Urgent Surgery advice

Skbr

Hi everyone. I’m in need of some urgent advice about breast surgery options. I have been given two different opinions by two different surgeons and I need to decide ASAP, which to go with (surgery April 16th). 

I’m 36, with grade 2 & grade 1 invasive ductal carcinoma 2-3 lumps in a line at 10 O’clock(in line with underarm), ranging over a 5cm area, no children/Small C cup. 

Dr Cindy Mak initially recommended a nipple sparing right mastectomy, with immediate implant and radiation. I was afraid of capsular contracture because I heal poorly/radiation.

She now wants to try removal of the cancer in one large lumpectomy (scar from under arm, along side of breast). 

Then a second surgery to perform a LICAP flap reconstruction (I think they take a flap of fat from under the arm to fill the void?). I’ve lost weight over the last few weeks so I don’t have a huge amount of fat. She said I’ll be at least one cup size smaller and my nipple may be off centre. She could try fat transfer to help at a later date.

Dr Elisabeth Rippy suggested that in trying to keep my breast, I may end up with a less desirable shape/aesthetic result. She recommended a full nipple sparing mastectomy (scar hidden under breast fold) with an expander. Then radiation, followed by a second surgery for implant placement and fat transfer. 

I was wondering if, given your decision again, you’d try to keep your breast tissue at all costs? And if unhappy with the size and shape, have a breast implant/augmentation at a later date? Is it even possible to have a breast implant after LICAP and breast radiation? Does radiation change the texture of a natural breast so much that an implant is impossible afterwards?

Or because the cancer is so large, is a mastectomy safer? 

I’ve read that your initial surgery & shaping is very important in relation to future aesthetic outcomes. I really don’t know how to make a decision this important with so little information.

 I would really love any advice (or even other surgeon suggestions in Sydney, for a final opinion). X

MicheleR

Hi @Skbr,

Sorry you are here and have this difficult decision. I cant personally help you with this as i havent been reconstructed. There is a group on here that the admin @Giovanna_BCNA may be able to sort you out with. 

One of the other very knowldgeable ladies will probably come on here and give their experiences so hang in there. 

Hope you are ok. Its a bit shocking at this point i know and rushed. 

My tumour was large and i had a mastectomy but different kind of cancer so I cant advise there either. What i will say is that a mastectomy wasn't as bad as i thought. I didnt react badly to seeing the end result. Will having a lumpectomy allow you to breast feed if you want to have children? Is that a consideration?

Hugs
Michele

Julez1958

Hi sorry you have to be here.
I was diagnosed with a 5.5 cm lobular cancer in my left breast.
At the first consult with my ( very experienced) breast cancer surgeon he talked about a choice between lumpectomy and mastectomy but that was when we thought the the cancer was 4.5 cm.
At the second consult he said it was my choice but that it might be he could not get clear margins with a lumpectomy given the extent of the tumour and then I would need a mastectomy anyway.
I am 62 and that may have been a factor but I decided to go the mastectomy route.As it turned out the cancer was more extensive through the breast ( apparently that’s a lobular thing) so the mastectomy was the right choice.
I had  a skin sparing mastectomy with insertion of tissue expander ( plastic surgeon operated with breast cancer surgeon) and will have a DIEP flap surgery in the next few months.
its a lot to take in and not an easy decision to make, I asked my surgeon what he recommended and he said “ it’s your choice, I can only give you the pros and cons”.In my case my breasts were E cup so there was the possibility of still having enough breast tissue with a lumpectomy.It would have been a lot easier decision if I was a smaller cup as it would have leant much more towards a mastectomy then.
I got a reduction in my other breast and don’t regret my decision at all.
It might be worth  joining the “Choosing Breast Reconstruction group here to see other people’s stories. Hope that helps.

Julez1958

Sorry I didn’t read you post fully/ properly.
I am in Sydney  and my breast cancer surgeon is Dr Davendra  Segara  my plastic surgeon is Dr James Southwell - Keely.
Both excellent.

iserbrown

"Reclaim Your Curves - Welcome" https://www.reclaimyourcurves.org.au

lrb_03

Such a personal decision
I will say that my surgeon recommended lumpectomy, and I went with her recommendation. I ended up with a re-excision as margins weren't clear even after chemo. 5 years down the track, some additional breast shrinkage post radiation and my treated breast is at least 30% smaller than the other. Significant enough that I  wear a partial breast form.  I'm waiting for some revision surgery that's been delayed by Covid, then other health reasons.
If I'd known all that then, I probably would have pushed harder for a mastectomy. I didn't have to think about it so I still don't know what I'd do about reconstruction 

FLClover

Hello @Skbr 🙂
Tbh, I’m surprised Cindy Mak would’ve suggested an implant at the time of mastectomy, knowing you’d need radiation. I’m not a doctor, and even I know radiation damages implants, so it’s very odd that she’d suggest that. 

