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The overall goal of breast reconstruction is a positive image and sense of well being for the patient. The process begins with you and your plastic surgeon identifying and visualizing the end result. This involves understanding the size and shape of the breast you want. Some patients have specific desires, while others are content with the mere suggestion of a breast mound. Some opt for multiple procedures to achieve the desired result; others prefer the simplest and shortest route.
The Non-Involved Breast
In most cases, only one breast is affected by cancer. One of the first decisions is what to do with the non-involved breast. This breast becomes the template for the reconstructed one.
Prophylactic (preventive) removal of the healthy breast may be recommended. The threshold for recommending prophylactic surgery varies depending on the patient and physician. For some, an increased lifetime risk of developing a second primary cancer in the opposite breast is sufficient to warrant treatment. For others, the risk would need to be quite substantial to consider such a measure.
The pros and cons of prophylactic mastectomy should be discussed with the oncologist, oncological surgeon, and plastic surgeon. A plastic surgeon's input is crucial to the discussion. One of the goals of breast plastic surgery is symmetry. Similar and symmetric procedures generally yield better symmetry.
Implants vs. Autologous Reconstruction
The next issue to consider is how you feel about an implant vs. using your own tissue for reconstruction. Some people have a bias for or against implants, especially silicone gel implants.
Silicone gel implants are sometimes better than saline implants in reconstruction, and may feel and appear more natural. Using your own tissue (autologous reconstruction) to rebuild the breast may provide more desirable results than implant reconstruction. With the autologous approach, the reconstructed breast may be virtually indistinguishable from the natural breast. There are a variety of ways to achieve this result, all requiring surgery that is more involved and complex than implants. Patients may end up with additional scars either in the back or the abdomen.
Your plastic surgeon can discuss with you all of the alternatives for implant or autologous reconstruction.
Immediate vs. Delayed Reconstruction
Another important consideration is the timing of the reconstruction. In the past all reconstruction was delayed at least six months; now we recommend immediate reconstruction in most cases. Breast reconstruction is a quality-of-life issue. Many patients who begin their rehabilitation at the same time their cancer is removed are emotionally and psychologically uplifted. Moreover, delayed reconstruction is always more surgically difficult and demanding than immediate reconstruction.
Advanced stages of cancer are not necessarily a reason to delay or withhold reconstruction. As long as the reconstruction does not interfere with or delay appropriate curative treatment, this life-enhancing surgery is appropriate. If you are undergoing mastectomy, you should discuss the optimal timing of breast reconstruction with your surgeon, plastic surgeon, and oncologist.
Immediate reconstruction means beginning the reconstruction at the time of the mastectomy; it does not mean the reconstruction is completed immediately. Usually, complete reconstruction requires two or three stages spaced no less that three months apart.
In patients who want reconstruction but can’t decide on or commit to a specific method, the initial reconstruction phase should at least consist of the insertion of the temporary implant (inflatable expander).