Silicone implants are not the only techniques surgeons can use to rebuild breasts after mastectomies. During the past decade, doctors have refined techniques that, in effect, rearrange part of the anatomy to fashion a new breast. Most of these techniques involve the use of "flaps" -- slabs of fat, skin and muscle that can be taken from one part of the body and reattached to the chest wall. Surgeons can also use implants containing saline, a harmless saltwater solution.

The most common flap operation is called a TRAM procedure, because it involves making a transverse, or horizontal, cut across the rectus abdominis, the strap-like muscle that runs straight down the abdomen from the base of the sternum -- the bone in the center of the rib cage -- to the pubic bone.

During a TRAM, a surgeon makes an incision at the mastectomy site and then uses an electrocautery device to tunnel between the muscles of the chest wall and the fat that lies under the skin. When the tunnel is completed, the surgeon slices an eye-shaped slab of skin and underlying fat from the area around the woman's navel, and then cuts through the rectus abdominis, leaving part of the muscle attached to the slab of skin and fat. This is important because the nerves and blood vessels that supply the slab run through the muscle.

The surgeon then pushes the slab up through the tunnel and out the incision at the original mastectomy site. By folding the slab a certain way, the surgeon can make it look like a real breast.

During the procedure, the opening in the abdomen is also sewn back together again -- leaving the woman with a scar and a tummy tuck.

"It takes from an area where there's an excess and adds to an area where there's a deficit," said W. Earle Matory, an assistant professor of surgery at the University of Massachusetts Medical School in Worcester.

TRAM is a long procedure -- the average operation takes five hours -- and involves a lengthier recuperation period than a simple implant operation. Many TRAM patients expect to spend four to five days in the hospital after the procedure -- as opposed to one to two days after an implant. Recovering from a TRAM can be very painful and usually requires more pain medications than are necessary for other procedures.

TRAMs are not recommended for heavy smokers or for women who are seriously ill, because of the risk of complications.

According to the American Society of Plastic and Reconstructive Surgeons, in 1988 there were 34,210 breast reconstructions, of which 11.5 percent were TRAMs. There are no national figures of complication rates from the procedure, but Carl R. Hartramps Jr., a clinical professor of plastic surgery at Emory University School of Medicine, who developed the procedure and has performed about 500 of them since 1980 says that he has never had a patient die as a result of a TRAM.

Hartramps says that two of his patients had to have the new breast surgically removed because of inadequate blood supply to the site. Other postoperative complications he reports include abdominal hernias, infection and hematoma, or bleeding under the skin. But Hartramps, whose complication rate is probably lower than the national average, said these occurred in only a few cases.

Patricia Melendy, 50, of suburban Boston, underwent a TRAM last year. She described the operation as "more debilitating than any surgery I've ever had," and more exhausting than her mastectomy. But now, she says, "I am just so pleased with it. I don't go around showing it to everybody, but I'd love to."

Surgeons can also reconstruct breasts using "free" flaps -- slabs of skin, fat and muscle that are removed from the body completely and sewn back onto the chest wall. These flaps are usually taken off of the lower abdomen or buttocks.

The advantage of a free flap over a TRAM is that it keeps the rectus abdominis muscle intact, thus preserving abdominal strength and the ability to do sit-ups and similar movements. The disadvantage is that the free flap operation takes much longer than a TRAM -- more than seven hours on average -- because the surgeon must use a microscope to sew tiny blood vessels in the flap to vessels in the chest wall. There is also the risk that the flap might not "take" to the site and might need to be surgically removed.

The other choice mastectomy patients have is an implant -- round silicone or polyurethane envelopes that are usually filled with either saline or silicone, or a combination of both. The implants can be placed under the skin and fat at the mastectomy site or can be positioned under a flap brought over from the latissimus dorsi muscle, which runs along the back.

While the saline-filled implants may not have received as much negative publicity as the silicone-filled ones, many surgeons say they suffer from the disadvantage of being hard, unlike the soft silicone-containing device, which feels more like a real breast. These implants may also rupture, thus requiring another operation to replace them.

The main advantages of both types of implants, surgeons say, is that they can be installed easily, in an hour-long operation, with very little pain afterward.

But there are disadvantages. Many women who want a simple implant first have to have the skin and fat on their chest wall stretched using a balloon-like device called a tissue expander. The expander is usually placed under the skin about two months before the implant surgery, and the patient usually has to go to her doctor once a week to have it filled with saline, a major inconvenience for some people. This technique also has the disadvantage of requiring the patient to undergo surgery twice: once to have the expander put in, the second time to have it removed and the implant installed.

And, as with any operation in which a foreign device is placed in the body, infection is a concern. For Sybil Goldrich, a Los Angeles woman who had implants after both her breasts were removed for cancer in 1983, infections and hardening were a constant problem for more than a year after her initial surgery, resulting in lost days from work and exhaustion, she said. When she underwent a TRAM procedure in 1984, the problem disappeared.

"I had an excellent reconstruction, and I've never regretted the TRAM for one moment," said Goldrich, who is now 50.

Surgeons have refined a technique that involves the use of "flaps" -- slabs of fat, skin and muscle taken from one part of the body and reattached to the chest wall.

Implants -- round silicone or polyurethane envelopes that are filled with either saline or silicone, or a combination of both -- can be placed under the skin and fat at the mastectomy site or can be positioned under a flap brought over from the latissimus dorsi, the broad muscle that runs along the back.

The most common flap operation is called a TRAM procedure, because it involves making a transverse, or horizontal, cut across the rectus abdominis, the strap-like muscle that runs straight down the abdomen from the base of the sternum -- the bone in the center of the rib cage -- to the pubic bone.

An eye-shaped slab of skin and underlying fat is sliced from the area around the navel, then pushed through a tunnel under the skin and out the incision at the original mastectomy site. By folding the slab a certain way, the surgeon can make it look like a real breast.

SOURCE: AMERICAN SOCIETY OF PLASTIC AND RECONSTRUCTIVE SURGEONS INC.