I don’t think I’d try to save my breast tissue at any cost. It would depend on a number of factors: tumour size and grade, breast size, importance of aesthetic outcome to you etc. I chose to have a nipple/skin sparing mastectomy because I had multifocal and simultaneous bc, so there was a lot of activity going on in there. I thought just take it all away to ease my worry. But there was the possibility of needing radiation, so I had tissue expanders inserted. They are great for radiation. So Dr Rippy’s suggestion sounds better for me. After radiation, if you take a break of about 6 months, that should give your skin enough time to heal so that putting implants in would be more successful. Radiation does change the skin and shrinks it, but implants are still successful in lots of ladies, especially with a fat transfer. 

Of course you could try and save your natural breasts with a mammoplasty, then you could still have radiation. Def an option I think. 

In regards to surgeons, I’d strongly recommend Eva Nagy. She’s very well trained in all these procedures, especially breast conserving surgery (mammoplasty). I know a few ladies who are very happy with her work, myself included. She’s a bright spark in the bc world. She also works with Dr James Southwell Keely for DIEP procedures. You pretty much can’t go wrong with her. Feel free to PM for more info if you’d like.
Anyway, good luck with your decision. Just please do more research in the time you have to be sure you’re happy with what you choose ♥️

Sister

I won't try to give you advice (or surgeons as I'm in a different state) but as @FLClover said, radiation can affect outcomes.  My surgeon, who is quite respected for his outcomes, told me that as I would need radiation, he would not consider recon until he was satisfied that the skin and scar was good enough to proceed.  I had very little problem with radiation side effects and I only got the nod last December, 3 years after surgery - much longer than he thought it would take.  I'm also quite small but he has recommended that the best for be would be to take the tissue from the stomach.  I've chosen at this stage not to reconstruct.

I should say that I had ILC, which is sneaky, but to my limited knowledge, even with IDC they won't know for sure how big it is until they go in.  For me, I ended up with a beautiful lumpectomy only to have a mastectomy a week or so later - but that is lobular.  Do I regret the mastectomy?  I regret the need to have it but I don't regret the decision to excise any suspect tissue.

I can't answer your questions about future recons and I'm nowhere near expert enough to make judgements about the processes but if you're keeping the breast, aesthetics will be important I would think.  And be aware,  I doubt you will have much sensation from the nipple (though again, I could be wrong).

Good luck with whichever you choose.

iserbrown

"Types of breast cancer" https://www.bcna.org.au/understanding-breast-cancer/what-is-breast-cancer/types-of-breast-cancer/

"Types of surgery | Breast Cancer Network Australia" https://www.bcna.org.au/understanding-breast-cancer/treatment/surgery/types-of-surgery/

@skbr

A couple more links for you to read and garner questions from

Within the Reclaim Your Curves website is a pdf " Questions to ask your Surgeon " link I put up earlier 

We are all different in diagnosis and treatment and if there are underlying health issues et cetera 

You mentioned implant.   Check to see if that is a Temporary Expander first and implant weeks or even months later.  I was 6 months between. 

