When attorney Barbara Gay found a lump on her breast, she went to her doctor for an evaluation and was referred to a surgeon to have a biopsy. It took a week before the results came in. "I remember he looked at me and said, 'You have breast cancer,' then he spun his stool around and wrote a note in the chart and handed me a piece of paper with an appointment to have it removed." Barbara didn't know what her options were or where to go for help. That was seven years ago. She had two lumpectomies, because the first surgery missed some areas of cancer, chemotherapy every three weeks for six sessions and six weeks of radiation five days a week. She sought out a support group and learned from other women about treatment options and their experiences. "Everybody is really different as to the risks they're willing to take, the amount of surgery they are willing to undergo, the amount of time they can take off work and their insurance coverage. I wanted to work as much as possible during the treatment. I wanted things to be as normal as possible, and I also feared losing my job and health insurance. Several women in my support group had the same issues. Many women I've known who have breast cancer are limited in their treatment choices by the kind and amount of insurance they have. Insurance companies used to fight covering an overnight stay in the hospital after a mastectomy or breast reconstruction, which is a form of plastic surgery." Many women opt for a mastectomy because they live too far from anywhere they can get radiation treatment daily for six weeks, which is required when one goes the lumpectomy route. In 2005 when Barbara was diagnosed, implants were the most common form of reconstruction and the choice was between saline and silicone, both of which had significant drawbacks. "Members of my support group discussed the pain involved with the insertion of the spreaders in the chest, which were gradually expanded to accommodate the implants." Implants also come with risks such as rupture and infection, and they have to be replaced after roughly 10 years, requiring more surgery. Dale, who is now in her seventies, has been dealing with the aftereffects of implants since she was diagnosed with breast cancer 14 years ago. "In l998 I had a lumpectomy, chemo and radiation, and then the cancer came back. In 2010 I had bilateral mastectomies, and then had implants put in. My left chest kept collapsing and getting infected. I was on so many rounds of antibiotics. The implants were removed, and then I went back to the doctor. I was sitting in my hospital gown, and he said to me, 'You're a nice lady, but I'm sorry, there is nothing more I can do for you.' He handed me a piece of paper with the names of other doctors on it. I was shell-shocked. The next day he disappeared, and no one knows where he is." Dale has had to go for hyperbaric treatment for the chest infection and now has an opening in her chest that won't close. "I've had three operations in three and a half weeks. I am now going to a doctor who specializes in latissimus flap surgeries, which my other doctor did not specialize in." Women today have many more options available to them than they did when Barbara and Dale were diagnosed. As Barbara commented, "The point is that a breast cancer diagnosis doesn't automatically entail mastectomy and reconstruction. There are often a series of decisions to be made-lumpectomy vs. mastectomy, reconstruction vs. prosthesis, implants vs. flap." Newer procedures starting to gain favor are the tissue-flap procedures, in which tissue is removed from the abdomen, back, thighs or buttocks to rebuild the breast. The two most common types of flap procedures are the TRAM flap or transverse rectus abdominis muscle flap, which uses tissue from the lower abdomen, and the latissimus dorsi flap, which uses tissue from the upper back. In both of these cases healthy blood vessels are needed for the tissue's blood supply, so flap procedures are not usually offered to women with diabetes, connective tissue or vascular disease, or to smokers. In a TRAM flap, the skin, fat, blood vessels and at least one abdominal muscle are removed from the abdomen to the chest wall. There are two types of TRAM flaps: a pedicle flap, in which the flap is attached to the original blood supply and tunnels it under the skin to the breast. The other is a free flap, in which the flap of skin, fat, blood vessels and muscles for the implant are cut from the original location and then reattached using microscopic surgery to connect the vesicles. This procedure is a longer process and not done as often, but it can result in a more natural shape to the breast. The latissimus dorsi flap moves muscle and skin from the upper back and is tunneled under the skin to the front of the chest. The side effects of this are pain and weakness in the back, shoulder and arm after surgery. A newer form of surgery-the nipple-sparing procedure-has been around for about five years, but it's not appropriate for all patients. In this procedure, the patient's breast skin, areola and nipple remain. An advantage of this procedure is that the breast remains more cosmetically attractive. The disadvantage is that the nipple and areola lose sensation. Dr. Deborah Axelrod, associate professor of clinical surgery and the director of clinical breast services programs at NYU Langone Medical Center, specializes in this type of surgery. "This kind of surgery is really for those women who do not have cancer by the nipple but have it peripherally. Someone who had cancer close to the nipple or imaging that showed areas close to the nipple would not be a good candidate, and someone with very large breasts is also not a good candidate." The procedure is long and can last up to eight hours, depending on the breast reconstruction performed. Axelrod describes it as being "like an envelope-you are taking the letters out and leaving the envelope, so you are leaving the envelope of skin intact. The nipple stays on the skin, but it is also biopsied to make sure there is no cancer." Axelrod acknowledges that women have changed the way breast cancer has been treated. "Women don't want to be slashed. There is now a team approach to the conversation between the plastic surgeon and the oncologic surgeon to design something so that every time a woman looks down at her chest, she won't be reminded that she had this horrible surgery or that she had breast cancer. Women say that they feel much more whole and not as hollow." She does caution that there are not many long-term studies on this type of procedure. With any kind of surgery, it is important to do your research, ask questions and find a physician who is not only experienced but with whom you feel comfortable, as Patty Harold, an attorney in Long Island, shared with me. Her breast cancer was discovered after she fell off a bike. Patty had a lumpectomy as an outpatient and opted not to have plastic surgery. "My advice would be to make sure you have a surgeon whom you have ultimate confidence in. I loved my surgeon and I was less scared because of her. I also think women should bring someone along who can act as their 'ears.' Even though the doctor is speaking to you, somehow it is hard to hear. I had friends and family take turns in visiting doctors with me so they could listen, take notes and help me make decisions when needed."