Options and resources for breast reconstruction after mastectomy

Breast reconstruction is an option for women and men after having a mastectomy due to a breast cancer diagnosis. It is also a consideration for women who have tested positive for a BRCA gene mutation and wish to have a prophylactic mastectomy to greatly decrease the chances of getting cancer. Breast reconstruction is a personal choice, a choice that is not for everyone, but a choice that everyone deserves to know about. So what are the options for breast reconstruction? There are three types:

1. Reconstruction using implants, either saline or silicone gel.
2. Reconstruction using your own tissue called autologous reconstruction.
3. Reconstruction using a combination of implants and autologous tissue.

It is important to research all options before deciding on a method to consider. There are reasons why you may choose one option over the other. There are still many challenges that individuals face when it comes to considering their reconstruction preference. They might include the following:

1. Your overall health and the stage of your breast cancer. You may have an advanced breast cancer that requires adjunctive therapy before reconstruction begins. Radiation can also delay reconstruction. Treating your cancer should always take precedence over reconstruction. Talk to your plastic surgeon about this and they should guide you through a shared decision-making process to optimize your health before surgery and decide on the best option of reconstruction for you.
2. Availability of a qualified plastic surgeon and a medical facility that performs reconstruction that is geographically nearby can be a deterrent to some due to lack of funds for travel or fear of travel after surgery. Although medical travel can be claimed as a tax deduction it is an out of pocket expense for breast reconstruction if there is not a qualified surgeon or facility nearby. This is a particular challenge for those in rural areas.
3. The area of resulting scars from surgery is also of concern to those seeking reconstruction. There is a difference in scar placement in the three types of reconstruction and this is an important and personal consideration for many.
4. Support in recovery after surgery. Not all individuals have family, friends or local support nearby to help them with post-reconstruction recovery and care.
5. Time off work. Women must consider a possible 4-6 weeks off work for recovery depending on the type of reconstruction they choose. This may vary for men and again the complexity and type of surgery chosen will depend on the time needed to be away from work to allow time to fully recover.
6. Insurance. Although a 1998 federal mandate requires reconstruction to be covered by insurance, there are those still facing barriers with insurance coverage depending on the facility and what insurance is carried by that facility.

The passage of the Breast Cancer Patient Education Act in December of 2015 hopes to not only educate a larger populous of men and women about their breast reconstruction options but also speak to many of these challenges that are faced in making a decision to have reconstructive surgery after breast cancer or for prophylactic reason due to a BRCA gene mutation. As with any new educational initiative, this will take time and implementation but there is greater hope that we can reach a broader audience and continue to educate and inform about options with the passage of the Breast Cancer Patient Education Act.

There are many resources available to begin research for what choice might be considered for breast reconstruction. There are survivors and advocates who write informative blogs about their own breast reconstruction experience and provide helpful information from how they chose their surgeon and continuing through to the recovery process.

Travel assistant programs are available for patients but you must call to find out if you are eligible. There are also 501c3 groups who assist women with travel in breast reconstruction. Below are just a few of those travel resources:

• Patient Airlift Services
• Angel Flight
• Mercy Medical Angels, Medical Transportation Services
• Alliance in Reconstructive Surgery Foundation

It is imperative to be your own best advocate. This can be a daunting task when you are faced with a breast cancer diagnosis. You are inundated with information about your diagnosis and treatment and sometimes reconstruction is the last thing on your mind. You just want the cancer to be gone. However, you may very well want to consider reconstruction at some point in the process. It is to your benefit to consult with a plastic surgeon soon after your diagnosis to consider your options and timing.

An important question to ask when you have been told you are facing a mastectomy is, "What are my reconstruction options if I choose to have my breasts rebuilt after my mastectomy?" Every woman and man diagnosed with breast cancer has the right to this information to move forward with making an informed decision. Your radiologist, breast surgeon, or oncologist may just have a connection or name to a board certified plastic surgeon for you to talk to.

The American Society of Plastic Surgeons has a "surgeon finder" on their website with board-certified plastic surgeons who perform breast reconstruction. If you are considering autologous reconstruction, the American Society of Reconstructive Microsurgery also has a "surgeon finder" for patients. When choosing autologous reconstruction it is important to find a microsurgeon, a specialty in plastic surgery that requires a specialized fellowship and further training.

Important questions to ask your plastic surgeon, whether for implant based or autologous reconstruction include but are not limited to the following questions:

• How many procedures have they performed?
• What is their success rate?
• Do they work with a team? The shared expertise is a factor as well and often minimizes time for the patient in surgery.
• Do they have before and after photos?
• What aesthetic outcomes can I expect based on my individual health history and case?
• What type of insurance carriers do they take?
• Will they accept insurance from out of state? These laws are tightening and it is a good question to ask as many patients travel across state lines to find the most qualified surgeon.
• Do they balance bill? Balance billing is when a surgeon sets a fee and asks the patient to pay the remaining amount not covered by insurance. This is not the case at every facility but it is an important question to ask.

Breast Reconstruction does not involve one surgery in most instances. It can take two or more surgeries to complete the process and time to heal and recover in between surgeries. Revision and symmetry phases, as well as nipple and areola rebuilding or tattooing (for those who have not had a nipple-sparing mastectomy – NSM), can be part of this process.

There is a lot that goes into the planning process of this surgery but reaching out for help makes it an attainable goal. Many have had it done successfully and the hope is that this will continue to be an attainable goal for more as the science and developments in breast reconstruction continue.

For more information, including a list of ASPS plastic surgeons in your community, please use our Find a Plastic Surgeon tool.

Please join Dr. David H. Song (@DrDavidSong) and Terri Coutee (@6state) on Twitter this Monday (Feb 22) at 9pm ET for their #BCSM tweet chat. For more information on how to be involved with this tweet chat, please check out the #BCSM guide to tweet chats.