Methods of Surgically Removing Breast Cancer



The Cure - Phase 2 - The Surgery

Dr. Dougherty told me the main weapon I have to rid myself of cancer is to remove the cancerous tumors. This means either a lumpectomy or mastectomy. Dr Dougherty, even though he told me my cancer was HER2 negative and not growing very quickly, was able to call WNY Breast Health and get Dr Vivian Lindfield to move my appointment from Thursday January 24th up to Monday January 14th.

Once again, I showed up for my 9am appointment with Dr Lindfield with my entertainment entourage. Sadly though, Dr Lindfield's staff did not leave out any cotton balls for us to play with... Dr. Dougherty must have called ahead and given her the heads up. In fact all the drawers were locked. Busted. And Bored....

Dr Lindfield came in and explained in further detail the pros and cons of a lumpectomy versus a mastectomy. She did not try to sway me towards either procedure, but laid out what I can expect either way.

Removing the Cancer

Example of a Breast post-Lumpectomy

The option of a lumpectomy was the least invasive, however she wanted me to understand that they will take more tissue than just the lumps.  My tumors ranged in size from 10mm to 18mm. When they remove the lumps, they need to take the cancerous tumor, the tissue immediately surrounding the cancerous tumors, and if there are multiple tumors on one breast, which there are, they will need to remove the tissue between the 2 tumors.  After a lumpectomy it is almost certain that I would need radiation therapy. Radiation would affect both healthy and cancerous cells in the areas where the lumps were removed. If any cancer cells were left behind, radiation will kill them. Radiation will not affect healthy cells in the long term. Lumpectomies very often will disfigure the breast. In extreme cases, plastic surgery may be available to return the breast to a normal shape and consistency.

A mastectomy is another option I had to consider.   Up to this point, I thought a mastectomy was a radical decision, only to be used in the most aggressive of breast cancers. I learned from Dr. Lindfield that it is actually fairly common.  No longer are the days when mastectomy meant living with craters in your chest. If I chose a mastectomy, the option to reconstruct both breasts at the same time was available. Even with a mastectomy, there is still a chance that I will need radiation, but the need for radiation is radically lessened when the entire breast is removed. If I chose a mastectomy (I would need a double mastectomy since I had tumors on both breasts) I have a choice of 2 reconstruction options... or I could choose not to reconstruct. Since I consider my boobs two of my best assets, 'no reconstruction' is not even an option I considered so I can't provide much insight into this option.

These are the facts about the mastectomy and lumpectomy that I considered, but there are others that you should consider if you need to choose a mastectomy or a lumpectomy for breast cancer removal. Take the link to see other considerations.

Rebuilding New Breasts



Example of Breast with Implant Reconstruction

One method of reconstruction is with the use of implants. When I arrived at Dr. Lindfield's office, I thought that to reconstruct using implants they would simply scoop out my breast tissue from the skin pocket, like an avocado, and then fill it in with a silicone implant.  Oh boy was I wrong on this one. The first step is to remove the breast tissue, nipple, and most of the breast skin. Before sewing the skin shut, a temporary breast expander is placed under the pectoral muscle. The temporary expander is a flexible saline implant which is mostly deflated with a magnetized penetrable rubber seal towards the top.  Over the next few weeks as you heal, the expander starts to slowly stretch your pectoral muscle and breast skin.  Every 2-3 weeks, you return to the plastic surgeon and using a magnet to locate the rubber seal he will inject more saline into your expanders.  Again, you wait a few weeks for the skin and muscle to stretch and return for another injection into your expander. This continues until you and the doctor have decided that you are happy with the size of your breasts.  Once optimal size is reached, you wait 2-3 months for the skin and muscle to relax to this size. When the plastic surgeon is confident that your body has adjusted, you go in for surgery again to remove the expanders and replace them with permanent implants. Then you have to choose either saline or silicone implants. 

Something else I learned... you may notice that the picture I chose to show an example of post implant reconstruction boobs has no nipples... When performing a mastectomy, the nipple and areola are removed because they are attached to the mammary glands and ducts. When the ductal system is removed, the nipple will die. So when the breasts are reconstructed, they are done so without any nipples.  After most of the healing has occurred, nipples can also be constructed using skin or cartilage from elsewhere on the body for the nipple itself, and the areola is actually tattooed on. Now you have some information that I'll bet you never knew that you didn't know!

