By Ram Kalus, M.D., F.A.C.S., F.A.A.P.

A sense of self is an integral part of being human. A desire to look “normal” includes the desire to feel physically whole or symmetrical.

A woman losing a breast to cancer not only has to endure the shock associated with the diagnosis of the disease, but the physical, emotional and psychological impact of losing one of the most intimate and defining characteristics of the female anatomy. The impact can be devastating, both to the patient and those closest to her, and can have both short and long-term effects on her marriage and intimacy.

The reasons a woman might choose to proceed with breast reconstruction are fairly evident — a desire to feel whole, symmetrical or “restored” to her pre-cancer state. The reasons she might choose to avoid reconstruction are perhaps more troubling and complex. These may include guilt (“Am I being vane?”); fear of recurrence (“Will reconstruction in any way reduce my chance for cure or place me at greater risk of recurrence?”); and even physician bias.

Believe it or not, some physicians who care for breast cancer patients still regard reconstruction as frivolous and unnecessary. This is truly unfortunate since the evidence is overwhelming that breast reconstruction does not in any way impact negatively on the prognosis or survival rate of women with breast cancer. In fact, the benefits of reconstruction clearly outweigh the risks. Furthermore, the majority of plastic surgeons performing breast reconstruction do so in close consultation with the oncologist, general surgeon, and radiation therapist to insure an optimal treatment for the patient.

Still, each patient has to decide whether or not breast reconstruction is the right choice for her. Much of what goes into making the right decision is based on knowing all the options, once the recommendation for a mastectomy has been made. This article will, therefore, focus on those women who either lost one or both breasts to cancer. It will also include a brief discussion of those patients who face significant physical changes in their breasts following lumpectomy and radiation therapy.

While plastic surgeons continue to perfect breast reconstruction techniques, there are already many options available for women with some remarkably gratifying outcomes for many patients. Below is a summary or these options, from the simplest to most complex, with some illustrative photographs of each method of reconstruction.

	This 55 year old woman underwent a left breast reconstruction with tissue expander followed by insertion of a saline implant permanent prosthesis along with a right mastopexy (breast lift). Her appearance in and out of a bra.
	Pre-operative and post-operative appearance of a 59 year old woman who underwent a left latissimus dorsi musculocutaneous flap reconstruction with underlying silicone gel prosthesis, and simultaneous right breast reduction.
	Pre-operative and post-operative appearance of a 44 year old woman who underwent a right mastectomy and immediate TRAM flap breast reconstruction, as well as subsequent left mastopexy (breast lift), simultaneous with right nipple reconstruction.
	Pre-operative and post-operative appearance of a 50 year old woman who underwent left mastectomy and radiation therapy, followed by a delayed TRAM flap reconstruction.
	Pre-operative and post-operative appearance of a 40 year old woman with a significant deformity after initially undergoing left lumpectomy and radiation therapy (Breast Conservation Therapy), who was subsequently reconstructed with a left TRAM flap and right mastopexy (breast lift).

In this procedure, referred to as a “Tissue Expander,” the plastic surgeon temporarily places an expandable breast implant at the site of the mastectomy. This is done either at the same time as the mastectomy (Immediate Reconstruction) or at some later date (Delayed Reconstruction). Over the course of four to twelve weeks, the patient makes weekly or bimonthly visits to the doctor’s office for follow-up. During the office visits, the doctor uses injections with a tiny needle, to fill the expander with saline (physiologic salt water) until the desired breast size (or slightly) larger is achieved. This is followed with a fairly simple outpatient procedure to exchange the tissue expander for a permanent breast implant whose outer shell is made of silicone and whose inner filler may be either saline or silicone.

Despite the concern about silicone breast implants, both silicone gell filled and saline filled implants have been shown to be safe, with silicone filled implants showing some advantages in terms of softness and a more natural feel. Saline filled implants can sometimes feel firm or demonstrate ripples or creases. Although the FDA has limited the use of silicone gel prostheses primarily for women undergoing breast reconstruction, the overwhelming scientific evidence supports their safety (See Figure 1a, b).

A “Flap Reconstruction” involves a plastic surgeon utilizing a suitable muscle near the breast and overlying skin and fatty tissue to mimic the female breast. This surgery is more complex and generally involves a slightly more prolonged recuperation. The most common muscle flaps used are the latissimus dorsi or LD (see Figure 2), the large triangular muscle extending from the back and inserting into the upper arm, and the rectus abdominis muscle or TRAM flap (Transverse Rectus Abdominis Muscle, see Figure 3). Other flaps that can be utilized include just skin fat wihtout the use of a muscle, but these require microsurgical techniques.

The advantage of a flap procedure is the use of the patient's own tissue to mimic the breast, rather than an implant. With the LD flap, there is usually a requirement for a small implant since most women do not have enough volume in their latissimus dorsi to allow for an adequate size breast.
Alternatively, a TRAM flap almost always allows for avoiding an implant altogether. In general, a flap procedure is indicated in women who have had prior radiation, since a flap brings with it a new blood supply, which is critical to the skin and soft tissues that have been previously radiated.

Since a flap procedure is significantly more involved, particularly the TRAM flap, recovery is between 4-12 weeks, compared with an expander/implant where recovery is usually between 2-6 weeks. In some cases, following lumpectomy and radiation therapy, both expander/implants and flap procedures may be necessary to correct significant asymmetries. These patients may have particularly challenging reconstructive problems which more often require flap reconstructions(Figure 5).

All reconstructive procedures can be associated with potential complications which should certainly be discussed with the patient when she consults with her plastic surgeon. But in general, in the hands of a skilled board certified plastic surgeon who is experienced in breast reconstruction techniques, complications should be rare and the vast majority of patients can expect a very apparent and significant enhancement in their appearance, self esteem and quality of life after breast reconstruction.

Ram Kalus M.D. is a Board Certified plastic surgeon in Columbia, South Carolina and founder of Plastic Surgery of the Carolinas, PA. Much of his plastic surgery practice today is devoted to reconstructive and aesthetic surgery of the breast.