SURGERY

Surgery is a vital part of the treatment of breast cancer. Whether you have a small lumpectomy that just removes the cancerous tissue or you opt for a mastectomy which removes the entire breast, it is a surgery that effects your emotions and sense of well being.

There are no right or wrong answers in making your decision. However, some answers are made for you because some tumors simply need a more complete surgical procedure than others.

As always, knowledge is power. Learn as much as you can in order to make an informed decision.  By educating yourself you will also learn of the many options there are available to you. Tremendous strides have been made in the treatment of breast cancer and its surgery and reconstruction. There is a lot of hope and optimism out there among all the confusion and fear you may be feeling now.

 Let’s start at the beginning.

LUMPECTOMY

A lumpectomy removes the tumor and surrounding tissue. It has been proven that a lumpectomy followed by radiation has the same survival rate as a mastectomy. You must decide what you feel comfortable with. If your tumor is small in relation to the size of your breast, then a lumpectomy, or breast conserving surgery, is a good option for you. If your tumor is large, there is chemotherapy that can be administered before surgery, known as neo-adjuvant chemo, which shrinks the tumor making it possible to remove it and still conserve the breast.

A lumpectomy is not recommended if you have cancer in more than one area of the breast or if you have another medical condition, such as Lupus, Scleroderma, or rheumatoid arthritis.  If you have a lumpectomy you must be followed with radiation treatments. Radiation effects on women with these conditions, also known as collagen vascular diseases, can result in severe scarring and even ulceration.

MASTECTOMY

A mastectomy removes all the breast tissue from your breast area and the area known as the axilla tail that goes up under your arm. Most surgeons are performing skin sparing mastectomies today. This leaves your skin in tact, while the breast tissue is completely removed underneath it. This procedure then makes reconstruction, should you choose to have it, more natural looking.

Many women opt to have a bilateral mastectomy at the time of their surgery. One side would be removed because of the cancer and the other would be removed prophylactically to protect against further cancer and to also make reconstruction more symmetrical leaving you with matching breasts.

 For obvious reasons, the recovery time from a lumpectomy is shorter than for a mastectomy, particularly if you have reconstruction following your mastectomy. But you do heal and get better. Talented breast surgeons can perform lumpectomies without leaving much of a scar at all. And a strong team that combines your breast surgeon and a breast reconstructive surgeon can present you with two, new breasts when you wake up from the anesthesia.

RECONSTRUCTION

There are many ways a breast can be reconstructed, and the choice is best made with careful consideration regarding your lifestyle and what your expectations are. There is also the choice to not reconstruct, and many women choose this as well. The following is  a brief overview of reconstructive surgery.

For more detailed information please visit the following website that answers all your questions.  It is run by a breast cancer survivor who has vast experience:  breastreconstruction.org.

Should you choose NOT to reconstruct, another breast cancer survivor has started a site for women who opt out of reconstruction.  She covers everything you need to know. Please visit breastfree.org for more options and choices available for you.

Reconstructive Procedures

Implant

An implant is a two-step procedure. First a tissue expander is inserted followed by the implant at a later date. An implant requires the tissue expander to create a pocket for the implant to be placed. It is placed behind the pectoral muscle. It is an empty sac that has a metal port connected to it. After your initial healing you will visit your doctor’s office for “fills”. The doctor or nurse accesses that port by locating it with a magnet. When they have found the access point they fill the expander with saline solution in small increments stretching the skin. There is some discomfort in this procedure, there will be a feeling of tightness in the chest area. But over the counter pain relievers are all that is usually required.

When the plastic surgeon is satisfied with the amount of room he now has under the skin and muscle you will then go in for your “exchange” surgery.  This means, exchanging the temporary expander with your permanent implant. You will have to decide on Saline Implants or Silicone Implants. Silicone implants are back on the market again. The FDA reversed their decision to remove them because they did exhaustive studies and found that there are no health risks to a woman, other than scarring, that are caused by silicone. The scarring can also occur with saline implants as well. It is a surgical risk one must take into consideration when deciding on what reconstructive option is best for you.

There is a new product called AlloDerm. This is made from donor tissue that has been stripped of all its DNA. When implanted under the breast pocket it heals as part of a woman’s own tissue, taking on her DNA. It strengthens the skin making it possible for even previously radiated skin able to support an implant. Not all doctors are up to date on its uses, but as its success stories grow, more and more reconstructive surgeons will learn how to use AlloDerm, and as a result, more women will have more options in breast reconstruction.

