Breast Surgery

Many women are candidates for incision via the inframmamary fold (the bra line). I had mine done this way and one can hardly tell that I had a mastectomy. This is often available for small and medium breasted women, less so for women with large breasts. Be sure to discuss this option with your doctor to see if you are a candidate. Many do not offer this option, so be sure that you determine if you are not a candidate or if your surgeon simply does not offer the procedure.

I opted for a bilateral. I only had cancer on the right side, but after finding that and getting my MRI, something popped on the left. We weren't sure what it was. I could have had it tested, but at that point I just knew I wanted to have both sides removed. So I chose to not get that side tested and proceed with a bilateral mastectomy.

After surgery, pathology showed it was not cancer, but I don't regret
making that decision. It was 100% correct for me.

That said, what is right for me, may not be right for you. And it's a hard decision to make. And I wish you best of luck making it. You have to do what you think is right for you, and only you. ((hugs))

I see. I did not realize it was an individual plan related to autonomy. Very helpful.

The first visit post-diagnosis will be a discussion of the biopsy results, type of cancer, and treatment options. Additional tests will be mentioned. This will take in the order of 45 minutes to an hour. There should be ample time for questions. Families are encouraged to take notes. Literature may be provided to the patient and family. There may be referrals to other team members such as radiation oncology, medical oncology, plastic surgery, social work or counseling.

Obesity is a risk factor. In terms of the surgery itself, lymphedema rates are reduced with sentinel node biopsy (2-5%) compared to full axillary dissection (20-35%). Radiation to the axilla and supraclavicular nodes increases lymphedema risk.

Image-guided biopsy is preferred. This can be done with a core biopsy using the stereotactic table or under ultrasound. There are many different biopsy needles available, but for all a small knick is made in the skin after injecting local. The devise is then inserted into the breast, and several cylinders of tissue are removed and placed in formalin then sent to pathology.

Generally lumpectomy is offered for unifocal (one site of disease), and the patient is willing to undergo radiation. If the tumor is large relative to the breast size, neo-
adjuvant (up-front) treatment may be given to shrink the cancer before lumpectomy.

Questions to ask would be:
How large is the cancer? Can clear margins be obtained? Should I receive chemotherapy or endocrine therapy prior to surgery to shrink the tumor? How will the incision lines be placed? Will oncoplastic techniques be used? How much deformity will there be? Is there a reason not to preserve the breast?

It depends on the patient and if reconstruction is performed, and what type of reconstruction. If a mastectomy without reconstruction is performed, usually a 24-48 hour hospital stay is required, and a patient is discharged with drainage tubes in place. The drains are usually removed after about 7-10 days, but may stay in place longer depending on the amount of fluid that is being produced. Overall recovery in terms of return to work and other normal activities can take anywhere from 2-3 weeks up to 6-8 weeks.

If reconstruction is performed using tissue expanders or implants, the recovery is similar to that of a mastectomy without reconstruction but the initial pain is usually more as the tissue expanders or implants are placed underneath the pectoralis muscle. If reconstruction using muscle or fatty tissue is performed, the hospital stay is usually 3-5 days, and may include an intensive care unit stay; overall recovery is typically 6-8 weeks and sometimes longer.

This may be a woman's individual choice - if a woman is a candidate for immediate reconstruction, she may have a preference regarding the timing of the surgery. Some prefer to undergo the mastectomy and other treatment first, delaying the reconstruction, while some women like the idea of having a large part of the reconstruction performed at the time of the mastectomy. Some patients with more aggressive tumors are not candidates for immediate reconstruction, but if the woman has a choice, it is really an individual decision.

Full preparation includes review of all imaging studies such as mammogram, ultrasound, and MRI, as well as consultation with appropriate specialists such as the medical oncologist, radiation oncologist, and plastic surgeon. Of course reviewing all options with the patient and making sure she is understands her treatment options and is comfortable with her decision is of utmost importance.

