[2023-11-06] Breast reconstruction options

I've been simultaneously looking forward to and dreading today. I returned to The Ottawa Hospital to meet with Dr. Zhang, the plastic surgeon who installed my breast implants on July 7, following my prophylactic bilateral mastectomy, and who removed my right implant on July 27, following an infection. While I've met with Dr. Zhang a few times since July to monitor my recovery, today was my first opportunity to spend a significant chunk of time with her focused exclusively on next steps.

I met her in her office at 1:00 PM. She took me in right away, telling me she had set aside an hour for our discussion. I was grateful, as I had lots of questions.

I had prepared for our meeting by spending the morning doing research into the options for breast reconstruction. For months, I've been thinking about the possibilities. Not a day went by that I didn't think about what I would choose, when the time came to choose. When worries crept in, I would shoo them away with the simple response: "I don't have enough information yet." But I waited until today to do in-depth research because I didn't really want to think about what's to come. I suppose I'm still a little sad that I'm in this position at all.

But today was the day to get better informed. I knew that I would have a more productive appointment with Dr. Zhang if I prepared for the discussion, read up on the options—along with their risks and implications—and wrote down my questions. Planning and research often make me feel more calm. Such was not the case today. I felt nervous. None of the options I read about were without downsides. It reminded me of my decision to have a prophylactic bilateral mastectomy in the first place: doing nothing was a risk, doing something was a risk. I'm just in the messy middle, I concluded.

Through my discussion with Dr. Zhang, we identified three reconstruction options and one back-up plan.

Three options and a back-up plan

Option 1 - Autologous breast reconstruction for both breasts

As per the Canadian Cancer Society, "Autologous breast reconstruction uses skin, fat and sometimes muscle from other parts of your body to create a new breast." In this option, Dr. Zhang would use skin and tissue from my belly to fashion new breasts. Given that I don't have a lot of extra tissue on my belly, my recreated breasts would be smaller than my original breasts, and smaller still than my existing implant. "So, about a B cup?" I asked her. "Maybe more like a B+," she said. I smiled. "Or an A-," she suggested. Read: small.

This option has several advantages:
  • This surgery would use my own tissue and the resulting breasts would feel softer and more natural than a breast with an implant.
  • The reconstructed breasts would grow with me: if I were to gain weight, they would grow; if I were to lose weight, they would shrink.
  • It would be easier to achieve symmetry between both breasts.
  • This type of surgery would avoid implant-related infections and implant-related complications, such as leakage.
  • This option would eliminate the need for additional surgery to replace implants in 10-15 years should they wear out.
It also has several implications and risks:
  • It would be a lengthy surgery: 6-8 hours.
  • It would require a hospital stay of at least 2 nights—typically 3—and as many as 4 or 5 nights.
  • Recovery would take 2 months, with no heavy lifting (nothing more than 5 pounds) for 6-8 weeks.
  • I could experience pain, tightness and weakness in my belly as well as bulging of the abdominal muscles in the area where the tissue would be removed, and issues with healing, though this is reduced because the type of surgery proposed (DIEP flap) spares the abdominal muscle.
  • Risks include death of the transplanted tissue (1%), blood clots (1-2%), infection (1-2%), hernia (1-2%), bulging of the abdominal muscles (5%) and issues with healing of the abdominal incision (10%).
On the one hand, the reconstructed breasts would be small; on the other, they would be less prone to sagging over time.

Option 2 - Autologous breast reconstruction (right breast only) and retention of existing implant (left breast)

As with Option 1, this would entail the creation of a breast using tissue from my belly, but since only one breast would be constructed (the right one), it could be bigger—the size of my existing implant. If the new breast were smaller than my existing implant, Dr. Zhang could replace my left implant with a smaller one as part of the same surgery.

The biggest advantages of this option—as I see them—are that it would maintain a breast size more consistent with what I've had to date and it would take advantage of the progress I've made with my one successful implant. The disadvantage—I believe—is that I would be more likely to experience a mismatch between my breasts, though I have a lot of confidence in Dr. Zhang's abilities as a surgeon. What would happen if I lost or gained a lot of weight? Would a breast constructed from my tissue behave the same way over time as a breast constructed with an implant (in other words, what impact would aging have on different breast types)?

Option 3 - New implant using a back flap (right breast only) and retention of existing implant (left breast)

This option would supplement my existing right breast skin—which has shrunk since the explant—with a flap of skin, tissue and muscle from my back, and would involve installing a new implant to match my existing implant.

The advantage of this option over a tissue expansion implant is that it could be achieved in one surgery. A tissue expansion implant would entail one surgery to install an expander implant and several visits to the surgeon to slowly increase the size of the expander implant through the addition of saline through a needle inserted through the skin and into the valve of the expander implant. Once the breast skin has been stretched to the desired size—typically several months later—a second surgery would be needed to replace the expander implant with a more permanent implant.

On the upside, the single surgery using a back flap and implant would be a 3½ surgery, as it would not require the same level of microsurgery as Option 1 because the back tissue would be swung around to the front, as opposed to cut away and transplanted. This option would eliminate the need to touch the right breast (with the exception of doing a nipple lift, which would also be part of Option 2). It would require 1 night in hospital. On the downside, I might experience more tugging and pulling through the back, and I would have a big scar on my back (as opposed to on my belly).

Back-up Plan - Aesthetic flat closure

I indicated to Dr. Zhang that I would be prepared to go flat. Such an option—called an aesthetic flat closure—would entail a surgery to remove the extra fat, skin and other tissue in the breast area and to tighten and smooth out the remaining skin and tissues to achieve a flat chest. While it is an option, we agreed to keep it as a back-up for now.

Conclusion (for the moment)

In recent months, I've used the analogy of feeling like I have one foot on the dock and one foot in the boat: an inflated breast on the left (where I have the implant) and a deflated breast on the right (where I had the explant). Should I try to go back to two generous breast implants (Option 3), choose to retain one implant and add a comparably sized breast reconstructed with my tissue (Option 2), or go forward to two new much smaller breasts reconstructed with my tissue (Option 1)?

As Dr. Zhang and I spoke, I increasingly leaned towards Option 1, as did Dr. Zhang given my desire for symmetry (an option where both breasts are the same) and to maintain as much strength in my body to simply live life. Dr. Zhang noted that autologous breast reconstruction, using a DIEP flap, is mature, having been done for as many as 20 years. She has been doing such surgery for about 10 years, with almost 100% success (no insurmountable complications). She acknowledged that it would be more challenging to go the route of using a tissue expander and/or a back flap plus implant.

The right answer is not obvious to me. Dr. Zhang put no pressure on me to make a decision. Neither she nor I saw today as a decision-making conversation. It was about understanding the options, asking questions, and expressing my wishes. She listened patiently, allowed me time to take notes (I came prepared with research, questions and a laptop), and confirmed my comprehension as I repeated back to her what I was hearing. In the end, she spent more than an hour with me. I had no idea that we had talked for that long.

I indicated that I would speak with others who have chosen one of the various options I'm contemplating. She supported and encouraged this work. We agreed that I would return on another occasion to pose additional questions and then sign the paperwork. Surgery could occur in the first half of 2024.