Breast Reconstruction: Deciding on Timing
With all the stark information and high-stakes decisions thrown at women diagnosed with breast cancer, whether to have breast reconstruction may seem like one of the few choices that can wait. But for women interested in surgery to restore the shape of their breasts, immediate breast reconstruction -- done right after mastectomy during the same operation -- offers advantages. While women may prefer to delay reconstruction or decide they don't need it at all, they deserve to know their options. See what a plastic surgeon and patient have to say about breast-reconstruction timing.
Start Thinking Early
When you've trying to make sense of the "avalanche of information" and treatment decisions coming your way as a woman newly diagnosed with breast cancer, it's tough to consider reconstructive surgery as well, says Dr. Minas Chrysopoulo, a plastic surgeon and microsurgeon at PRMA Center for Advanced Breast Reconstruction in San Antonio.
"The reason [patients] should start thinking about it as soon as possible is because if they choose to have reconstruction, then ideally it should be done at the same time as the mastectomy," Chrysopoulo says. While that's not always possible, and not every woman is a candidate for immediate reconstruction, he says it's often a good choice, especially for early stage 1 or stage 2 breast cancers.
Dana Donofree of Philadelphia recalls rapidly sorting out her treatment options after the 2010 breast cancer diagnosis she received on the eve of her 28th birthday. "I wasn't sure at first if I was going to have the lumpectomy or a single mastectomy or a double mastectomy," she says. "All of those questions came at me very quickly." Bilateral mastectomy was considered the best option for Donofree, then a patient at Rose Medical Center in Denver.
Once Donofree understood the choices, she says immediate breast reconstruction "was definitely something I wanted in my treatment."
Immediately after mastectomy, she had an expander -- a temporary, balloon-like device to stretch the skin and make a "pocket" -- placed in each breast. That was the first phase of a two-stage process to prepare her body for the rebuilding procedure with permanent implants, which she underwent about a year later. According to the National Cancer Institute, that time frame usually spans about six weeks to six months after mastectomy.
Time to Choose
"You can do reconstruction at any time," Chrysopoulo says. "It doesn't have to be at the same time as mastectomy. In fact, most women end up having it later because, to be honest, they're not given the option at the beginning, at the time of diagnosis."
With immediate reconstruction, he says, an advantage is that "you don't have to live without a breast. You wake up with breasts, and they're different, but you're whole." Better cosmetic results, with less scarring, are more likely with immediate reconstruction surgery, Chrysopoulo says, compared to results from separate procedures for mastectomy and breast reconstruction.
Misconceptions prevent some women from getting immediate reconstruction, he says. "You obviously want to get the cancer taken care of quickly," he says. But, he adds, a sense of urgency, while understandable, shouldn't obscure the importance of reconstruction.
"We know from studies that having a mastectomy two weeks after diagnosis is no different than having a mastectomy four weeks after diagnosis," he says. "So those extra two weeks don't make any difference in terms of your outcome."
Immediate reconstruction does not appear to delay treatment or affect breast cancer outcomes, according to findings from a 2011 study in the journal Plastic and Reconstructive Surgery that looked at the surgery's safety in patients with advanced-stage breast cancer. It found a low risk of complications, including those related to radiation therapy, and no significant treatment delays.
However, complex treatment scenarios -- for example, patients receiving chemotherapy through central intravenous lines who then develop blood clots -- can delay breast reconstruction, according to a small study published in the March 2015 issue of the Annals of Medicine and Surgery.
Decision Details
In Donofree's case, fortunately no barriers occurred to immediate reconstruction. Her Colorado surgeon was "awesome," she says, and took the time to consider what was right for Donofree's individual wishes and athletic body type. "There was a lot of discussion on what the size was going to be; what shape did I want? It was really kind of bizarre that you can sit there and pick out your boobs," she recalls, laughing.
Of course, shape, size and timing around breast cancer surgery aren't the only decisions patients need to make with breast reconstruction. Choosing between implant and tissue flap procedures is another. Tissue flap reconstruction uses a woman's own body tissue to create a breast mound. In that case, the next decision is which type of flap procedure, depending on where tissue comes from -- such as the belly, upper back or buttocks.
Whether to undergo nipple reconstruction, an added phase, is another decision. You can research these and other technical options online in addition to talking to your plastic surgeon. While reconstruction is less common with lumpectomy, Chrysopoulo says, it can reduce noticeable breast differences and improve symmetry, especially in women with smaller breasts. The American Cancer Society provides a detailed list of questions to ask your plastic surgeon.
Surgery: Who and Where?
Even with immediate breast reconstruction, it's not a single-surgeon operation. "In the U.S., it's a different surgeon," Chrysopoulo says. "The surgeon that removes the cancer is a general surgeon or breast surgeon, and they do the lumpectomy or the mastectomy. The reconstructive surgeon is a plastic surgeon who's responsible for the reconstruction. So you have to coordinate it ahead of time."
To do so, he says, you should ask your breast surgeon or oncologist -- whoever made your initial diagnosis -- which surgeon they recommend. "You need to see a plastic surgeon who does a lot of breast reconstruction," he adds. "Most plastic surgeons can do breast reconstruction, but not all of them do a lot of it." Ask the plastic surgeon about the most common procedures he or she performs, Chrysopoulo advises, along with how many he or she performs and whether all the reconstructive options are available.
Living a long distance from a treatment center can present a geographical barrier to breast reconstruction after mastectomy, according to a study released in January that used data collected between 1998 and 2011. During that period, researchers also found an increase in immediate breast reconstruction rates with mastectomy, from about 11 percent to more than 32 percent of procedures.
It's worth traveling to have the procedure you want in a center of excellence or a high-volume facility, Chrysopoulo says. If physical, financial or other constraints preclude immediate travel, he says, that might be a good reason to delay breast reconstruction.
According to the Women's Health and Cancer Rights Act of 1998, if your insurance covers your mastectomy, it must also cover reconstructive surgery.
Talk to Your Peers
"For me, being 27 years old, and 28 at the time that I started to get surgeries, was very overwhelming," Donofree says. "At the point when I was getting treated, I hadn't met a lot of other young women that were faced with this decision." She received encouragement from other, older women, however, who helped her sort through the choices.
"It's really about reaching out to other women who have been in this situation with the surgery -- the procedure you're thinking about," Donofree says. She recommends connecting with other women and finding resources and information through groups like Living Beyond Breast Cancer, for which she serves on the board.
At 34, Donofree is doing well. Although there's some scarring across her breasts, overall, she says, her body feels good. She's run into a few limitations she didn't expect -- she no longer feels comfortable doing a pushup, for instance -- but has found workarounds. Donofree designs and owns AnaOno, a lingerie line for breast cancer survivors. Most encouraging of all, she recently hit her five-year mark following cancer treatment. "So far, so good," she says.
Lisa Esposito is a Patient Advice reporter at U.S. News. You can follow her on Twitter, connect with her on LinkedIn or email her at lesposito@usnews.com.
