I'm kidding.
Two surgeons because one is the oncology surgeon who performs the mastectomy and the other is the plastic surgeon who begins the reconstruction. My visit with my oncology surgeon last week had rekindled a lot of confidence in me as chronicled in my post "Picture Everyone Bald". I was hoping to keep that momentum going but it didn't happen that way at this visit. While I was at the office for almost an hour a good portion of that was pre-operative necessities such as filling out paperwork, photos and q&a time with the office nurse. I spent about a quarter of that time with the doctor to discuss what conclusions I'd come to and any concerns that still lingered.
I've come to learn that a mastectomy isn't simply "a mastectomy", there are many different ways to approach the procedure. I've also learned that reconstruction isn't simply "reconstruction" but there are many decisions to be made regarding the type of reconstruction with a number of possible outcomes. If a patient chooses reconstruction that process is usually (not always) begun at the time of the mastectomy. That is why I have met with two surgeons in the span of one week and two days.
For a woman faced with need for a mastectomy there are a number of decisions to be made:
First, will it be a single mastectomy or bilateral? The answer to this will typically depend upon the risk involved in keeping the other breast in tact. If there are genetic factors that heighten the risks, as is my case, then a bilateral mastectomy is typically recommended or chosen.
Secondly, will it be a nipple sparing or skin sparing (just what they sound like) mastectomy? This typically depends upon the patient's pre-operative size and shape. Sometimes the type of cancer/tumor is a factor in this decision for doctor and patient.
Third, with or without reconstruction? This, as I've already explained, is a complex question. It's been a very difficult decision for me to make, and even though I've made a decision, I feel like I haven't really made a decision. For me, at my age and activity level, reconstruction is a given. There are many women who have chosen the mastectomy without reconstruction who utilize prosthetic bras and are content with their decision. That was something I could not fathom for myself.
So, reconstruction it is.
At my last visit with my plastic surgeon I was dealt a devastating blow. I touched on this in my "I Have to Tell it Like a Story" post. When I was told, way back in March, that a mastectomy was my best option to deal with my cancer and given the risk factors involved, I spent much time talking myself into the idea. I read and re-read about the different types of surgeries, including reconstruction. I asked questions, and read some more. I looked at pictures and read and prayed for peace. I finally settled on bilateral mastectomy with DIEP flap reconstruction. To put it very plainly, the reconstruction would be to take excess fat tissue from my abdomen and relocate it to build the breast mound on my chest. This was a comfortable decision for me because I liked the idea of the reconstructed breast being from another part of my own body (no implant, prosthetics, etc). It seemed the more natural choice. The surgery, as it was explained to me, was not an easy one as not only fat tissue but also veins would need to be transplanted. All in all the surgery would take about 10 hours. I spent much time preparing myself for this and mentally/emotionally reached a place where I was peaceful with the choice. At the end of June at my last appointment with the plastic surgeon, all of that changed. Due to being unable to eat during chemotherapy I had lost all of that fat that was going to be transplanted and was no longer an eligible candidate for the DIEP flap reconstruction. I couldn't discuss any other options at that time. I was in tears and could not make myself stop crying.
It's been a month now. It really only took about a weeks time for me to collect myself once again and consider my options, now limited, for reconstruction. It came down to implants. There are two types of implants, silicone or saline. Not only that but the size, timing and placement of the implants are other factors to consider. Some women are candidates for direct implant, meaning, at the time of the mastectomy implants are placed and there are no further surgeries required. Other women have to take into consideration the effects of future radiation treatments on their skin, such as a tightening or toughening of the skin which can impact the size or type of implant they would receive. In such cases reconstruction is often postponed but tissue expanders may be placed to stretch the skin as far as it can be stretched at time of surgery with the plan to expand more once radiation treatment has been completed.
Since I will not be having radiation I was hoping for a direct implant at time of mastectomy. I am not a fan of surgery and have had many in my day. If I could avoid one more, that's what I would do. However, at my appointment friday when I brought up my wish for a direct implant I was told that would not be the best option for me. Expanders that would be placed at the time of mastectomy then filled slowly over the course of the next few weeks after surgery, were the recommended course of action. After the expanders are filled another surgery to place the implants would be performed. The second surgery in the reconstruction process is just another step, two or more out-patient surgeries are required for detail work. All in all this process spans over the course of about one year. My thought/feeling of "I just want to have the surgery and be done with it" does not work in this scenario.
I've heard other women talk about their surgical decisions and they seem so confident in their decisions. I don't feel confident at all as I've tried different decisions on for size. I haven't found a decision that feels right just yet. I know what I should do, or even must do, but something is nagging.
Despite the nagging I am so thankful for kind and patient surgeons who take the time to answer my questions, allow me to get to know them a bit so that I feel more comfortable, and who are skilled at what they do. I know I'm in good hands and in a good place in this process but I've come to realize a difficult truth: there are just no simple decisions here.
So I will do what I've done all along and continue to seek the peace. I'm near it, I know, but complicated decisions just take time.
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