Many women also choose to get breast reconstruction, either simultaneously with their mastectomy (immediate reconstruction) or as a second operation later (delayed reconstruction), often after chemotherapy, radiation therapy, or hormone therapy. “There are pluses and minuses to each approach,” says Dr. Schneider. “In immediate reconstruction, when the patient goes to sleep, she has a breast. When she wakes up after surgery, she still has a breast, although it is now a reconstructed one. Psychologically, that can be helpful in terms of managing the sense of loss that comes with the mastectomy surgery and removal of the breast. In patients who undergo direct-to-implant or autologous (the body's own tissue) reconstruction, that single combined surgery may be the only one they need.” “However, it is important to note that for the majority of patients, at least one additional (typically outpatient) surgery is required, whether to exchange a temporary tissue expander for a more permanent breast implant, perform adjustments or revisions, or even just construct a new nipple.” Immediate reconstruction may be off the table for a number of reasons, says Dr. Schneider:Â
- The patient may just want to initially focus on her cancer treatment and recovery or opt against reconstruction and later change her mind.Â
- There may not be a reconstructive plastic surgeon available or nearby when the cancer surgery needs to take place.Â
- If the patient has relatively advanced cancer or a cancer with certain biological characteristics, it may be life-saving to have the cancer surgery as soon as possible and start chemotherapy very quickly afterward.Â
- Many patients require radiation after mastectomy surgery, which can change or harden a reconstructed breast, making it preferable to wait.
In cases where cancer treatment must take precedence, a hybrid option between immediate and delayed reconstruction may be considered. “I often recommend to patients to place a tissue expander or temporary implant at the time of the initial mastectomy,” says Dr. Schneider. “This gives the patient at least some breast, which is helpful psychologically and also preserves the skin envelope.”
Interestingly, according to 2014 research, 59% of women in urban areas and 71% of women in rural areas decide against reconstruction in favor of just “going flat” or wearing a breast prosthesis under their clothing. It’s possible that many of these women don’t have health insurance, don’t know that their insurance is legally obligated to cover breast restoration, or aren’t aware of their options. According to the BRAVE Coalition Foundation, fewer than 30% of women know their breast reconstruction options.
In a 2015 review of common misconceptions about breast reconstruction, Dr. Schneider and coauthor Dr. Babak Mehrara concluded, “Breast reconstruction might not be the right choice for every patient, but every patient deserves to have a complete discussion before cancer treatment to make a fully informed decision. The more involved they are in the decision process, the more likely they are to be satisfied with postoperative outcomes.”
Related: 5 Things You Need to Know About Your Breast Reconstruction Options