So Much to Process

I had appointments with both the plastic surgeon and the breast surgeon this week to review the surgeries and sign the consent forms.  There is so much to process!

The surgery will take place at Memorial Sloan Kettering in NYC on August 1.  I will find out the night before exactly what time to arrive, but it will probably be around 6 AM.  The mastectomy part of the surgery will take about 1-1.5 hours, and the reconstruction can take anywhere for 5 to 8 hours. I was surprised to learn I would probably spend only 2 nights in the hospital.  They will approve a third if I need it but they typically try to get patients home as soon as possible.

I met with Dr. Mamtani, the breast surgeon, on Tuesday.  She explained the mastectomy process.  I will have a skin-sparing mastectomy.  In this procedure, she will make incisions around the areola and remove the nipple and areola, and through that incision remove all of the breast tissue.  Nerves will be cut, resulting in little to no sensation in the breasts.  The skin remains—it is considered a different organ and it is healthy so there is no reason to remove it.  The skin creates an envelope where the fat will be inserted, then the envelope is closed up (that’s the plastic surgeon’s purview).  The breast tissue is routinely sent out for pathology; it takes about 2 weeks for the results to come back. 

This procedure will reduce my risk of getting breast cancer to 1%; however Dr. Mamtani said this is really a theoretical number because they never want to say 0%.  Realistically, I will never have to worry about getting breast cancer for the rest of my life.  We had briefly discussed doing what is called a nipple-sparing procedure, where the nipple and areola remain.  However, this requires leaving behind a small amount of breast tissue.  Since the whole point of this procedure is to remove breast tissue to reduce the risk of getting cancer, it didn’t make sense to me to go through all of this and leave breast tissue behind.

The major risks from this part of the surgery are infection and bleeding.  I will be monitored in the hospital closely.  Any complications usually happen within the first 24 hours. 

On Monday I had undergone a routine mammogram; we reviewed the results on Tuesday.  It was exciting because it is probably the last mammogram I will never have.  The results were clean.  Because of this, there is no reason to involve the lymph nodes in the surgery, which is great news. 

I met with Dr. Dayan, the plastic surgeon, on Monday.  He will do the reconstruction part of the surgery.  That is by far longer and more complicated than the mastectomy itself.  Much of our conversation was spent reviewing the surgery, risks, procedures, etc.

After the mastectomy part of the surgery is complete, Dr. Dayan and his team come in.  He will make a hip-to-hip incision between the belly button and pubic line, remove abdominal fat, skin, and blood vessels, then pull the skin flap down over the incision (that’s the “flap” part of DIEP flap).  He will then use that tissue to mold two new breasts, reattaching the blood vessels from the abdominal tissue in the breasts.  The time-consuming part of the surgery, and the skill necessary to perform it, comes from the microsurgery necessary to reconnect the blood vessels from the abdominal tissue to the blood vessels in the breast area. 

Part of the procedure involves getting a new belly button.  The belly button visible on the body is connected under the skin to the umbilicus, which is connected to the liver so it cannot be moved.  However, when the skin flap is pulled down, the umbilicus is covered up by the skin, so a new belly button must be cut.

The surgery involves many risks which we discussed.  They include:

• Necrosis.  The primary goal of the first phase of this surgery is simply to get the breasts to live.
• Possibility of removing some abdominal muscle, resulting in some abdominal weakness
• Possible need to insert mesh in the abdomen to support the abdominal wall
• Removing a small portion of rib cartilage on each side of the chest
• Bleeding and infection
• Loss of sensation. Dr. Dayan is going to perform a nerve graft using a cadaver nerve in an attempt to preserve some sensation.  The procedure is still experimental and works a little less than 50% of the time.
• Hernia/abdominal bulge.  The mesh can help prevent this.

The goal of the initial phase of this surgery is to get the breast to survive and create the overall shape of the breast.  There will be a second surgery, commonly known as “phase 2,” to create the final shape and size of the breast as well as fix any ripples and indentations, fill out the breasts, and clean up scars.  That will take place about 3 to 6 months after the initial surgery and is done on an outpatient basis.  The final size will be determined based on the amount of abdominal fat that is available to be transferred.

Nipples can be reconstructed after the breasts heal.  There are several options for this but we did not discuss this in detail yet.

I will leave the hospital with several drains, probably 6 to 8.  They will need to be emptied twice a day, and the fluid measured and recorded each time.  I was disappointed to learn that insurance generally doesn’t cover visiting nurse services.  This is a problem because I probably won’t be able to empty the drains myself.  This wouldn’t be a big deal if Evan were around.

My brother-in-law Rick has graciously agreed to do this for me.  This will involve him coming to the house twice a day for several weeks.  I feel so bad about him doing this, but I’m also very grateful.  I hope that he will be able to teach Jon how to do this, and perhaps at some point I’ll be able to do it myself.