There's a saying about New York that applies to the breast-cancer community too: There are 8 million stories in the naked city.

Every woman with breast cancer has a specific set of factors she must consider in making decisions about her treatment. For some women, the choice is clear. For others, the decision-making process is the most stressful part of the breast-cancer experience.

My decision to undergo a bilateral mastectomy after having a lumpectomy and re-excision on my right breast was based on a unique set of circumstances: There was disagreement between my first- and second-opinion doctors about whether the margins around the re-excision were clear. My tumor was an unusually aggressive kind of lobular cancer, and women with lobular cancer are somewhat more likely to get a tumor in the other breast. My tumor hadn't shown up on the mammogram I'd had a couple of months before I was suddenly able to see and feel it, so I was concerned that a new tumor wouldn't be found by mammography either. Both breasts were dense and had areas of micro-calcifications—risk factors for breast cancer—so I was going to require frequent monitoring of various kinds.

All those concerns, plus the fact that I'm a worrier by nature, led me to choose the most aggressive surgery.

I actually didn't have much trouble deciding to have both breasts removed. But a friend suggested that I make a list of pros and cons so that if I ever felt regrets, I could look at the list and remember why I chose that course. I haven't felt regrets, as it turns out, but making the list was reassuring because I realized how certain I was about my decision.

Another woman in my situation might make a completely different decision. She might choose to keep one or both breasts. And I can understand that. After all, even my well-trained, experienced and talented doctors disagreed in their advice. But I feel confident that my decision was right for me.

For me this was not a difficult decision. When I learned that there was no survival benefit for mastectomy in my case, I decided to keep my breast and have radiation therapy. The prospects of a smaller surgical procedure as well as my appearance and sensation all seemed positive.

However, if I had carried the BRCA gene or if any other medical situation had made mastectomy an appropriate choice, I would not have hesitated to choose it.

I honestly never considered a lumpectomy. I wanted to be as aggressive as possible and leave no breast tissue behind. I was young and had a fairly large tumor and lymph node involvement so I felt like that was the best choice for me.

Cording, also described as axillary web syndrome, can occur after axillary surgery such as full axillary dissection, sentinel node biopsy and after excision of masses from the axillary tail of the breast. It presents as a visible and palpable cord of subcutaneous tissue running from the axilla to the elbow.

It is thought to be a superficial thrombophlebitis (inflammation of the superficial veins), a variant of Mondor's disease (superficial thrombophlebitis of the breast). http://www.ncbi.nlm.nih.gov/pubmed/21987036

Other authors describe it as an inflammation of the lymphatics in the upper arm.

Cording generally resolves in about 12 weeks. Anti-inflammatory drugs can help, as can massage, range of motion exercises, and physical therapy.

Adhesions is a term used for intra-abdominal scarring from prior surgery or infection.

Depending on the specifics of your situation, you may still be a good candidate for another type of flap, or for a tissue expander. If you feel more comfortable getting a second opinion, then I'm sure your original plastic surgeon will understand. Because of the complexity of your case, if you do see another plastic surgeon it would be best if it is someone with significant experience in breast reconstruction, either here in the NYC metro area, or closer to your home if you prefer and can locate someone with the appropriate experience.

