Happy BRA Day! October 15 is officially Breast Cancer Reconstruction Awareness Day. It’s a natural time to discuss commonly-asked questions about breast reconstructive surgery.

Breast cancer is a devastating diagnosis and the treatment tends to have a direct impact on a woman’s self-esteem, especially if there has been a mastectomy or partial mastectomy. Just knowing breast reconstruction is an option is consoling; it offers hope for many patients. Yet physicians and patients typically have questions about the process of breast reconstruction.

Who is a candidate for breast reconstruction?

Virtually anyone who has had a mastectomy or partial mastectomy. Neither age, nor physical size, nor type of surgery or treatment should be a barrier.

For women with certain health issues, there are some considerations. For example, more careful management may be necessary for those with type 1 diabetes to help prevent infection. Women taking anticoagulants will be asked to stop taking that medication before surgery. Smokers will need to stop not just before surgery but afterwards; even a single cigarette postoperatively can destroy the edges of a newly-placed skin flap. Unfortunately, there can be instances where reconstruction is not an option. Women with other cancers, such as leukemia or sarcoma, and patients with serious mental health issues may not be candidates for breast reconstruction.

What are the various options?

Because the diagnosis of breast cancer is increasingly being made at the microscopic level, there are more options than ever before.

First the cancer and some surrounding tissue are removed, and the reconstructive surgeon places a temporary implant that stretches the skin in such a way that the body grows new skin. (Interestingly, this approach was discovered when a plastic surgeon saw how his wife’s skin naturally expanded in pregnancy.) Over approximately two to three months, the skin is stretched via a small “filling valve” to the temporary implant. Once the size of the new breast is matched to the other side, the temporary implant is removed and the permanent implant is placed.

When women are undertaking chemotherapy and/or radiation, the reconstruction process typically occurs after treatment has been completed. If the patient has metastases, reconstruction is usually not recommended until she is tumor-free.

For those who have had radiation therapy and incurred some burning of the skin, there is the option of transferring a skin flap from their back or their abdomen.

When women have had a single mastectomy, the reconstruction process involves matching the other breast. Sometimes that involves reducing the size of the normal breast to match the reconstructed breast size; or, a small implant can be added to the normal breast to create more fullness.

What will the end result look and feel like?

It’s important for women to have realistic expectations. The reconstructed breast looks more like a mound than a natural breast. They will never have a totally “normal looking” breast; it will be a breast substitute.

Today, most implants are made of a gel-like substance that feels something like a gummy bear. The reconstructed breast feels natural and compressible.

After a mastectomy, a new nipple can be created but it will no longer have feeling. That’s because a branch of the fourth thoracic nerve — the one responsible for nipple sensation — is cut during the mastectomy surgery.

The new nipple is made out of skin flaps and the pigmentation is created by tattooing, matching the shade to the normal breast. It’s not likely to be an exact match to the normal breast’s nipple, but it’s close. Some women do not opt to have the nipple created; they are satisfied with the mound itself. The nipple-creating phase occurs after the mastectomy and can be done in the office.

Does it matter if the cancer was an early stage cancer or not? 

In rare cases, based on the type and size of the tumor, the general surgeon, medical oncologist and the hospital’s “tumor board” — a committee that provides guidance on how to manage more challenging cases — may decide that reconstructive breast surgery should not be pursued. But most patients are candidates for the procedure.

Does reconstruction make early detection of a potential future cancer more difficult?

That depends. The breast sits between the skin and the chest muscle. If the implant is behind the muscle and the skin, a recurrence could be seen subcutaneously, or under the skin.  Sometimes, however, if a skin flap from the back or abdomen needs to be used, it may lie on top of the muscle, making the detection of any recurrence more difficult to identify.  Ideally, the tissue expansion approach (as discussed in question number two above) provides the greatest likelihood of earliest detection.

In summary, women need to have reasonable expectations and understand the process and inherent risks of breast reconstruction.  Finding a reconstructive plastic surgeon with a great deal of experience in breast reconstruction is key.  Reconstructing a woman’s breast is both an art and a science, and it requires broad knowledge and a great deal of experience. But it’s worth the effort.

Having breast reconstruction can have an enormously positive impact on a woman’s body image, self-confidence and sexuality.

David M. Charles is a recently retired plastic and reconstructive surgeon with Plastic Surgery Clinic, Denver, CO, and member, board of governors and chair, investment committee, The Doctors Company.