There's no right or wrong!  It is what is best for you

Take care

NeG

Hi SKBR - your situ  sounds very similar to mine.  I too met with Cindy Mak and Dr Rippy.  I had 3 lumps grade 2 and Grade 1 IDC.  Mak suggested lumpectomy and flap recon with radiation, but ordered an MRI to assess first what was going on to be sure that was the right way to go.  Rippy suggested a mastectomy with immediate recon because she thought there might be more activity in there - no radiation.  Rippy showed me lots of recon work she had done - all of which looked really well done.  She also recommended me former patients to talk to.  The doctors both seemed great but in the end I chose to go with Rippy and I was not disappointed.  The resulting pathology showed that the Mastectomy was the right way to go - there were in fact 11 tumors, most tiny.  The largest being 2.7cm.   I am now three weeks post surgery, nipple sparing and skin sparing and the boob looks good.  Still bruised and battered and nipple a bit scabby but Dr Rippy assures me it will come good.  The question then became would I need both chemo and radio as the pathology revealed there was more going on than initially thought - however I was node negative, 100% Pr/ER positive so a good candidate for hormone treatment.  I have sent off to do an oncotype DX text to the States (goodbye $5k) - that will confirm for sure best treatment for me.  While my initial thoughts were lumpectomy, what I didn't want was to then have to go back because the margins weren't clear.  Mastectomy was the right choice for me.  Keep talking to your surgeons and other people so that you know for sure you have arrived at the right decision for you.  I felt "ready" by the time the surgery rolled around - I had explored all avenues and felt that I made the right decision.  I think this has helped in my post surgery state of mind which has been very good.  Good luck with your journey. X

Skbr

NeG said:

Hi SKBR - your situ  sounds very similar to mine.  I too met with Cindy Mak and Dr Rippy.  I had 3 lumps grade 2 and Grade 1 IDC.  Mak suggested lumpectomy and flap recon with radiation, but ordered an MRI to assess first what was going on to be sure that was the right way to go.  Rippy suggested a mastectomy with immediate recon because she thought there might be more activity in there - no radiation.  Rippy showed me lots of recon work she had done - all of which looked really well done.  She also recommended me former patients to talk to.  The doctors both seemed great but in the end I chose to go with Rippy and I was not disappointed.  The resulting pathology showed that the Mastectomy was the right way to go - there were in fact 11 tumors, most tiny.  The largest being 2.7cm.   I am now three weeks post surgery, nipple sparing and skin sparing and the boob looks good.  Still bruised and battered and nipple a bit scabby but Dr Rippy assures me it will come good.  The question then became would I need both chemo and radio as the pathology revealed there was more going on than initially thought - however I was node negative, 100% Pr/ER positive so a good candidate for hormone treatment.  I have sent off to do an oncotype DX text to the States (goodbye $5k) - that will confirm for sure best treatment for me.  While my initial thoughts were lumpectomy, what I didn't want was to then have to go back because the margins weren't clear.  Mastectomy was the right choice for me.  Keep talking to your surgeons and other people so that you know for sure you have arrived at the right decision for you.  I felt "ready" by the time the surgery rolled around - I had explored all avenues and felt that I made the right decision.  I think this has helped in my post surgery state of mind which has been very good.  Good luck with your journey. X

Wow, our situations sound almost exactly the same! It’s a relief to hear you had a good experience with Dr Rippy - I was worried because I couldn’t find much info/reviews. Did you go via Mater or North Shore Private?

Skbr

MicheleR said:

Hi @Skbr,

Sorry you are here and have this difficult decision. I cant personally help you with this as i havent been reconstructed. There is a group on here that the admin @Giovanna_BCNA may be able to sort you out with. 

One of the other very knowldgeable ladies will probably come on here and give their experiences so hang in there. 

Hope you are ok. Its a bit shocking at this point i know and rushed. 

My tumour was large and i had a mastectomy but different kind of cancer so I cant advise there either. What i will say is that a mastectomy wasn't as bad as i thought. I didnt react badly to seeing the end result. Will having a lumpectomy allow you to breast feed if you want to have children? Is that a consideration?

Hugs
Michele

Thanks so much for your kind response. Sorry it’s taken so long to reply, I’m a bit overwhelmed. I’m not sure if you can breastfeed after radiation? I think it changes the breast texture & milk ducts completely? I’ll definitely ask though, thank you x

Skbr

Julez1958 said:

Hi sorry you have to be here.
I was diagnosed with a 5.5 cm lobular cancer in my left breast.
At the first consult with my ( very experienced) breast cancer surgeon he talked about a choice between lumpectomy and mastectomy but that was when we thought the the cancer was 4.5 cm.
At the second consult he said it was my choice but that it might be he could not get clear margins with a lumpectomy given the extent of the tumour and then I would need a mastectomy anyway.
I am 62 and that may have been a factor but I decided to go the mastectomy route.As it turned out the cancer was more extensive through the breast ( apparently that’s a lobular thing) so the mastectomy was the right choice.
I had  a skin sparing mastectomy with insertion of tissue expander ( plastic surgeon operated with breast cancer surgeon) and will have a DIEP flap surgery in the next few months.
its a lot to take in and not an easy decision to make, I asked my surgeon what he recommended and he said “ it’s your choice, I can only give you the pros and cons”.In my case my breasts were E cup so there was the possibility of still having enough breast tissue with a lumpectomy.It would have been a lot easier decision if I was a smaller cup as it would have leant much more towards a mastectomy then.
I got a reduction in my other breast and don’t regret my decision at all.
It might be worth  joining the “Choosing Breast Reconstruction group here to see other people’s stories. Hope that helps.

