the future. The reconstructed breast will feel different. The remaining breast may change, too, even if no surgery was done there. Dr. Gray can help you understand what is normal so that you can notice and report any changes as quickly as possible. To learn how to do breast self-examination, ask your doctor.