“Reconstruction helps many women put their cancer experience behind them and move on with their lives.”

“The last thing on my mind was getting another breast,” says Kathy Ramiel. For her, breast reconstruction was simply never an issue. “I had the surgery to remove my breast, and I felt that took care of the problem.” In fact, she bristled when her doctor mentioned—more than once—the possibility of reconstruction. “He assumed it was important, as if restoring my breast would make any difference to me at all.”

Breast reconstruction made a huge difference to Loretta Belotti. She was relieved that she was a candidate for immediate reconstruction because “waking up and feeling a breast was very important to me.” Belotti admits, unabashedly, that her ample breasts have always been a “focal point.” Over the years, she’s enjoyed the admiring glances from men and the way low-cut blouses showed off her cleavage. She wasn’t about to trade in such a prized feature for a prosthesis. Naturally, she’s most triumphant about being cancer-free these days.

The decision to have breast reconstruction or not is emotionally laden. A woman’s breasts, after all, are often intimately tied to her self-image, sense of womanliness, and sexuality, points out Colette Haag-Rickert, M.D., an obstetrician-gynecologist in South Hadley, Massachusetts. Especially in this culture, “where both men and women are brought up on Barbie dolls and Playboy images, breasts have become a charged part of our anatomy,” says Christiane Northrup, M.D., co-founder of the OB-GYN practice Women to Women in Maine, and author of Women’s Bodies, Women’s Wisdom.

And if a woman makes that leap and opts for the procedure, other tough dilemmas await her: Should she do it immediately or wait? What type of reconstruction should she have? Will she be content to look good in clothes, or will she be satisfied only if her breast appears natural when she’s naked? As a woman navigates these decisions, she should keep the following considerations in mind.

To Reconstruct or Not

“Reconstruction helps many women put their cancer experience behind them and move on with their lives,” says Timothy J. Eberlein, M.D., Dirctor of the Cancer Center at Washington University School of Medicine in St. Loius. Restoring a breast can rebuild a woman’s sense of confidence and self-esteem. It can spur her to embrace life and her body again. If she feels as though her body has betrayed her by getting cancer, breast reconstruction can help to repair that connection to her old self.

Yet other women feel that breast reconstruction is a form of denial. Instead of rushing to pretend the disease didn’t happen by hiding its disfigurement, they argue that women should proudly announce to the world that they are breast cancer survivors. And some women, like Ramiel, aren’t interested in breast reconstruction because their breasts don’t hold any special meaning for them.

To Wait or Not

From a medical perspective, experts recommend that reconstructive surgery should immediately follow removal of the breast. That way, patients undergo only one hospitalization and one round of anesthesia. There are exceptions, though. Women who are smokers, diabetics, or obese would benefit from waiting, since the blood supply to their skin isn’t optimal, notes Jeanne Petrek, M.D., a breast surgeon at Memorial Sloan-Kettering Cancer Center in New York City. Such patients are at increased risk of infection with back-to-back surgeries and the intense stretching of their breast skin.

In cosmetic terms, too, an immediate reconstruction is preferred. “When the surgeon can save the woman’s skin flap, the result is best,” says Katherine Young, M.D., a plastic and reconstructive surgeon at California Pacific Medical Center in San Francisco. Without this skin, “a woman may get only an okay-looking reconstruction, not a gorgeous one.”

Psychologically, however, the answer to the timing question is less clear-cut. Immediate reconstruction may be right for many women. “It can save a woman from experiencing the loss of a breast when she regains consciousness after surgery,” says Marilyn Leitch, M.D., associate professor of surgery at UT Southwestern Medical Center and president of the Texan division of the American Cancer Society. For many women, immediate reconstruction takes the edge off their grief and trauma and instills a sense of hope as they begin to reclaim their lives. But a surprisingly strong case can be made for waiting until a woman knows what she truly wants.

Dr. Petrek recalls various patients “who wanted an immediate reconstruction but were forced to put it off because they developed an infection in the biopsy site. Six months later, when the timing was right for reconstruction, they said, ‘Gee, I’m content this way.’” As Dr. Petrek sums up, “unless you’re absolutely certain you want a reconstruction, you might be wise to postpone the procedure.”

Which Type Of Reconstruction is Best?

There are two types of reconstruction: the implant, either silicone or saline; and the technique known as “TRAM flap” (or transverse rectus abdominis myocutaneous). According to the American Society of Plastic and Reconstructive Surgeons (ASPRS), roughly one-quarter of the breast reconstructions performed last year were TRAM flaps. Unfortunately, neither option is without risks. As far as implants go, a recent study at the Mayo Clinic found that about one-third of women who’d had implants after a mastectomy experienced complications within five years following the surgery.

The TRAM flap isn’t fool-proof either. In fact, because the procedure is so intricate, it’s critical that you find a highly-skilled surgeon who performs at least a few TRAM flaps per month. With this procedure, the surgeon transplants skin and fat from the lower abdomen (or sometimes the buttocks) to build a breast. The surgeon also “tunnels” the rectus abdominis muscle (used for sit-ups) up into the breast, so that the artery and vein inside this muscle can provide blood flow to the breast. The main risk of the procedure involves an insufficient blood supply to the new skin—a complication that affected almost one-quarter of TRAM flap patients in a 1990 study at Columbia-Presbyterian Medical Center in New York City.

Recovery from a TRAM flap also lasts about 6 weeks, due to the belly’s long healing time, compared to about 4 weeks for an implant, says Dr. Young. A hip-to-hip scar remains, though it’s hidden in the bikini line, and most women need a touch-up to the new breast within a few months in order to achieve symmetry with the healthy breast.

To compare the cosmetic results of an implant with a TRAM flap, it’s best to interview women at a breast cancer support group. “Breast cancer survivors are often eager to show women who are considering the procedure what their reconstructed breast looks like,” comments Dr. Young. When you consult a doctor, you can also check “before” and “after” photos of her work. Consider, too, that a 1994 study published in the Annals of Surgery found that women tended to prefer TRAM flaps to implants because they feel more natural.

This is not to say that an implant can’t have a beautiful result, too. It surely can. As mentioned above, one key to success is having immediate reconstruction, so that the overlying skin flap can be used. If a woman waits, a surgeon will use a “tissue expander” to stretch her skin gradually until an implant can fit inside. Sometimes, this technique is done with immediate reconstruction, if the remaining skin isn’t sufficient to cover the implant.

Whichever route a woman takes—reconstruction or not, implant or TRAM flap—the choice is always deeply personal. Just ask any breast cancer survivor who is willing to talk about her decision. If she was hazy about what her breasts meant to her pre-diagnosis, she becomes crystal-clear about their significance afterwards. And she’ll offer you reasons for her decision, ranging from the practical to the philosophical. But all resonate with who she is and has become.