The other option for post-mastectomy reconstruction is autologous reconstruction.  Autologous reconstruction allows you to create breasts using your own tissue rather than synthetic implants. The two most popular methods of autologous reconstruction are the TRAM flap method and the DIEP flap method. TRAM involves severing a diamond shaped piece of skin, fat, and muscle tissue from the lower stomach and weaving it through the chest cavity. The surgeon will then use the stomach tissue to create 2 new breasts complete with fatty tissue from the tummy. After the tissue is transplanted to the breast, the stomach is stretched and sewn shut. The result is basically a tummy tuck. The DIEP flap is similar to the TRAM with the exception that the skin is completely removed and microscopically reattached to the blood supply in he chest.  Also, the DIEP flap does not remove any muscle, only skin and fatty tissue. This allows for a faster recovery time. Again, with the anologous reconstruction, nipple construction is EXTRA! (Want fries with that?? Why YES I DO! duh) 


Example DIEP Reconstruction Before and After

 Pros and Cons of Reconstruction Methods

Both implants and autologous reconstruction have their pros and cons. With implants, you come to the hospital with boobs and you leave without them. You will have an expander in, but to start it won't be very big. So to someone like me with a DD cup, that would be quite shocking and could totally mess with your psyche.  Also, you will have to go back to the plastic surgeon every 2-3 weeks for the first 6 months or so. Then when your expanders have reached full size and you wait 2-3 months for your muscles to settle, you need to go in for surgery again to have the expanders removed and the permanent implants put in.The whole process can take a year or more, depending on how large you want your new boobs. On top of that, you will need to return to your surgeon every year or so for a check up to make sure your implants are in place and not ruptured.  Believe it or not, if you choose silicone implants, it may not be apparent if you rupture. That was pretty scary to me.  There is also the risk of infection around the implant. If that happens at any point in the expansion process, the expander must be surgically removed, you must heal, and then you must be operated on again and started over with a new expander.  The scars are usually straight lines across the breast that can, for the most part, be covered later by a nipple add-on (I still think its hysterical that those are an optional add-on). On the bright side, the mastectomy and all subsequent surgeries are same day procedures, so there will be no long term hospital stay.  Also, within a day or so of each surgery you should be able to resume a pretty normal life, except to stay away from heavy lifting, lifting over your head, and chest presses (and other no brainer activities).

An anologous reconstruction brings a whole different set of circumstances. You come for your mastectomy with boobs and you leave with boobs. The reconstruction is immediate. There will likely be follow up visits to your plastic surgeon to reposition the breasts to be more even, to add nipples and arreola, and to treat any infections. There is also about a 5% risk that the skin from your stomach will not "take" to the transplant and die. If that happens the doctor can try to operate again and try once again to connect the blood vessels from the chest to the blood vessels from the stomach, but if it still doesn't take,  you need to be sewn up, heal, and begin reconstruction with implants. There is also the risk for infection at the breast or at the stomach suture site. If an infection occurs, it is easily treatable with antibiotics. The scarring from an analogous reconstruction is much more significant than with implants.  Not only will your breast be scarred in a straight across or diamond shaped patter, you will have a scar across your stomach from hip to hip at the site of the flap removal.  You need to be ok with scars if you choose this type of reconstruction.  And finally, because autologous reconstruction occurs at 2 sites on your body (chest and stomach) there is a longer recovery period.  When you choose this type of reconstruction, you can expect to be in the hospital 4-5 days and to be at home on light duty for 3-6 weeks. 

 What's Next

After Dr. Lindfield presented me with these 2 options for reconstruction she told me that she works with and recommends three plastic surgeons.  She sent me first to a female plastic surgeon who specializes in implant reconstruction. At this point this was the way I was heading. However, if I wanted to consider the autologous reconstruction, she could recommend 2 male doctors in the area that also do implants but are also known for analogous reconstruction.

Then she asked if I was leaning one way or another. I told her with 3 tumors on both breasts and having so much of my life ahead of me still, I was definitely leaning towards a bilateral mastectomy (bilateral means both boobs for those of us who only speak English) with reconstruction.  While she left the office to get me contact information for the plastic surgeons she recommended, my entertainment entourage asked me if I was going to get implants.  They had just assumed that's what I would do. I have to admit, the idea of age-proof perky boobs was intriquing, but I was more intrigued by autologous reconstuction. Not only would I get the tummy tuck that I have always dreamed of since 2003 but the lower overall maintenance appealed to me too. I can't maintain the oil in my car, how the heck will I maintain implants over the next 40-50 years?  Plus, I am a proven clutz. I mean, how many times now have I broken or sprained my ankle?  Every single time I fall or walk into a wall, I am going to be paranoid that I busted an implant.  This has a habit of happening a lot. 

Then my entourage asked if I was really considering autologous reconstruction. I said "Yeah!" Then they both said "Why?" and of course I said "Why not?". It has everthing going for it.  Or so I thought. Then my entourage pointed out what happens when stomach scars go bad. I hadn't thought of this. And the down time may just be too much. I would miss a month of work, Dr. Lindfield said, and would not be able to sit up and do much for weeks. Not only would I go crazy, but when I finally did come to, I am sure I would be disgusted with the house.

I had decided then that I would get the double mastectomy with implant reconstruction.  Funny how making my decision reminded me sort of like picking something for dinner off a menu where there are lots of good choices. So Dr. Lindfield made an appointment for me to see the implant specialist that Wednesday to get on her surgery schedule.