Implants do have one downside, and that is they can become contracted. This means that scar tissue has formed around the implant and it hardens. This is your body's natural reaction to a foreign body. If your plastic surgeon compensates for this by creating a large pocket to hold the implant and if you are diligent with post surgical massage, you can prevent this from happening. This is a link to an excellent site that provides post implant massage techniques to prevent capsular contracture:

http://www.womensplasticsurgery.com/video_massage-recon.html

 TRAM Flap

(Transverse Rectus Abdominis Myocutaeous)

This is popular because you get an instant tummy tuck with it. The results are very natural looking and feeling breasts. Abdominal muscle, excess tissue, and a main blood vessel are slid up your torso, over your rib cage, and put in place of your breast on your chest wall.  You will have two surgical sites when you are through and both need time to heal. You must be aware that you will be on the operating table for a very long time. All these factors and your current state of health should be considered.

DIEP Flap

(Deep Inferior Epigastric Perforator)

There is another procedure that actually takes even longer to perform than the Tram Flap  and it is known as the DIEP (Deep Inferior Epigastric Perforator) procedure . Only a board certified reconstructive surgeon,  who is experienced in micro vascular surgery, should perform this. For in this procedure, also known as the “Free TRAM”, “Free Flap”, etc., the fat and micro vascular tissue are removed from the abdomen, leaving the rectus muscle in place. The surgeon then attaches the tissue to the area where the breast was removed and reconnects each blood vessel.

When factoring in all the details of what you are willing to undergo, one of the most important decisions is  the  physician who will  perform it. He should have done several hundred.  Ask to see photographs and if possible ask for patient recommendations. AND ask for his success and failure rate of transplanted tissue.

The TRAM cannot be performed if you do not have enough of a belly to work with. Meaning, if you are thin in your abdomen and store your fat in your butt, the TRAM isn’t for you, but the GLUTEAL would be.

Gluteal Flap

Gluteal flap procedure is a DIEP, or Free Flap procedure where your excess skin and muscle from your buttocks are used to make the breast. The cut is made just below the bikini line on the buttocks and the skin is removed. After you have healed, a ‘revision’ is done where the surgeon goes back to the area and lifts it, creating a new and better looking butt. Putting cosmetics aside, this is micro vascular surgery, for the safety of your health as well as the overall cosmetic outcome of the procedure, you need only the best and most experienced doctors performing it.

The LAT Flap

(Latissimus dorsi flap)

This option takes the muscle and excess skin from your upper back just around the bend of your shoulder blade and it is tunneled around your torso under your arm and into place. There is no need to remove any blood vessels because of the proximity of the area used, so they are just shifted along with the rest of the tissue and muscle. This procedure probably has the highest success rate of all the “flaps” because there is less to reconnect.

Note: Even though these procedures create new breasts, it is often necessary to also require an implant to fill the area out.

NO RECONSTRUCTION

(As mentioned above, please see breastfree.org)

Prosthesis

There are several types of prosthesis you can get. First, after your surgery, your skin will be tender. You will need to get a post-surgical prosthesis. Then you can be fitted for a permanent one. There are all styles and types from silicone to fiberfill.  Find a good mastectomy boutique where they can help you with each decision. The nurses in your breast surgeon’s office will be able to recommend a good one to you.

They even have special prosthesis made for swimming. So if you like to swim, you don’t have to give that up, and you don’t have to ruin your good prosthesis with chlorine from a pool.

REMEMBER: THEY ARE COVERED UNDER INSURANCE

OTHER SURGICAL PROCEDURES

The Sentinel Node Biopsy

A newer and more preferred procedure to test  your lymph nodes is the Sentinel Node Biopsy. This was created to minimize the amount of lymph nodes removed because that surgery has the potential to create a serious effect. When you get a full axillary lymph node dissection you are left without any lymph nodes under your arm. Since you don’t have lymph nodes anymore, the lymphatic fluid can sometimes have trouble filtering in your arm and swelling, known as lymphedema, may occur. The theory behind the sentinel node biopsy is that by not removing the entire bundle, you reduce the risk of lymphedema.

Your surgeon will inject a tracer dye into your tumor field to see which node the dye goes to first. That first one is the sentinel node. The nodes surrounding it are then watched to see if they collect the dye as well. Usually two or three are sent dye from the sentinel node. These are removed and tested. If they are clear, the chances are the rest of the nodes in the axillary sac are also clear and no further surgery is required. If there is cancer found in them then the sac will be removed.

Ports and Port Insertion

If you are going to be getting chemotherapy, a port or portacatheter will need to be placed. This saves the veins in your arms from being scarred from the chemicals being administered.

A port is a tube with a drum attached to it. The tube is inserted into your upper chest area, near your collar bone, and into an artery that delivers the medicine to your system. The drum attached to it is placed just under your skin. This is where your oncology team can access the port and draw blood as well as give you your chemotherapy treatments.

Please note: Only special needles can be used with a port. Do not let anyone inexperienced try to access your port or use a traditional needle on it. If you have to go to the hospital ask for someone from the oncology ward or the blood lab who is experienced with ports and who has the proper equipment, do your blood draws.

Side Effect from Surgery: Lymphedema

There is a complication that breast surgery and the removal of lymph nodes can produce. Please see THIS PAGE for complete information on Lymphedema. It is important that you learn about it.