Surgery

Surgery is really the least interesting part of the journey, but the one you should take the most time making decisions about. I wish I had taken more time, but that is water under the bridge, I can only write about my experience and hope someone else gives their decisions more time and comes away happy with those decisions when looking back. Know your options before you make any choices. I can't stress this enough. A few days or weeks won't make any difference in your ultimate outcome.

I was diagnosed on January 7, 2005 via Stereotactic Biopsy. On January 19 2007, I had a Lumpectomy for the initial tumor as well as biopsies on three other "areas of interest" as my doctor called them. During surgery the surgeon found two lymph nodes in my breast tissue (not the sentinel node) that he thought didn't look right. He halted the surgery after removing the nodes and had a frozen section done. The nodes came back Cancerous as well and my surgical outlook changed in what seemed like instant. He had already removed the three other areas two in the same breast and one in the other breast, but the Lumpectomy wasn't done.

The next day when the lab work came back I got my answer. All the tumors in my left breast were Cancerous, the one in my right was not. The final diagnosis: Multifocal Invasive Breast Cancer with Lymph Node involvement. The largest tumor was about 1 cm in size and the total of all the tumors was over 2 cm. The Lymph Nodes meant Chemotherapy the multifocal nature of the Cancer meant mastectomy with Lymph Node removal. Unfortunately the Lymph Nodes removed during surgery rested on my chest muscle and the Cancer had spread to the muscle and more would need to be removed to get clean margins.

I had conversations with my doctors about removing Lymph Nodes. They spoke about the Sentinel Node but thought complete removal was a better option for me. I did not have the knowledge at the time to make an informed decision. With recovery from the first surgery and prep for the second I also didn't have the time to do the research. Also, I think I was somewhat shell shocked and almost blindly agreed to everything.

My surgeon also spoke about reconstruction options and skin sparing surgery. Once again I was so focused on getting rid of the Cancer that I didn't consider reconstruction at all. I said over and over again "I don't care about the cosmetic outcome." To give you some background, I have never been especially concerned about my looks. I didn't consider myself anything beyond so so looking. My body was nothing special, so the cosmetics of the situation were really unimportant to me. That being said, reconstruction is about much more then cosmetics. (see the upcoming post on reconstruction)

On January 31, 2005, I had a Mastectomy with part of the chest muscle removed and 12 Lymph Nodes removed under my arm. This surgery had a less painful recovery than the Lumpectomy which was unexpected for me. As with any surgery the worst part of recovery was the surgical drains and fatigue. I was hospitalized for three days total and was back at work part time after two weeks. You need to fully heal after surgery so Chemotherapy doesn't start for 6-8 weeks. I recommend choosing and speaking with an Oncologist before the Mastectomy. I did this right and felt great about those decisions when time came for the surgery. I do count myself as lucky. I did not need any Radiation Therapy.

No matter what your surgery expectation is, the surgical outcome may be different when you come out of anesthesia, then what you were told going in. No scan or imaging procedure is perfect. The surgeon doesn't know what he/she will find until they get inside and they do not know if you have lymph node involvement beforehand. That being said, you need to have a surgical plan laid out with your surgeon before anything happens. Below are some questions you should have answered before surgery, although that is still no guarantee things will go as planned.

1. Are there other areas in the breast that need to be checked besides the primary site?
2. Will there be Lymph Node removal? Push for removing only the Sentinel Node. This is the first node going from the breast to the the nodes under your arm.
   
3. If the Sentinel Node is Cancerous what do we do about the rest of the nodes?
4. Ask about the side effects and repercussions of removing all the nodes under your arm.
5. Is the Cancer advanced enough to warrant removal of the Nodes in the chest area?
   
6. If a Lumpectomy is planned and the Lymph Nodes are Cancerous will this lead directly to a Mastectomy. This should not be automatic, it is one of the choices you have a right to make for yourself.
7. If I will be having Chemotherapy, should I have a port placed at the time of my surgery. If so, what are my choices of location for the port. Ask about the side effects of using and clearing the port. This is an often overlooked point.
8. What about Radiation? How does it effect reconstruction? Speak to a Plastic Surgeon about this not just the General Surgeon.
9. Can I do the Mastectomy and the reconstruction at the same time? Usually yes. It will take longer to arrange and the overall surgery will take longer but I have seen it done. And really isn't one surgery better than two? If your surgeons won't do this find different surgeons.
   
10. There is Cancer in one breast. Should I have both removed? This is one of the hardest questions there is to answer. The answer depends on many things including your age, marital status and whether or not you have/want children.
11. What are my reconstruction options? Do not assume you have to have an implant. There are several "flap" procedures you can have that use the fat from other parts of your body.
12. If I choose a tram flap procedure do I need to give up my abdominal muscles? You do not. There is a free or "Deip" flap procedure that is more involved has a slightly higher chance of failure but leaves your abs in tact.
13. If doing reconstruction with Mastectomy should I have skin sparing surgery? After surgery, you breasts will look most "normal" with skin sparing surgery. You won't have nipples and aureoles but those can be added later or tattooed on. I have a friend with Celtic Knot Tattoos.
    

I realize this list seems a little overwhelming and it is by no means complete. Really the whole experience is overwhelming. If there is anything you take away from reading this blog it should be this: You have time to make the correct decisions for you, to arrange surgery to your ideals not someone else's, to consult with all the different types of specialists you feel should be involved in your treatment and get whatever second or third or fourth opinions that you want.