Six-Month Checkup and Discussion of Surgical Options

A few weeks ago I had my 6-month checkup.  At each 6-month visit I alternate imaging between mammography and MRI.  This visit I was scheduled for a mammography.  The good news is that mammographies are quick compared to MRIs.  The bad news is they hurt. Oh well.  I’ve been getting them for years, so I’ve accepted that the discomfort is short-lived.

Since enrolling in the Memorial Sloan Kettering Cancer Center (MSKCC) High Risk Program, I get all my imaging done in their Bergen County facility, about 20 minutes from my house. The best part of working with MSKCC is that I get my results almost immediately.  An hour later I received the good news—no changes, images were clean.

After the imaging, I had an appointment with the clinic’s PA.  Jessica is wonderful.  I feel like I’m talking to a friend when I meet with her every 6 months. At each visit she does a thorough manual breast exam, but we spend most of each visit just talking.  She asks how my family is, how I’m feeling, and what’s on my mind.  She lets me take the lead.

At this visit, I told her that I’ve been thinking more and more about surgery. I asked her about the surgical options, especially with regard to reconstruction.  Here is what I learned.

In a mastectomy, the breast tissue is removed.  (No news there).  However, what happens next is very individualized.  That’s what we spent most of our time discussing.

One option is to forego reconstruction.  In colloquial terms, this is known as “going flat.”  All of the breast tissue is removed and just enough skin is left for the surgeon to neatly sew everything up.  This is the simplest and fastest option, and many women opt for this and are very happy with their results.  They like the freedom of not wearing a bra, and can wear a prosthetic device on the occasions when they want the look of breasts. 

I don’t think I could choose that option.

Another option is reconstruction with implants.  The breast tissue is removed, and a silicone or saline implant is inserted where the breast tissue was.  In some cases, women can have this done in a single surgery (known as direct-to-implant) but more often the reconstruction is a separate surgery.  At the time of the mastectomy the patient is given expanders, which are similar to implants but are gradually filled with saline to stretch the pocket where the implant will go.  Once the skin and pocket are at the appropriate size for the implant, the expander is removed and the permanent implant is inserted.  The patient has some flexibility regarding what size implant they want; many women go larger or smaller than their natural size.  I’ve spoken to many people with implants, and they are pleased with the results and the process.

What are the negatives with this option? Many people don’t realize that breast implants are not permanent.  They are designed to last 10-15 years, at which time they need to be replaced.  Also, while both saline and silicone implants are considered safe, they can rupture or leak. 

With implants, mammograms are still required and may be more complicated.  Also, implants can often feel unnatural.  Finally—and this can be true for all mastectomies—sensation is typically lost, including sensitivity to sensation as basic as heat vs cold. All the nerves are cut.

The third option is autologous reconstruction.  I must confess this option intrigues me the most.  In autologous reconstruction, the breast tissue is removed and replaced by the patient’s own body fat.  Typically, the fat comes from the abdomen, although it can come from other locations on the body as well.  The more common term for this is a DIEP flap.  Pronounced “deep,” the acronym stands for Deep Inferior Epigastric Perforator.  During surgery, the plastic surgeon removes skin, fat, and blood vessels from the lower belly (below the belly button), and reshapes it and attaches it to the chest to form a new breast.  The abdominal muscle is undisturbed.  Basically, it’s similar to getting a tummy tuck.

There are many advantages to DIEP flap reconstruction.  One is that it uses the patient’s own body tissue; no implants are inserted into the chest.  That aspect really appeals to me.  And since there are no implants, nothing needs to be replaced in 10-15 years.  The fat feels more natural than an implant, and some women report that they regain some sensation.  An added benefit, I must confess, is the flatter stomach when the fat is removed.  Also, in autologous reconstruction, no more mammograms are needed.  This all sounds great, right?  So why don’t more women select this option?

Because there are big disadvantages as well.  There is an additional surgical site which means a longer surgery and longer recovery.  A microsurgeon is required since reconnecting blood vessels is part of the process.  All of this results in a longer hospital stay.  If you have a young children, are just want a faster recovery and quicker return to daily activities, implants are surely a better option.  Also, since the surgery is more extensive, the presurgical workup is much more thorough; surgeons won’t perform the procedure on women who have medical issues such as clotting and cardiac abnormalities, and women who are thin or who have had other abdominal surgery may not be candidates.  Also, the patient is left with a large scar across their belly.  I confess, from the photos I’ve seen, this large incision extended across the entire width of the abdomen bothers me.

Of course, I don’t need to have surgery at all; I can continue with twice-yearly screening and monitoring.

Sooooo much to think about.