12:29 PM EST on Tuesday, January 31, 2006

Both of Kerry Herman's parents had cancer. Her mother survived breast cancer that was treated when she was 48, and her father died of colon cancer at 51.

In October, at the age of 55, Herman learned that one of the "hot spots" in her breasts was an early noninvasive cancer.

Instead of just having that area treated, she opted to have both breasts removed and reconstructed.

"I didn't want to worry for the rest of my life, and have to undergo periodic biopsies," said Herman, who lives in Brooklyn, N.Y., and is the mother of a high school student.

She took several weeks to research the matter, discussing it with her husband, with a gynecologist and an internist, and then with a breast surgeon and a plastic surgeon.

All supported her decision. Her husband told her: "It's your body. It's not up to me to tell you what to do with it."

Herman also spoke with several women who'd had breast reconstruction -- women who, like her, had been physically active before their surgery and wanted to remain so.

Total mastectomy with reconstruction is becoming an increasingly popular choice, among women with cancer and among those with an unusually high risk of developing it.

Deciding to undergo breast reconstruction -- whether at the time of mastectomy, or months or even years later -- is not as straightforward as you might think. There are emotional, physical, medical and sometimes financial matters to consider.

"I knew that with reconstructed breasts, I'd be different from what I was, but I'd be more like everyone else," Herman said. "There will be a new normal."

The decision was less a matter of vanity, she said, than of wanting to feel whole and not feel awkward getting undressed at the Y. Having seen her mother's breast prosthesis, she did not like that option, though many women deal well with it.

Like Herman, Barbara Resnick, an assistant professor at the University of Maryland School of Nursing, who was 41 when her breast cancer was discovered, decided on a double mastectomy and reconstruction.

"Looking good and feeling comfortable in a T-shirt or swimsuit mattered to me," she said in The American Journal of Nursing, in an article she wrote with Anne E. Belcher, who is now at Johns Hopkins School of Nursing. But, Resnick continued, "putting on and taking off the external prostheses didn't appeal to me."

A woman should be encouraged "to imagine how she'll feel performing a particular daily task, such as pulling a shirt over her head, without one or both breasts, with a prosthesis, or with a reconstructed breast," the nurses wrote.

They also suggested that she look at pictures of women who've had reconstruction, and talk to at least one woman who opted not to.

Reconstructed breasts may look as good as natural ones, but they will not be sensitive to sexual stimulation and they cannot nurse a baby.

Women considering reconstruction should also know that -- even when it is done at the time of mastectomy -- more than one operation is usually needed.

For those who choose implants, adjustments and even replacements may be required (implants don't last indefinitely); a nipple may be constructed; and surgical changes to the normal breast may be needed, to produce a better match.

Similarly, the other approach to breast reconstruction -- using tissue from the woman's own body -- is, in effect, two operations at once. And nipple construction and adjustments to the second breast still may be desired.

The timing of reconstruction may be influenced by a woman's need to undergo radiation therapy, because radiation increases the risk of postoperative complications. Obese women may be advised not to have reconstruction, because they are at higher risk of impaired wound healing.

But reconstruction has no known effect on the recurrence of cancer, nor does it interfere with chemotherapy or radiation, should cancer recur.

Whether reconstruction is to be immediate or delayed, it is most important that this decision be discussed with both a cancer surgeon and a plastic surgeon before the mastectomy, since it may alter the way the cancer surgery would be done.

There are two main approaches to reconstruction: implants and tissue flaps. But they are not both available to all women.

Herman, for example, is slim and has no excess tissue that could be used to create breast mounds. Instead, she will get two synthetic implants filled with silicone gel. Despite much adverse publicity surrounding this choice, neither the U.S. Food and Drug Administration nor the National Cancer Institute has linked silicone implants to connective-tissue disease.

At the time of Herman's mastectomy, tissue expanders were inserted under the skin, and they are gradually being filled with saline to stretch the skin enough to accept an implant comparable to the size of Herman's natural breasts. Had she wanted, she could have chosen smaller or larger breasts than the 34-Bs that nature gave her.

Later, she will undergo a second minor operation, to replace the tissue expanders with permanent silicone implants.

Lynn Marks of Philadelphia -- who runs a support and information group called Living Beyond Breast Cancer (lbbc.org) -- chose saline implants.

At the time of her double mastectomy in 1998, she was fitted with permanent silicone bags, into which saline was gradually injected over six months until she was restored to her previous size. Four months of chemotherapy did nothing to impair the reconstruction.

"I'm really glad I did reconstruction when I did," Marks said. "I never once felt mutilated. I woke up whole from surgery, and I appreciate the fact that my breasts match."

Still, there can be problems with implants. An implant may rupture or deflate; scar tissue may tighten or squeeze the implant; the implant may change position; or wrinkling may occur.

Last year, the government produced a hefty patient guide, "FDA Breast Implant Consumer Handbook," that women may want to consult before having cosmetic breast surgery. It is available online at: www.fda. gov/cdrh/breastimplants.

Reconstruction with a tissue flap is done one of two ways.

In one method, a flap of tissue still attached to its blood vessels is cut from the woman's back, then tunneled or threaded to the front of the chest to either support an implant or form a breast mound.

More often, a free flap of tissue is taken from a donor site -- usually, the abdomen; sometimes, the buttocks, back or thighs -- and transplanted to the chest wall to create a breast mound.

Either technique creates two surgical sites, and postoperative recovery is longer and more challenging than with implant surgery, though tissue-flap surgery can result in the most realistic breast.

Flap surgery, however, may not be available to women who are very obese or very thin; who smoke; or who have had previous surgery at the donor site.

Jane Brody is a columnist with The New York Times.