Reconstruction after radiation is more difficult, because the skin and blood supply are damaged by the treatment. Implant reconstruction after radiation has a particularly high potential for complications or loss of the implant. Sometimes the remaining breast skin is too thin and fragile for the implant process, and extrusion (the implant breaks through the skin) can occur. It sometimes works, especially if the skin is expanded very slowly. If it’s damaged extensively and doesn’t expand or the implant fails, a tissue flap is the only remaining reconstructive option. If you have your heart set on implant reconstruction, some surgeons will place an expander during mastectomy, quickly complete expansion, and exchange it for an implant before radiation.

Alternatively, saline can be removed from an expander before radiation, then refilled after the last treatment. If you need radiation after mastectomy, tissue flap reconstruction usually produces better results. Flap reconstruction may also be difficult after radiation, because the blood supply to the new breast is compromised. The risk of necrosis is higher, but in most cases, it isn’t a serious problem.

If you choose not to reconstruct your breasts, as many women do, your chest will be flat after mastectomy. You might be just fine with this, especially if you’ve always had very small breasts or don’t want to have additional surgery. If you decide against reconstruction but want to fill out your clothes, you can use prostheses, breast forms made of cotton, foam, latex, or silicone that stick to your chest or fit into a pocket in your bra. Wearing a prosthesis can also help to provide balance when trying to fit into clothes after unilateral mastectomy, or between mastectomy and delayed reconstruction.

Prostheses come in a variety of shapes, weights, and prices. Silicone is the most expensive because it has a consistency that is most like a natural breast. It’s important to have a qualified fitter in a mastectomy boutique or department store help to fit you correctly. Visit tlcdirect.org, a website maintained by the American Cancer Society, for more information about breast prostheses.

MY STORY: My Breasts Don’t Define Me

I chose no reconstruction for a simple reason: I wanted to be done with surgery. Part of me will always miss my breasts, but they don’t define me, and reconstruction would not have given them back. One breast was removed due to invasive ductal breast cancer, and I chose the fastest surgery—reconstruction would have meant waiting for the plastic surgeon’s schedule and a longer recovery. The other breast was removed a year later, along with my ovaries, after I learned I was BRCA1 positive and diagnosed with leukemia. I then opted for no recon because I didn’t want to risk infection, reconstruction failure, or additional surgeries. For me, coming to terms with my new reality meant accepting that my own breasts were gone. I knew if I ever changed my mind, reconstruction would still be an option. Six years later, I haven’t changed my mind. I am undeniably different, but I’m still me. I have no regrets about foregoing reconstruction. My choice may not have been right for everyone. It was simply the right one for me.

—LISA

Refilling the breast skin with saline or silicone implants is the quickest route to reconstruction, involving the shortest surgery and recovery. Implants come in different sizes and widths and are either round or anatomically shaped. Which is used is mostly determined by your anatomy. Saline implants are silicone shells filled with salt water. They’re firmer than silicone gel implants, which are softer and feel more like natural breast tissue. Ask to hold and feel both before deciding which you prefer. You’re a candidate for implant reconstruction if you’re not excessively obese, don’t have advanced disease, and haven’t had multiple infections or surgeries at your mastectomy site.

Direct-to-implant reconstruction uses patches of acellular dermal matrix (donated human tissue that has been stripped of all its cells but retains all the elements necessary to support new tissue growth) sewn onto the muscle to form an immediate sling that holds the implant. It also helps to camouflage implant edges that may be felt or seen under the skin. Less frequently, surgeons place implants over the muscle if the skin is thick enough. Sometimes one-step procedures turn into two-step reconstruction if revisions are needed to fix a problem or asymmetry. Direct-to-implant surgeries are becoming more common, especially for women who have PBM, but most reconstructive surgeons still prefer the traditional expansion method. If you’re interested, be aware that some surgeons now use acellular dermal matrix with traditional expansion to better cover the expander and define the inframammary fold under the breast. When a surgeon says he uses dermal matrix, ask specifically if he uses it in a single-stage or expander process.

MY STORY: Better Than Ever

—ANDREA

Implants Aren’t Permanent

Flaps are a good option for women who:

• want new breasts made of their own tissue.

• have previously had radiation to the chest or breast.

• don’t want to risk problems inherent with implants or endure the expansion process.

• want to match one reconstructed breast to their other natural breast.

One disadvantage of flaps is the risk for necrosis, where some or all of the transplanted tissue dies from an inadequate blood supply. When a small area of necrosis occurs as a hard lump or an area that feels thickened, it may resolve on its own or require surgical removal. Rarely, an entire flap fails and must be replaced. When this does occur, it’s usually within the first few days after reconstruction; necrosis sometimes occurs weeks or months after surgery. Fat necrosis usually isn’t cause for concern, but any lumps or changes should be checked by your surgeon.

Free flaps are complete transplants of skin, fat, and a small portion of muscle surrounding the blood vessels. This is technically more demanding than implant or attached flap reconstruction, because the surgeon must transfer the flap from the donor site to the chest and use a surgical microscope to reconnect the blood vessels at the mastectomy site. Free flaps can be taken from the abdomen (free TRAM) or the buttock (free gluteal flap). Less frequently, flaps from the hip (lateral transverse thigh flap) or inner thigh (transverse upper gracilis or TUG) can be used. Unlike attached flap procedures, free flap surgeries remove only a portion of the muscle to build the breast, so recovery is usually shorter and less painful.

When women don’t have enough abdominal fat for reconstruction, the buttock is often an adequate resource. The superior gluteal artery perforator (SGAP) uses tissue from the top of the buttocks; the inferior gluteal artery perforator (IGAP) takes tissue from the lower buttocks. These are lengthy operations, because the patient has to be turned twice: first to harvest the buttock tissue after mastectomy, then again to transfer the flap to the chest. Most plastic surgeons don’t perform GAP reconstruction; those who do usually perform only one side at a time, requiring patients to have two separate ten- to twelve-hour surgeries. A few surgeons, most of whom devote their practice exclusively to reconstruction, perform bilateral simultaneous GAP in eight or nine hours.