Honesty, I thought it was strange that the surgeon was calling the shots. After I was diagnosed, I was told that I might have to see an oncologist and possibly have chemo but only after the surgical biopsy revealed the extent of my disease. In my initial stages of fear, panic and conflict, I followed that trail, like a deer in headlights. I was scheduled to have surgery, a double mastectomy and double tram reconstruction; although I am a poor candidate for that procedure. I am relatively thin and very athletic. The plastic surgeon did not explain that my abdominal muscles would be part of the rerouting and that I would not be able to continue my active lifestyle. I would also drop from a 34A/B to ??. They don’t make bras for that…………………,but then, I guess I would not need one :o/ . Anyway, sore subject……. My mother, who lived in another state, broke her hip a few days prior to my scheduled surgery. Everything went on hold as I helped her and I also took it as a sign to have a plan B. I consulted with 2 highly recommended oncologists who essentially said the same thing, “The cancer in your breast is not going to kill you, it is the cells that get away that might.” SOLD! The core biopsy sample that was initially taken when I was diagnosed was submitted for oncotyping and the results showed that chemo was indicated. The beauty of having the chemo up front was that we would be able to actually see if it would work, by watching the tumor shrink, and if so, we knew it would be getting any cells that might have escaped, as opposed to hoping. This also gave me time to help my mother AND explore my surgical options. I had 4 rounds of Taxotere and Cytoxan followed by a nipple sparing mastectomy 4 weeks after my last blast. The original tumor, invasive ductal carcinoma, was 2.6 cm at the time of my diagnosis. When it was removed after chemo, it was a nonviable scar. It was GONE, totally disappeared :o) Fortunately, I did have a mastectomy because they found a totally different microscopic but invasive tumor when the tissue was biopsied, invasive lobular carcinoma. Fortunately, also, all of the 11 lymph nodes that were removed were clear :o). Having chemo up front was the best decision for me and according to my oncologist, the standard practice in Germany.

Just diagnosed for the 3rd time & had a double mastectomy and reconstruction during one surgery 3 weeks ago. Had the BEST surgeons in Santa Barbara and am forever grateful to them. Surprisingly the skin sparing went very well especially on my 20 yr. old radiated breast. They both said that they would not be able to spare my nipples so I had already made an appt. for tattoos and was considering nipple reconstruction. But, my genius surgeons in the middle of surgery decided to spare one nipple and part of the areola of the current breast cancer breast. I was so shocked and happy when my family shared the news with me after I came out of recovery. I gasped when they told me. So, even though I look in the mirror and see many stitches and atypical breasts at this point in time in the game looking back at me, seeing my nipple and part of the areola makes everything (including my psyche) more at ease. We are all dealt different cards on this journey and this aspect of my recovery has definitely lifted my spirits. Others not going through this journey may say it doesn't matter, but it does and I am truly grateful. I would have dealt with whatever was handed my way, but again, I am very happy with my outcome and can't wait to see how 'they' turn out after my final implant surgery in April!

The sooner you can resume normal activities the better off you are. I don't mean push it, and I don't mean start doing jumping jacks. Start walking and add distance incrementally. And do this every day. One block, two, three, until you're comfortably walking a mile or so.

Equally important is the rehabilitation of your arm. If you haven't had physical therapy many excellent resources are mentioned above. You can run through arm exercises in fifteen minutes or so. I still do so to this day. After full lymph dissection and radiation the natural tendency of the arm and skin is to retract and tighten.

One of the best things I'e found is yoga. Many cancer treatment centers (in Houston through MD Anderson and Memorial Hermann) now offer yoga for cancer survivors. It's excellent and a gentle way to reduce stress.

Massage after mastectomy is generally considered to be beneficial. There was some concern a few years ago that massage may spread breast cancer cells. This notion has been overturned.

It has been shown that massage reduces anxiety, pain and requirements for pain medication. A study form the University of Miami showed that massage also increased levels of a brain chemical called dopamine, which helps produce a feeling of well-being. In addition there was an increase in protective white blood cells that help boost the immune system (called natural killer cells) from the first to the last day of the study.

This is the easiest question of all for me.
I was my mom's caretaker for 2 years. I literally went through her cancer diagnosis & treatment with her as well as taking her last breath with her.
When my next family member was diagnosed & we found out that we carried the BRCA gene mutation, in my mind it wasn't an if for me, it was a when.
I knew that I had to do everything that I could to not go down this road.(No woman in my family has lived past the age of 60.)
I knew that for me giving up my breasts & ovaries was my only choice with the odds stacked so high against me. In MY opinion taking prophylactic measures was far easier than the choices I would have to make if I developed one cancer cell.