Breast Reconstructive Surgery: During or After a Mastectomy?

Dr. Jones: Disfigured, mutilated. These are words that are the way some women feel after mastectomy, the extensive surgery for breast cancer. What can we offer women who have had this surgery, to help them recover their self-image?

Different Options after Breast Cancer Diagnosis

Dr. Jones: About a quarter of a million women will be diagnosed with invasive breast cancer in the US this year. Some will choose a smaller operation, a lumpectomy, but many will choose a larger surgery in their hope for a cure. And the percent of women choosing mastectomy is increasing. Although we're grateful for the treatments that can cure breast cancer, mastectomy can leave a woman and her body image profoundly changed. The Scope's Seven Domains of Women's Health team is in the office. I've Dr. Agarwal, a breast reconstructive surgeon at the Huntsman Cancer Institute, and we're going to talk about breast reconstructive surgery. So, Dr. Agarwal, tell us a little about your training. How is it different from a breast cancer surgeon, the person who did the mastectomy?

Dr. Agarwal: Well, I'm a plastic and reconstructive surgeon so my role is to try and rebuild. After a patient undergoes a mastectomy by the breast cancer surgeon, I work with the patient to try and then rebuild the breast. And this can be really any part of the body. As a reconstructive surgeon, our goal is to try and restore form and function for a patient.

Breast Reconstruction While Getting a Mastectomy

Dr. Jones: Can you do the reconstruction at the time of the mastectomy, or are there advantages of doing it immediately versus delayed?

Dr. Agarwal: You can do the reconstruction at the time. We often, in fact, start the reconstructive process on the same time, in the same operative setting as the mastectomy surgery. Sometimes, it's a staged operation in which the first stage is started at the time of mastectomy and then the subsequent stages occur in the future. And sometimes, you can complete the entire reconstruction all in one setting.

There are advantages and disadvantages to doing it all at once. Some patients like the idea of just having one operation or, at least, having one operation where the majority of the surgery is done. Some patients like waking up from the operating room with the start of a creation of a breast, rather than waking up with a flat chest. The downsides are it does add surgery time and does add recovery time to the operation, but, in general, we're starting to see an increase in the number of patients that are having reconstruction that is initiated at the time of mastectomy.

Dr. Jones: Right. So women actually use to think of reconstruction as something that came to them six months or a year later when they felt like they were cured of their cancer and they were really ready to go on with the next step of their life. But now I think women are expecting to walk out knowing that they're going to feel a little bit more like themselves.

Dr. Agarwal: I think that's true. I think, in the past, reconstructive surgery was often considered something that was not part of the cancer care process of a patient. And today, reconstructive surgery and the role of a reconstructive surgeon are really integral into the entire comprehensive care of a cancer patient.

New Technology in Breast Reconstruction

Dr. Jones: Right. So what's changed with our new tissues, new materials?

Dr. Agarwal: The types of surgeries we do and the technologies that we have have improved. We don't quite have the 3D printing of a breast down yet, although we may get there in the near future. But the quality, the implants, the implant material, and the ability to use tissues from different parts of the body has really improved dramatically over the past 15 years.

Dr. Jones: So we're using some of the woman's own tissues for some of the breast, and some implants, or combinations?

Dr. Agarwal: Both scenarios. So patients can have implants only, their tissue only, or a combination of implant and their own tissue. And that sort of depends on their body, their choices, and what may be the best option. And that often requires a discussion with their surgeon.

Single Vs. Double Mastectomy

Dr. Jones: Well, honestly, Dr. Agarwal, as a woman, my personal fear about mastectomy, with or without reconstructive surgery, would be that I would be asymmetrical, that I'd have one normal breast and one plastic breast, and I just wouldn't be balanced. And I feel that breast had betrayed me already, and I wouldn't want to have breast cancer in the other breast. So I might ask you as if I were your patient to just do them both, so make them, when we're done, they can both look the same and be the same. Are you getting more requests? Does this sound crazy?

Dr. Agarwal: This isn't crazy. In fact, we're getting an increasing number of requests for bilateral mastectomy and reconstructions. And it's a very personal choice, it's not a choice that every woman makes, and it's not an easy choice. I think there are a lot of factors that go into it. Fear is, by far, the biggest factor. Patients exactly like you said, patients are worried that they might develop cancer in their other breast, or they're always going to be nervous and can't sleep at night and so they want to be free of that fear. And that's a real consideration when we consider doing a bilateral mastectomy.

I will say, though, just like any surgery, you have to be prepared that the more surgery you do, the more recovery, the more potential for a problem. So think carefully, talk to your surgeon, talk to your family before you make these decisions.

Dr. Jones: Fears of cancer and fears of disfigurement may lead women to avoid mammograms or seeking medical help if a lump is noticed. There are many more options for women as they face the challenges of breast cancer, and challenging, and living after a breast cancer treatment. Dr. Agarwal, thanks for helping us and think about our options, and thank you for joining us on The Scope.

updated: June 17, 2021
originally published: October 22, 2015