The Breast Reconstruction Guidebook

The following is an excerpt from Kathy Steligo's The Breast Reconstruction Guidebook, now in its fourth edition.

If you’re facing mastectomy to treat or prevent breast cancer, you have a lot of decisions before you. Will you keep a flat chest after surgery, wear temporary breast prostheses, or have your breasts reconstructed? If you do want to have breast reconstruction, is your priority to have the shortest procedure with the quickest recovery or to pursue a method that will give you the most natural breasts possible? Does keeping your own nipples and areolae appeal to you? Do you have quite a bit of excess fat that you’d like to be rid of in the process?

Plastic surgeons have been recreating breasts for decades. Technological innovation and surgical improvements in the 15 years since The Breast Reconstruction Guidebook was first published now make reconstructive results with breast implants or your own tissue better than ever. If you’re interested in breast implants, you might choose cohesive silicone gel “gummy bears” that retain their shape and feel more like breast tissue. If you’d like to avoid the traditional method of tissue expansion that creates a space to hold your implant, you might be a candidate for nipple-sparing mastectomy with a direct-to-implant procedure, which completes in a single visit to the operating room what reconstruction with tissue expanders takes months to accomplish. (Solid data show that nipple-sparing mastectomy, considered to be unwise just a few years ago, is safe for most women, even many who are treated for breast cancer.) If your reconstruction is done with tissue expanders, perhaps you’ll prefer to control the speed of your expansion at home, avoiding routine office visits and shortening the overall reconstruction process.

“Flaps” of your own excess fat can also be sculpted into new breasts. Plastic surgeons continue to push the reconstructive envelope, developing better flap techniques and procedures that provide more predictable results and shorten recovery. Some tissue flaps use muscle along with skin and fat to rebuild the breast, but other more sophisticated options spare the muscle, preserving function and making for less intense recovery. These micro surgical tissue flaps, including DIEP (deep inferior epigastric perforator), GAP (gluteal artery perforator), TUG (transverse upper gracilis), and others, are no longer considered weird or experimental, and options for rebuilding your breasts with excess fat from your abdomen, back, buttocks, thighs, or hips are numerous. And flap reconstruction comes with a bonus: new breasts and a slimmer donor area. Methods of nipple reconstruction have also improved. Or like a growing number of women, you may prefer to have three-dimensional nipples tattooed onto your reconstructed breast, giving a lifelike illusion of having nipples where there aren’t any.

One of the most exciting reconstructive innovations is fat grafting— liposuctioning your own excess fat and carefully injecting small amounts into your reconstructed breast. Although fat grafting has been used for many years, recent improvements make it far more practical and successful, ensuring that more fat stays in the breast. Adding fat to the new breast can refine shape, increase volume, and improve contour with minimal downtime, making a good reconstruction even better. Perhaps the most important change is the increasing number of plastic surgeons who now routinely offer breast reconstruction, translating to more accessible experience, skill, and choice.

One thing that hasn’t changed in 15 years is that women who consider breast reconstruction share a common dilemma: “What is the best option for me?” Because no single procedure is right for all women, the wisest approach is to first carefully consider the alternatives; consult with two or three experienced, skilled surgeons; and then determine which reconstructive method, if any, matches your personal preferences and priorities. Fortunately, mastectomy and reconstruction are no longer one-size-fits-all. You have options, but that also means you need to make decisions. You may not be a candidate for all procedures. If you’ve undergone radiation for breast cancer, for example, that poses some reconstructive limitations. Some choices may not be available in your area or within your health insurance network. Others may not interest you, because of the investment in time or recovery. With you in the driver’s seat, you’re less likely to have regrets about how your reconstruction is done, and you’ll know what to expect in the hospital and at home during recovery.

Like its preceding versions, this edition of The Breast Reconstruction Guidebook was written to answer your questions, demystify confusing terms and concepts, and help you go from confused to confident. The text is deliberately objective. It doesn’t favor or recommend one procedure or another, because that’s up to you to decide.What’s most important, particularly if you’re feeling that you’ll never be the same, is that after mastectomy, you can have symmetrical, soft, rounded breasts. They won’t feel the same as your natural breasts, but many women find that their new breasts look as good or better. Reconstruction isn’t perfect, and it isn’t always easy. It can’t undo everything mastectomy takes away or replace lost sensation or the ability to breastfeed. But it can restore your post-mastectomy profile and profoundly affect your self-image and peace of mind, so that you can get on with your life, while you wear all the clothes you wore before your mastectomy and look natural again without your clothes.

As someone who has twice confronted breast cancer and twice had reconstruction, I understand just how you feel. I know firsthand that sorting through the various reconstructive options can be a confusing, time intensive, and frustrating experience. By the time you’ve read through this book, you’ll feel more confident in your choices and understanding of mastectomy and reconstruction. You may decide to go ahead with reconstruction. You may not. Either way, you’ll know what to expect. And even if you decide that reconstruction is not for you, after reading through different parts of the book, you’ll have a good understanding of breast cancer, mastectomy without reconstruction, and what to expect from your surgery and recovery.

How will the next 15 years change mastectomy and breast reconstruction? I hope that science is driving us toward a time when mastectomy will be archaic, and this book will be obsolete. But discovery isn’t easy, and the development process isn’t quick. Sooner or later, scientists will discover how to repair defective genes that cause disease. Women diagnosed with breast cancer may undergo gene therapy without needing chemotherapy or radiation. We’ll move breast cancer to the list of diseases we no longer need to fear, and mastectomy will no longer be needed. Until then, reconstruction is our best antidote for replacing lost breasts.

Kathy Steligo is the editor-at-large for Facing Our Risk of Cancer Empowered (FORCE). She is the co-author of Confronting Hereditary Breast and Ovarian Cancer: Identify Your Risk, Understand Your Options, Change Your Destiny and Confronting Chronic Pain: A Pain Doctor's Guide to Relief.