Women who have mastectomies face decisions about whether and how to reconstruct their breasts so they look as natural as possible. Fortunately, surgeons at The George Washington University Hospital are here to discuss the options with compassion and a high level of knowledge.

"It is important to build a relationship rather quickly with the patient," says Steven Macht, MD, a plastic surgeon at GW Hospital."We want to help her decide what is best for her, what she wants.We want her to fully understand her options so she makes an informed choice."

"Some of the women I meet have just been diagnosed with breast cancer," says Joanne Lenert, MD, a plastic surgeon at GW Hospital. "They're receiving a lot of information at a very difficult time.

"Everyone is a little bit different," she says. "Every patient has different goals and priorities, so the decisions vary."

There are two areas in which a woman must select a course of treatment. She must decide what type of breast reconstruction she would like and when to have the reconstruction done.

Two Ways to Reconstruct the Breast
The two primary types of breast reconstruction are:

Skin expansion and implant: This surgery is performed in two stages. In the first stage, an implant shell is inserted beneath the skin and chest muscle to expand the tissue and create space for a more permanent implant. A small port is placed beneath the skin where, over the next several months, the surgeon injects a salt-water solution to gently and gradually expand the tissue. This series of injections is done in the physician's office and begins about two to three weeks after surgery.

After the tissue over the breast area has stretched enough, a second surgery replaces the expander with a more permanent implant. Sometimes, the expander itself serves as the final implant.

"While the flap reconstruction requires more time and energy in the beginning (than the skin expansion and implant option), once it's done, it's done. The initial surgery leaves you with a breast that has a very natural appearance." -- Joanne Lenert, MD

Flap reconstruction: "In this procedure, we take tissue from another area of the body and use it to recreate the breast mound itself," says Dr.Macht. Flap surgery can be done by removing tissue, called a "free flap," entirely from the body and reattaching the free flap to the body in the breast area. More commonly, surgeons tunnel the tissue from its original site, usually the back or abdomen, through the body to the breast area. "This keeps the blood supply to the tissue intact," Dr. Macht says.

A flap reconstruction is a complex operation that involves an incision at an additional site on the body other than the mastectomy incision site. Recovery usually takes four to six weeks.

"While the flap reconstruction requires more time and energy in the beginning, once it's done, it's done," says Dr. Lenert. "The initial surgery leaves you with a breast that has a very natural appearance.

"Of course, with the implant surgery we are only operating at one site, so there are no scars or risks at any other body site," she says."With implants, the risks are different: leak or rupture, infection and capsular contracture (tightening of the scar around the implant causing hardness of the implant and pain). The patient must weigh the pros and cons and choose what is right for her." She adds that, in certain circumstances, flaps and implants can be used together.

When breast reconstruction is complete, the breast mound will be in place but not the nipple or areola, the dark area around the nipple."Another surgery must be performed to create the nipple and areola," says Dr. Lenert.

Additional surgery may be needed if the size or shape of the reconstructed breast does not match the other breast. A surgeon may recommend an operation to enlarge, reduce or lift the natural breast to match the reconstructed breast.

"The optimal scenario for breast reconstruction involves a well-informed patient who has a favorable lesion that doesn't require additional radiation or chemotherapy, and whose breast can be reconstructed with either an implant, expander or flap," Dr. Macht says.

"She should be a nonsmoker who has no other medical problems that might interfere with healing," he adds.