The goal of surgery is to remove the tumor. Breast cancer surgery varies from a partial to a total mastectomy, (or breast-conserving surgery, such as a lumpectomy.) Which one is done depends on what your breasts mean to you, your body image, the size of the tumor, the type, stage, and characteristics of the tumor viewed at the cellular level, and tumor tissue from your breast biopsy report. For example, if you had a type of breast cancer most apt to recur in the other breast or the probability is high for recurrence, you have a strong family history, and genetic testing comes back positive for the gene, you may opt for prophylactic bilateral mastectomies. Remember, most women will do well with a lumpectomy. Getting a bilateral mastectomy is actually fairly rare. Again, this is a personal decision that requires investigation.

A lumpectomy is usually done as day surgery at a surgical center or the hospital unless complications arise during the surgery. For a partial mastectomy, an overnight hospital stay is likely; a full mastectomy usually involves a hospital stay of one to two days, and a mastectomy with reconstructive surgery will generally require even longer hospitalization. Note that you need to let your surgeon and oncologist know if there is no support system at home or if there are any special considerations that may hinder your recovery. Perhaps you are the primary caretaker for a disabled child or other family member. This may alter your hospital stay requirements and you may need to stay an extra day. However, you may need to look at your insurance coverage and discuss it with your doctor. We will discuss insurance coverage in Chapter 6, including how to work with your coverage.

Surgery is stress-producing and a violation to your system. Breast cancer surgery has added stresses and, unlike most other surgeries, has more of an emotional impact associated with it. For example, when you have stomach or heart surgery, you can focus on the healing of your incision and perhaps consider some lifestyle changes in your recovery process. With breast cancer, surgery is often only the beginning of your treatment plan. It seems as though you need to not only heal from your surgery, but also think about what lies ahead in your treatment, and deal with a life-threatening illness and the physical and psychological factors associated with it.

Prepare yourself for your surgery by keeping your mind, body, and spirit focused and healthy. Prior to surgery, you can expect to meet with an anesthesiologist and it is your responsibility to share any pertinent medical history, previous experience with anesthesia or the experiences of your immediate family regarding anesthesia. The anesthesiologist will be looking for clues as to what type of anesthesia to use and your medication reaction history is important to determining this.

Post-surgery is the first time you will have a clear snapshot of your breast cancer situation and it is a more critical time for you, along with your doctor, to determine further treatment choices.

Side Effects

Post-surgery, expect to have discomfort in your breast and under your arm if an axillary dissection was done. Many breast cancer centers offer a pillow to use under your arm to alleviate this discomfort.

In Her Own Words

When the lumpectomy did not get all the margins and the tumor was larger than they thought, I had the choice of another lumpectomy or a mastectomy. I had DCIS [ductal carcinoma in situ] in one breast and it was not invasive. I met with a medical oncologist, a radiation oncologist, and a plastic surgeon about my choices. I got all the facts of reoccurrence. I decided to get a double mastectomy with reconstruction at age 42. For me it was what I needed to do to have the best chance of never having to deal with this again.

— Theresa, age 46, 4-year survivor

After having surgery, you may notice a numbness or tingling sensation in the affected breast. This occurs because nerves were damaged during the surgery. No further breast cancer treatment can begin until the surgical area heals and there are no signs of infection. You can expect a four- to six-week wait, but this also depends on your healing ability and your readiness to begin treatment.

Other possible side effects that may result from your surgery include infection at the site of surgery or more serious infections that spread through the body via the blood system.

Reconstructive Surgery

A total or simple mastectomy operation involves the removal of the entire breast but does not cut away any lymph nodes or muscle tissue. The surgeon tunnels under the skin all the way up to the collarbone to remove the breast. Drains are placed in the incision to prevent fluid building up in the empty space. If you are not having immediate reconstruction surgery, then the incision is closed and you will have a bulky wraparound dressing. The breast's nerve supply has been cut so the area around the scar will be numb permanently. Later a volunteer from the American Cancer Society's Reach for Recovery program will visit either in the hospital or at your home to discuss prosthesis and other fears or concerns. The Reach to Recovery volunteer has experienced breast cancer surgery and understands from a personal perspective about your experience. Resources and helpful tips are shared at this visit and, most importantly, it gives you the opportunity to share your concerns and fears and about the physical changes that are occurring.

If you opt for reconstructive surgery over the use of prosthetics (and this option is available to you) reconstructive surgery can be done in various ways. The breast can be surgically reconstructed using artificial substances such as silicone or your own body tissue.

The silicone implant (the simplest reconstructive method) is placed behind the pectoral muscle and then the skin is sewn over it, almost like a pocket. Then, where an implant has been placed under the skin, saline is injected slowly over a period of six months until you reach the size you want. Then the expander implant is removed and replaced with the silicone sack.

In a procedure using your own tissues, called a myocutaneous flap, a flap of skin, muscle, and fat is taken from your back or your abdomen to reconstruct the breast. In this type of surgery, tissue is taken with a feeding artery and vein and then planted in the breast and sewn over with the blood supply still intact. This feels more like your own breast because it is your own tissue that is being used, but it will still not have the sensation of a normal breast. For this type of surgery you can expect to stay in the hospital for four to five days.

When you meet with your plastic surgeon to discuss breast reconstruction, it is a good idea to bring someone with you to your appointment. It is difficult to comprehend all that is being said and having another set of ears can be helpful when taking notes and deciding on the reconstructive surgery that is best for you. It is also a good idea to ask the plastic surgeon to show you before and after pictures of her work, to give you a good idea of what to expect. Also the plastic surgeon will explain that initially you will not have a nipple but that can be created at a later time by various methods such as tattooing or taking skin from your thigh, which darkens when it is transplanted.

The decision to have reconstructive surgery is a personal choice, and there are many factors to consider when making the decision as to which type of surgery you will have. Psychologically, it may be easier to accept losing your breasts when you have it done at the same time as your mastectomy and you see that there is a replacement there. On the other hand, it may delay the adjustment process to the reality that you have had breast cancer. Many breast experts favor immediate reconstruction. For many women, the ease of not wearing a prosthesis and looking normal in a bathing suit and in their clothes offsets the time and effort it takes to go through reconstructive surgery. The choice of having reconstructive surgery at a later date is also a viable option if a woman is not ready emotionally or physically at the time of her breast surgery.

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