Thank you for your advice. A mastectomy sounds very scary to me, but I am leaning towards that option. Could I ask how you found the tissue expander? Is it painful/uncomfortable?

Skbr

lrb_03 said:

Such a personal decision
I will say that my surgeon recommended lumpectomy, and I went with her recommendation. I ended up with a re-excision as margins weren't clear even after chemo. 5 years down the track, some additional breast shrinkage post radiation and my treated breast is at least 30% smaller than the other. Significant enough that I  wear a partial breast form.  I'm waiting for some revision surgery that's been delayed by Covid, then other health reasons.
If I'd known all that then, I probably would have pushed harder for a mastectomy. I didn't have to think about it so I still don't know what I'd do about reconstruction 

Thank you! That’s so helpful. I am thinking the same thing - my cancer is a few tumours over a 5cm area, and I’m only a small C cup. If I have a large lumpectomy with radiation my surgeon said I’d be around a cup size smaller. I’m already self conscious about my size/shape.. 

I’m wondering if by trying to keep my natural breast, am I going to end up with a worse cosmetic result and worse health outcome? 

Can a standard breast implant augmentation be performed after your lumpectomy/radiation? Or a fat transfer?

Obviously beating the cancer is my priority, but I think maybe focusing on the aesthetic side is helping me cope/distract from the whole situation. 

Skbr

FLClover said:

Hello @Skbr 🙂
Tbh, I’m surprised Cindy Mak would’ve suggested an implant at the time of mastectomy, knowing you’d need radiation. I’m not a doctor, and even I know radiation damages implants, so it’s very odd that she’d suggest that. 

I don’t think I’d try to save my breast tissue at any cost. It would depend on a number of factors: tumour size and grade, breast size, importance of aesthetic outcome to you etc. I chose to have a nipple/skin sparing mastectomy because I had multifocal and simultaneous bc, so there was a lot of activity going on in there. I thought just take it all away to ease my worry. But there was the possibility of needing radiation, so I had tissue expanders inserted. They are great for radiation. So Dr Rippy’s suggestion sounds better for me. After radiation, if you take a break of about 6 months, that should give your skin enough time to heal so that putting implants in would be more successful. Radiation does change the skin and shrinks it, but implants are still successful in lots of ladies, especially with a fat transfer. 

Of course you could try and save your natural breasts with a mammoplasty, then you could still have radiation. Def an option I think. 

In regards to surgeons, I’d strongly recommend Eva Nagy. She’s very well trained in all these procedures, especially breast conserving surgery (mammoplasty). I know a few ladies who are very happy with her work, myself included. She’s a bright spark in the bc world. She also works with Dr James Southwell Keely for DIEP procedures. You pretty much can’t go wrong with her. Feel free to PM for more info if you’d like.
Anyway, good luck with your decision. Just please do more research in the time you have to be sure you’re happy with what you choose ♥️

Thank you for your very thoughtful response- it was very helpful. And for your surgeon suggestion! My tumor area seems to be quite large with a few satellites (~5cm). Could I ask how you found the expanders? Are they deflated at the beginning? And inflated for radiation? What does radiation do to the skin? My skin is very sensitive so I’m worried I will react poorly.. 

FLClover

No problem at all @Skbr 😊. I had similar, cos I had the two tumours in my rightie plus the satellite. My expanders were put in already filled. When my rad onco thought that only my right breast would be irradiated, she said it would need to be filled first cos the radiation shrinks the skin (and can thin it too). That way it would stay as big as my left one. But I ended up having them both done, so there was no need to inflate them more. For radiation I wore Mepitel film, cos my skin is also very sensitive. I’m very white, so I was freaking out. But I had no problems at all, cos it’s very good and protective. I’m not sure how the inside of the skin is, but the outside is fantastic. I also used and still use lots of moisturiser, and aloe vera gel straight from the plant. It works wonders. I skipped chemo. 

I also replied to your PM. 

Good luck with it all 🍀💖