So you have just received the shocking news that you need a mastectomy. Once the information has settled, maybe on another day, your doctor and breast care nurse will have a range of options for you and booklets. I’m going to lay things out exactly the way I do in clinic. the BCN (breast care nurse) may have given you the Breast Cancer Care booklet (Breast reconstruction | Breast Cancer Now) There are three basic options and I shall lay them open as simply as I do if you were sitting in front of me

Living Flat

So living flat is a good option for many reasons. It basically means removing your breast tissue but also the areola and nipple and reverting your shapely chest to a smooth surface. This enables the BCNs to be able to fit in prosthesis (fake silicone breast form) that can slip into a specially made bra (available widely now) or even swimming costume. Underneath your clothes you would find it difficult to know you were flat.

The other advantages of living flat are that the operation to go flat carries the lowest list of complications, and leaves the door open for a reconstruction at a later date if you are not ready right now for psychological or medical reasons. There is a website called flat friends for women who have chosen to live flat long term called Flat Friends that is really fantastic (flatfriends.org.uk).

Immediate Breast Reconstruction

So again, we remove the breast tissue, again we take away the nipple and areola, but the difference with doing a reconstruction at the same time as the mastectomy means that we leave the envelope of breast skin and then its just a matter of how we fill the space left behind by the breast. The advantages to having an immediate breast reconstruction are that you wake up having lost a breast but with a mound of implant or flesh that is a semblance of a breast. Psychologically, studies show that this helps women with the sadness associated with losing a breast – having something in its place. It also helps with the recovery. The downsides are that all kinds of reconstruction involve more surgery and more anaesthetic time and the risks associated with those. There is also the very real risk of reconstruction failure which can be devastating for the patient. to go from having a reconstruction to going flat, when that was never their intention. All patients having an immediate reconstruction must accept the risk of reconstructive failure.

Implant-Based Reconstruction

This can either be done as an immediate breast reconstruction or as a delayed reconstruction (go flat first and have an implant later). To fill the space left by the mastectomy, an implant is used to fill the space. I will measure you beforehand as there are many sizes and shapes of implants to choose from. sometimes we use a mesh or “matrix” to hold the implant in place. It is beyond the scope of this introduction, but I sometimes use something called an expander which is a temporary implant that can be expanded. The situations where this might be useful are if the lady wants to go larger, or maybe isn’t sure. Some types of implants can stay in as long as regular saline implants whereas some are designed to be the first step in a two-stage plan, where the second stage is swapping the exoander for a definitive silicone implant. The upside of implants is that people tend to be up and about faster as there is no second tummy tuck scar (see below) but people tend to need implant changes every 12-15 years or so.

Own-tissue reconstructions “tummy-tuck” or “thigh” fat

This can be done again as an immediate reconstruction or delayed, but usually at the same time as the mastectomy. As I do the mastectomy, the plastic surgeon takes fat from the tummy as if doing a tummy tuck. In the space left after the mastectomy , the plastic surgeon immediately fills the space with tummy fat (as if having a tummy tuck) or thigh tissue (as if having a thigh lift). After years of research, it was discovered that these pieces of fat from certain other parts, have blood vessels that can be joined up with ends left by me up in the chest. When the two ends have been joined, the fat from the tummy or thigh “takes” in its new position as a pretend “breast”. This type of ryeconstruction is popular as the new breast mound feels warm, is soft and ages similarly to the other side.

What to Choose?

Ultimately, the choice is yours and your surgeon and nurse will help you. Some types of reconstruction require you to have a certain BMI for anaesthetic reasons. All sorts of reconstruction tend to do badly in smokers. Take your time deciding, there are plenty of forums and my plastic surgery team will even introduce you to other patients who have had reconstructions.