This year, nearly 192,000 women will hear their doctor utter those dreaded words, "you have breast cancer." Nearly all will have surgery, with roughly half having a mastectomy to remove one or both breasts. Most women facing this operation will see a plastic surgeon beforehand to hear about, even view, options for rebuilding their breasts that seem nothing short of miraculous.

Seventy-five percent of women who have a mastectomy opt to have what one surgeon removes, reconstructed by another. Plastic surgeons can insert implants made of silicone or saline. They can also take fat and tissue from a patient's abdomen and move it to the breast, with the advantage of creating a more natural look than implants (not to mention that it gives some women a "tummy tuck"). They can also take tissue from a woman's back, or, her buttocks.

"The majority of women who have their breasts removed due to cancer are candidates for reconstruction," says Neal Handel, MD, FACS, chief of plastic surgery at The Breast Center in Van Nuys, CA.

Considering all that is possible, why is it then that less than a decade ago most women who had mastectomies didn't opt for reconstruction, and went on to live without their breast? Some wore bulky cardigans or business suits. Others wore a breast prosthesis, so they could look natural in clothes. Yet, the devastating emotional effects of mastectomy are highlighted underneath it all when the natural female line every women calls her own is removed along with the cancer. Only a slim 8% of women who had mastectomies then had reconstructive surgery, according to a report in the January 2001 issue of The Journal of the American College of Surgeons.

The turnaround, breast surgeons say, has to do in large part with a new law that requires insurance companies to pay for breast reconstruction, and the fact that women are better educated about their choices.

The 1998 Federal Breast Reconstruction Law - sometimes referred to as the Women's Health and Cancer Rights Act of 1998 - requires group and individual health insurance plans to cover reconstructive surgery after mastectomy, as well as implants and other work needed to make the other breast symmetrical - that is, to make both breasts match.

The number of breast reconstruction procedures following mastectomy jumped more than 180% from 1992 to 1999, a year after the new law was passed, according to the American Society of Plastic Surgeons (ASPS). In 1992, ASPS figures show that 29,607 women had breast reconstruction performed, compared to 82,975 in 1999.

Reconstruction isn't just a matter of looking "normal" or "even" in a sweater. It can provide a much-needed psychological boost for a woman during a very emotional and stressful time. "Reconstruction can relieve patients of anxiety, depression, and fear of cancer," says Dr. Handel.

With so many benefits, you might wonder why some women still do not opt for reconstruction. After all they've been through with a mastectomy, some women simply don't want further surgery. Others may still have some fears about reconstruction.

In the mid-90s, Dr. Handel and his colleagues surveyed 158 mastectomy patients who visited The Breast Center to find out why so few women were choosing reconstruction. He and his colleagues originally were worried that lack of knowledge might be part of the problem - and they were right.

They found women tend to have two major considerations on their minds about reconstruction:

• Cancer recurrence. Among those surveyed who did not choose reconstruction, 34% were worried about increased cancer risk. "There have been a lot of studies to show that women who have breast reconstruction do not have a worse prognosis as far as cancer goes. There might be a slightly higher rate of complication, but it's not significant enough to discourage you from doing breast reconstruction," Dr. Handel says.
• Worries about complications and about the possibility of further surgeries. Forty-two percent of the women who chose not to have reconstruction in The Breast Center study expressed this anxiety. In addition, 58% who opted not to have reconstruction said they were uncertain about how natural the end results would look. Dr. Handel says reconstructed breasts look and feel more natural than many people realize.

"We try to hide the scars in the most cosmetically acceptable fashion so that a woman can wear any kind of clothing comfortably," he says, and that includes a bikini or halter-top. "You could undress at a health club or sauna and not be noticeable. Those are the best-case scenarios."

Much depends, he adds, on the patient's anatomy, the skill of the surgeon, and how much tissue has to be taken out. Reconstruction can be done at the time of the mastectomy, or until any additional treatment for breast cancer, such as chemotherapy or radiation, has been completed.

What are your choices?

There are different techniques for breast reconstruction, but two basic choices - using your own tissue to form a breast- (called autologous breast reconstruction) - or artificial implants. Whatever the choice, breast reconstruction is a multi-staged procedure.

"Almost every patient requires at least one additional operation," Dr. Handel says.

That one additional operation might be to have a new nipple made. Surgeons don't do that right away because they need to be sure it's in the right place. They typically wait several months later until swelling from the reconstruction goes down. A new nipple can be made from your skin (often from your inner thigh, since it's darker than breast skin) or by tattooing color into the skin at the nipple areolar site. Women may opt to have the surgeon lift or slightly augment the other breast during reconstruction.

