Most mastectomy patients are medically appropriate for reconstruction, many at the same time that the breast is removed. The best candidates, however, are women whose cancer, as far as can be determined, seems to have been eliminated by mastectomy. Still, there are legitimate reasons to wait. Many women aren't comfortable weighing all the options while they're struggling to cope with a diagnosis of cancer. Others simply don't want to have any more surgery than is absolutely necessary. Some patients may be advised by their surgeons to wait, particularly if the breast is being rebuilt in a more complicated procedure using flaps of skin and underlying tissue. Women with other health conditions, such as obesity, high blood pressure, or smoking, may also be advised to wait. In any case, being informed of your reconstruction options before surgery can help you prepare for a mastectomy with a more positive outlook for the future.

Virtually any woman who must lose her breast to cancer can have it rebuilt through reconstructive surgery. But there are risks associated with any surgery and specific complications associated with this procedure. In genral, the usual problems of the surgery, such as bleeding, fluid collection, excessive scar tissue, or difficulties with anesthesia, can occur although they're relatively uncommon. And, as with any surgery, smokers should be advised that nicotine can delay healing, resulting in conspicious scars and prolonged recovery. Occasionally, these complications are severe enough to require a second operation.

If any implant is used, there is a remote possibility that an infection will develop, usually within the first two weeks following surgery. In some of these cases, the implant may need to be removed for several months until the infection clears. A new implant can later be inserted. The most common problem, capsular contracture, occurs if the scar or capsule around the implant begins to tighten. This squeezing of the soft implant can cause the breast to feel hard. Capsular contracture can be treated in several ways, and sometimes requires either removal or "scoring" of the scar tissue, or perhaps removal or replacement of the implant.

Reconstruction has no known effect on the recurrence of disease in the breast, nor does it generally interfere with chemotherapy or radiation treatment, should cancer recur. Your surgeon may recommend continuation of periodic mammograms on both the reconstructed and the remaining normal breast. If your reconstruction involves an implant, be sure to go to a radiology center where technicians are experienced in the special techniques required to get a reliable x-ray of a breast reconstructed with an implant.

You can begin talking about reconstruction as soon as you're diagnose with cancer. Ideally, you'll want your breast surgeon and your plastic surgeon to work together to develop a strategy that will put you in the best possible condition for reconstruction. After evaluating your health, your surgeon will explain which reconstructive options are most appropriate for your age, health, anatomy, tissues, and goals. Be sure to discuss your expectations frankly with your surgeon. He or she could be equally frank with you, describing your options and the risks and limitations of each.

Your oncologist and your plastic surgeon will give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and taking or avoiding certain vitamins and medications. If your surgeon recommends the use of an implant, you'll want to discuss what type of implant should be used. A breast implant is a silicone shell filled with either silicone gel or a salt-water solution known as saline.

While there are many options available in post-mastectomy reconstruction, you and your surgeon should discuss the one that's best for you.

Skin Expansion: The most common technique combines skin expansion and the subsequent insertion of an implant. Following mastectomy, your surgeon will insert a balloon expander beneath your skin and chest muscle. Through a tiny valve mechanism buried beneath the skin, he or she will periodically inject a salt-water solution to gradually fill the expander over several weeks or months. After the skin over the breast area has stretched enough, the expander may be removed in a second operation and a more permanent implant will be inserted. Some expanders are designed to be left in place as the final implant.

The nipple and the dark skin surrounding it, called the areola, are reconstructed in a subsequent procedure. Some patients do not require preliminary tissue expansion before receiving an implant. For these women, the surgeon will proceed with inserting an implant as the first step.

Flap Reconstruction: An alternative approach to implant reconstruction involves creation of a skin flap using tissue taken from other parts of the body, such as the back, abdomen, or buttocks, in one type of flap surgery, the tissue remains attached to its original site, retaining its blood supply. The flap, consisting of the skin, fat, and muscle with its blood supply, are tunnelled beneath the skin to the chest, creating a pocket for an implant or, in some cases, creating the breast mound itself, without need for an implant.

Another flap technique uses tissue that is surgically removed from the abdomen, thighs, or buttocks and then transplanted to the chest by reconnecting the blood vessels to new ones in that region. This procedure requires the skills of a plastic surgeon who is experienced in microvascular surgery as well.

Regardless of whether the tissue is tunnelled beneath the skin on a pedicle or transplanted to the chest as a microvascular flap, this type of surgery is more complex than skin expansion. Scars will be left at both the tissue donor site and at the reconstructed breast, and recovery will take longer than with an implant. On the other hand, when the breast is reconstructed entirely with your own tissue, the results are generally more natural and there are no concerns about a silicone implant. In some cases, you may have the added benefit of an improved abdominal contour.

Follow-up Procedures: Most breast reconstruction involves a series of procedures that occur over time. Usually, the initial reconstructive operation is the most complex. Follow-up surgery may be required to replace a tissue expander with an implant or to reconstruct the nipple and the areola. Many surgeons recommend an additional operation to enlarge, reduce, or lift the natural breast to match the reconstructed breast. But keep in mind, this procedure may leave scars on an otherwise normal breast.

Depending on the extent of your surgery, you'll probably be released from the hospital in two to five days. Many reconstruction options require a surgical drain to remove excess fluids from surgical sites immediately following the operation, but these are removed within the first week or two after surgery. Most stitches are removed in a week to 10 days.

Reconstruction cannot restore normal sensation to your breast, but in time, some feeling may return. Most scars will fade substantially over time, though it may take as long as one or two years, but they'll never disappear entirely. The better the quality of your overall reconstruction, the less distracting you'll find those scars.

Follow your surgeon's advice on when to begin stretching exercises and normal activities. As a general rule, you'll want to refrain from any overhead lifting, strenuous sports, and sexual activity for three to six weeks following reconstruction.