Decisions to make leading up to the mastectomy
Written April 3, 2022
One of my biggest frustrations about the process was that there wasn’t a clear guide for what to expect. I’d have to make decisions about things that I was lucky enough to have stumbled upon and learned about in someone else’s blog post. Yes, the doctors gave me LOTS of information, but it can be overwhelming at times (aka most of the time). So I thought I’d compile a list of some of the decisions I had to make during the journey. Many, I’m so glad I discovered prior to the relevant doctor appointment, so I could research them first. (I spent probably 50+ hours researching mastectomies, by reading blogs like this one.)
Here are some of the decisions my surgeons or I had to make:
1. Your medical team
You’ll likely have 2 main doctors you work with: your oncology surgeon (who does most of the mastectomy) — or “OS” — and your plastic surgeon (who reconstructs your breasts) — or “PS”. I loved both of my doctors, but I do have to say that because I didn’t have cancer, my time with my oncology surgeon was limited, so I ended up spending a lot more time with my PS than my OS. That being said, my OS (Dr. Tadros) was one of my favorite doctors in the world, and my PS (Dr. Dayan) is the absolute best breast PS out there, so I recommend checking them both out. But do your homework on yours, and make sure you like both of yours – especially since you’ll spend a lot of time with your PS, and obviously your life will be in the hands of both of them. By the way, I put together a list of questions I recommend you ask your doctors since most doctors don’t think of telling you everything unless you ask, so feel free to use this list to make sure you check off some of the big questions. (Trust me, some of this stuff they won’t tell you unless you ask, and you’ll want to know ahead of time.)2. Over vs. Under the muscle
Doctors can put implants over the muscle or under the muscle. My doctor said MSK always tries to do Over the Muscle unless there is a medical reason they can’t. After researching both, I believe OTM has way better recovery times (on average) and less likelihood of the patient needing physical therapy, so I happily went with OTM.
3. Silicon vs Saline
A decade ago, research came out that basically said silicone implants led to cancer. However, many years later, science has come far enough that they now create silicone implants that do not cause cancer. (Someone I know was actually on the legal team that sued the original silicone implant company, and even SHE went with silicone implants after her recent mastectomy!)... So doctors often let you choose which you want. Mine told me that if he is doing OTM (which he does almost always), that 90% of the time he’ll also do silicone, since saline implants are more likely to ripple – especially if it’s OTM. That being said, mine did give me the choice. He also let me touch each of the different options. He had told me that silicone felt the most real, and I totally agreed with him after feeling them. (Note: there is also a kind called “Gummy”, but MSK didn’t offer gummy, so I won’t go into that option. But it’s worth asking if your hospital offers non textured gummy bear implants so you can see if you like those.) You should also ask your doctor about how often you have to go in for MRI’s once you get the implants. Yep, you heard that right. Essentially, most implants break or rupture 15-20 years after you get them, so once that happens, you’ll likely want to go in and get it removed and/or replaced. For silicone implants, they ask you to go in every 3-5 years to check in on the implant and make sure it didn’t rupture. Ask your Plastic Surgeon for more information. It’s a lot safer and less scary than it all seems, from what I learned.
4. Direct to Implant (DTI) vs Expanders
This won’t be up to you, but your surgeon will let you know if you qualify to do all of the mastectomy and reconstruction in one procedure (“Direct to Implant”) or if they need to go through two surgeries – one where they take your breast tissue out, and a second where they put the implants in. See later blog posts for more on this.5. Size
What size breast do you want after this is all done? I guess this is one of the cool aspects for people who were unhappy with their breast size before. For me, I was actually really happy with my body, so I just told the doctor that I wanted him to make my chest look as close to the same as it had. Side note - I don’t know why, but it annoyed me a bit when people heard about my mastectomy and said “Well at least now you can get the breasts you always wanted!”... I understand that they were just trying to be nice, but I always wanted to respond “actually, I have to go through all of this to go back to my real breast size, and not just that, but they’ll never look the same due to the surgery, and that sucks.”
Quick note: if you’re not “DTI”, which I talk about in another blog post, you’ll have expanders that allow you to test different sizes until you’re comfortable. You can also compare the size to whatever your original size was (in “cc”, the measurement unit doctors use, which they’ll know after your surgery). From what I understand, it then takes 1+ months for your implants to settle into the ‘permanent’ size after your reconstruction.6. Cut
Again, not something you have control over (the surgeons do), but I’d recommend asking if you qualify for “Wise Pattern Incision”, and if so, ask to learn more. This is a cut that makes it so that they cut along the bottom perimeter of the breast and create almost an anchor cut, as opposed to across the breast, making it so you can’t even see the cut when you look down at your own chest. I felt very lucky to be able to get my surgery done this way, but be warned: only some surgeons know how to do this, and I’ve heard horror stories of doctors trying it for their first time and doing it incorrectly, since it’s a different technique than the typical mastectomy.7. Nipple-Sparing
You can keep your original nipples on your breasts, but that means you’re leaving a ~1% chance of breast cancer. If you do want to “spare” your nipples, some surgeons may require you to first get a breast lift if your breasts are large enough, meaning you have to go through an additional surgery prior to the mastectomy. If you decide not to spare your nipples, you can choose to either get a tattoo of a nipple/areola, and/or have them recreate a nipple using tissue or prosthetics.8. When to have your surgery
Here were the restrictions I considered when deciding when to do my surgery: I needed six weeks of time where I would not need to lift anything or do anything strenuous (no moving, for example); 2 weeks of time when I could take off work (and do NOTHING but watch tv); 1-2 weeks of time when I could find someone to help take care of me (in this case, my husband and my mom), several weeks of time where I wouldn’t need to be in pictures or attending events; and 3-4 months of time when I could regularly go into the doctor’s office for appointments. I chose to do this in Q1 2022, right after my wedding / honeymoon. Note: you’ll probably want to consult surgeons many months before the time you actually want to get the procedure done – most surgeons have a backlog of patients for 2+ months before they can actually perform surgery on you, assuming this is prophylactic.9. Nerve Block
I’m not sure that every hospital offers nerve blocks, but this was the best decision I made about my surgery. I can’t explain what it is (ask your doctor) but I was asked the day of my surgery if I wanted it, being told >90% of people say yes, but that there are some risks (as there always are with anything medical). By getting the nerve block, I woke up with nearly no pain, and I continued to have minimal pain for almost 24 hours after surgery, which is when the block started to wear off (and my pain meds came in handy).
I’m sure there are more but these were 9 I could think of. Feel free to message me through this site if you have more that you want me to add!