What's right for me?

Breast cancer and breast reconstruction are personal issues. Do you want both breasts to match? Do you just want to look good in clothes, or are you just as concerned about how your breasts will look out of clothes?

"It's a patient's preference," Dr. Handel says. He points out that it's important to discuss all the options with your plastic surgeon, before deciding on what would be best for you.

There are anatomical considerations, too. For example, if you have a lot of extra tummy, and your other breast is large, you might opt for the TRAM (transverse rectus abdominus skin-muscle) flap. If you're thin and/or you have tight tummy muscles, you might be an ideal candidate for implants. And there are other factors. Can you handle a big operation and a long recovery period?

Reconstruction techniques

Artificial implants

In this method, an implant of silicone, saline (salt water) or a combination of both is placed in your breast pocket (the skin that is remaining after the mastectomy). If enough of your breast skin was saved, you can have a full-size implant inserted right away. Often, though, surgeons insert an empty silicone sack called an expander beneath the skin and chest muscles following the mastectomy. The expander, which has a small valve attached, is periodically inflated with saline injections through the valve for the next several months. After the breast skin has been sufficiently stretched, the expander is removed and replaced by a permanent implant.

The pros: This option involves a shorter operation, which means less time under anesthesia and usually less blood loss, plus a quicker recovery time. Also, there is less scarring.

The cons: Reconstructions involving implants have a greater long-term complication rate, such as hardening and pain - caused by capsular contracture - and do not look or feel as natural as our own tissue.

Ruptures of implants may occur, although considerable force is needed to rupture an implant in good condition. There's no evidence that ruptured saline implants can hurt you. Implants filled with silicone gel were restricted in 1992 after hundreds of thousands of women filed lawsuits claiming the silicone had leaked into their bodies and caused connective-tissue diseases and other health problems. Few studies, however, have found any link between the gel implants and the illnesses. Implants do gradually deteriorate in time in some patients, and most need to be replaced over a patient's lifetime.

The TRAM flap

The so-called TRAM flap operation involves using a flap of the abdominal skin, fat, and muscles below the belly button to create a breast mound. Most commonly, the skin and fat remains attached to one or both of the rectus abdominus muscles, which provide its blood supply, much like an electrical cord supplies power for an appliance. The transferred skin and fat is shaped to resemble the opposite breast or into two breasts if both breasts have been removed. The abdomen is closed and leaves a scar that extends from hip to hip, much like that seen in a "tummy-tuck" operation.

The pros: Because your own tissue is used, your reconstructed breast looks and feels more natural. No foreign material is put in your body. Also, if you gain or lose weight, your reconstructed breast will get bigger or smaller just as your intact breast - unlike artificial implants.

The cons: A longer surgery time is involved (4 to 6 hours), as well as a longer recovery period. Since tissues are tunneled to the breast, all the tissue en route is disturbed. A hip-to-hip scar remains and the muscles in your abdomen are likely to be permanently weakened.

The latissimus muscle flap

Like the TRAM flap, this technique involves use of your tissues, only instead of taking tissues from the abdomen, the surgeon uses a large, flat, broad muscle from the back that lies across your shoulder blades, the latissimus dorsi muscle, and overlying skin. Although the skin and muscle may provide sufficient bulk to reproduce a small breast, an implant is usually needed to restore a larger breast. A scar remains on the back but can sometimes be designed to hide under a bra strap. Some flattening of the back remains from removal of the muscle, but use of the arm remains essentially unimpaired. Otherwise, the pros and cons of this surgery are similar to that of the TRAM flap - a more natural-looking and -feeling breast, with longer surgery and extended recovery period.

Free flap

Free flaps can be done by transplanting tissue from the abdomen, buttock, back, or thigh to make a new breast. Unlike the other flap operations, the tissue does not stay attached to its original location. It is removed and transplanted into the breast. The operation is much harder, because the surgeon has to be skilled at microsurgery (sewing blood vessels together under a microscope). While the free flap represents the most sophisticated and complex method of breast reconstruction, it is not available everywhere.

The pros: Like the other flap operations, it provides a more natural-looking and -feeling breast. Less tissue is taken out, the tissue in-between doesn't have to be disturbed, and because it is removed, rather than tunneled through the body, tissue can come from anyplace there's extra fat or tissue, such as the unwanted saddlebags on your thighs.

The cons: Not all plastic surgeons are expert at it. It involves 5 to 8 hours of surgery, and you'll probably be in the hospital for 4 to 7 days. Part of the tissue in the flap can die off, necessitating further surgery.