I knew very little about mastectomies and reconstructions before January, but have gained quite the education (as every breast cancer patient does).  I am very thankful for our team of physicians and patients who have gone before me; they answered many of our questions and made the decision-making significantly easier.

The Mastectomy

During the discovery phase of being diagnosed, almost every physician we consulted with agreed that I would need a mastectomy on my left side due to the size of the tumor. We hoped it would shrink through chemo (which it did).  And my oncologist even floated the possibility in May that I might be a candidate for a lumpectomy due to how dramatic my response to chemo had been.

Decision #1: Should I have a lumpectomy or a mastectomy on my left side where the cancer was present?

Decision #2: Should I have a mastectomy on my right side where no cancer was found?

The goal of a lumpectomy is to remove the “tumor bed”, scar tissue, and any disease still present in a patient, and to acquire a certain amount of “clean margins” around the diseased tissue to ensure the cancer has been removed from the breast.  A mastectomy removes all breast tissue.

When faced with the above decisions several months ago, one statistic made these decisions easy for me.  I asked each of my physicians (and the physicians we got a second opinion from) what was the chance of having cancer on my right (non-cancer) side?  The answers were varied, but two physicians told me it was 0.7% per year or approximately 35% over fifty years.  I am planning to live at least that long!  So the decisions were simple for me.  As a young mother of four little ones, a 35% chance of another bout with cancer on my right side felt far too risky.  Having a prophylactic mastectomy on my right (non-cancer) side brings my lifetime risk to 2%.  I’ll take that.

Decision #3: Skin-sparing or nipple-sparing mastectomy?

In a mastectomy, an incision on the breast is made, and the surgeon removes all possible breast tissue that he or she can access.  The patient’s skin is left intact the majority of the time, and becomes the “envelope” for the implant or tissue during reconstruction.

I had never heard of a nipple-sparing mastectomy before, although the name explains everything.  The pro is that the end result after reconstruction looks like you!  The con is that by choosing to leave additional breast tissue (the nipple), the lifetime risk of a new cancer increases slightly (from 2% to 3-4%).

The location of a patient’s tumor (or a patient’s anatomy) can make this decision for her.  My physician did an excellent job of explaining the risks / benefits to me.  Some women are candidates for a nipple-sparing mastectomy.  Others are better served to do a skin-sparing mastectomy.

Most Reconstructions

The mastectomy is done by a breast surgeon; the reconstruction is done by a plastic surgeon.  From talking to the physicians I have consulted with, it seems the most common method of reconstruction is a combined surgery: the breast surgeon does the mastectomy first, and then the plastic surgeon does phase 1 of the reconstruction in the same surgery.

Phase 1 of most reconstructions is placing a “spacer” behind the pectoralis muscle.  I’ve heard the spacer is like a flat balloon.  The patient then has several follow-up visits to the plastic surgeon’s office to inflate the spacer by adding saline to it.  Skin can stretch indefinitely, which is interesting.  So a woman doing this method of reconstruction can choose what size she wants to be.  The plastic surgeon inflates the spacer accordingly.  And then depending on whether she will receive radiation or not, at some point down the road, the patient will have a second surgery with only the plastic surgeon to remove the spacer and place the final implant.

The Zenn Delay Reconstruction

The reconstruction I did was pioneered by Dr. Michael Zenn, who spent the majority of his career at Duke University, before beginning his own practice, Zenn Plastic Surgery.

Since I will receive radiation after surgery, I was told that radiated skin feels somewhat “plastic” and is more difficult to work with during the reconstruction.  One plastic surgeon (Dr. Richard Carlino), who came with the highest recommendations and I fully trusted, told me he likes to wait about a year after radiation ends before proceeding with Phase 2 of the reconstruction (the surgery where the spacer is removed and the implant is placed).

Dr. Zenn’s approach is simply to do the full reconstruction before radiation.  He believes it is advantageous to wait at least 1-2 weeks after the mastectomy to allow the skin to recover, but then its safe proceed with the full reconstruction.

Several things appealed to me about his approach:

• The opportunity to do all the surgeries “together” (9 days apart).  Hopefully, I can spend one month recovering from two surgeries instead of recovering from them one at a time.  Precious time I can spend with my family instead of being down.
• Instead of having a spacer put under my pectoralis muscle, I “skipped” that step.  During the mastectomy, the breast tissue was removed.  During my reconstruction, an implant was placed under my skin (on top of the pectoralis muscle).  It sounded less painful / less invasive to me.
• I have no guarantees of what will happen to my skin after radiation.  Certainly, the skin texture could change, messing with the reconstruction, and requiring an additional surgery to tweak.  Since I underwent reconstruction before radiation, Dr. Zenn was able to do an excellent job.  We are praying one surgery will be all that’s needed.  Reconstructions done the traditional way have a 1/3 “failure rate” (where another surgery is required).  So either way, I may or may not need additional surgeries.

I am so thankful to be done with both surgeries, and we are grateful for your prayers and support through this time!  I should have the drains removed this week, and then may have another three weeks or so with limited mobility.  We’ll see!