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Topic: Same surgeon for mastectomy and reconstruction?

Forum: Breast Reconstruction —

Talk with others facing decisions about whether or not to have breast reconstruction, and if so, what type and when.

Posted on: Jan 15, 2022 03:46AM - edited Jan 15, 2022 04:04AM by Sarah_78

Sarah_78 wrote:

Hi everyone,

last week had been one of the hardest weeks after the week of the diagnosis so far. I have finished neoadjuvant chemo on the 7th of January (TCHP) and this week had surgery consultancy with different cancer centers. Needless to say I am so confused and hoping maybe your experience might help me make a decision.

Surgery to attempt: one sided mastectomy (skin will be removed) and lymph node dissection,

Radiotherapy in discussion: Probably no radiation since I got radiated before for Hodgkin's Lymphoma. If there is still cancer cells in the breast, they might attempt to radiate only tumour bed, which might leave a hard tissue due to overlap at inner corner of the breast.

Reconstruction to be attempted: DIEP flap, with skin transplant as well.

Surgeon A: He was very interested, noted down tons of things, took an ultrasound, checked every detail and marked it for me where he would make the cut, which is terribly high and looks bad but I hope they can adjust it later. He scheduled me for MRI (don't know why, perhaps basis?). The catch was, he said he reconstructed it with another surgeon together (micro surgeon) and that they were booked for a year. He wanted me to wait for 2 years before attempting that anyway due to probably radiotherapy.

Surgeon B: Easy to talk to, he said he would remove everything then talk to plastic surgeon and radiotherapist. He also performed a detailed ultrasound and make some notes for himself.

Surgeon C: He first sent me for MRI type of mamography (the name escapes me) but never checked the breast himself. Instead his assistant did and we only spoke about what to be done. He'd remove everything and send me to plastic surgeons after seeing if anything left in breast and to what degree. Also radiology has to weight in and radiotherapy will be discussed. This surgeon is in a university hospital which is very well organised. They have a nurse on call for me for my surgery questions and everything is explained to the point of fitting prosthesis, motion regaining etc.

I am about to select Surgeon C in uni hospital because they are so well organized, which I value. Then comes my ONC and tells me to go to the surgeon who will do the reconstruction because he has to know how to cut the skin to be able to fill it up later on, if someone else does it, it might be wrong. He also says Surgeon A doesn't have such a specialist in their hospital, the person is coming from other side of the county only a few days and Surgeon C's reconstruction specialist is in a private clinic situated outside of the uni hospital.

Now I have to get an appointment with a breast reconstruction specialist, next week. (He is in the same hospital as Surgeon B, but different department)

I was just about to decide and enjoy the last 3 weeks with my left boob but oh well... Any thoughts/ideas/stories are appreciated. Do you think plastic surgeon should do lymph node dissection and mastectomy? Can he know how to get the cancerous stuff out properly?

Thanks for all the knowledgable supporting ladies.

Sarah

DIagnosed at 43, Hodgkin's Survivor (at 33) Dx 9/8/2021, IDC, Left, ER-/PR-, HER2+ Targeted Therapy 9/24/2021 Herceptin (trastuzumab) Chemotherapy 9/24/2021 Carboplatin (Paraplatin), Taxotere (docetaxel) Targeted Therapy 9/24/2021 Perjeta (pertuzumab)
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Jan 15, 2022 06:57AM - edited Jan 15, 2022 06:58AM by 1982M

I'm confused. You would like surgeon C but your oncologist does not?

The best person to do your mastectomy is a breast surgeon. The best person to do reconstruction is a plastic surgeon. Some breast surgeons are trained in some ‘oncoplastic’ techniques. I’m not sure if many oncology based breast surgeons are also duel trained in microsurgery breast reconstruction. Have you looked at reviews and photos or results form them

Are you able to meet with plastic surgeons in surgeon C's network before choosing? (Im in Canada so your process is a bit confusing to me?)

Where I am from there are breast surgeons and plastic surgeons and they work together when a breast cancer surgeon needs reconstruction. Sometimes in the OR together and sometimes after.

Dx 7/13/2021, IDC, Left, <1cm, Stage IA, Grade 2, 0/4 nodes, ER+/PR+, HER2+ Surgery 8/12/2021 Lumpectomy: Left; Lymph node removal: Sentinel Dx 9/3/2021, DCIS, Left, Stage 0, Grade 2, ER+/PR+, HER2+ Targeted Therapy 9/22/2021 Herceptin (trastuzumab) Chemotherapy 9/22/2021 Taxol (paclitaxel)
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Jan 15, 2022 07:24AM ThreeTree wrote:

A very personal choice for sure, and I totally understand considering/desiring reconstruction, but with all you've described, are you certain you really want to go the reconstruction route?

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Jan 15, 2022 08:11AM abigailj wrote:

Sorry you’re going through this difficult situation. You mentioned wanting to have DIEP recon but if I understood correctly you were advised to wait because of likely need for radiation. My DIEP was immediate after a separate breast surgeon did BMX and was skin/nipple sparing and I didn’t have radiation so very different situation but I think it is critical have have a PS that has extensive DIEP microsurgery experience in order to have the most successful outcome if DIEP is your choice. I do recommend speaking with the PS affiliated with BS B - would he/she participate in the initial surgery in some manner to get the best cosmetic outcome once you can proceed with the DIEP? My best wishes for the best possible outcome.

Dx 1/2020, ILC/IDC, Both breasts, 2cm, Stage IB, 0/4 nodes, ER+/PR+, HER2- Surgery 6/23/2020 Mastectomy: Left, Right; Reconstruction (left): DIEP flap, SIEA flap; Reconstruction (right): DIEP flap, SIEA flap
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Jan 15, 2022 09:35AM Sarah_78 wrote:

@1982M, yes you are right, my onc doesn't like the surgeon C (who is also an onc). They are both breast surgeons but they both don't do DIEP flap but they could do mastectomy and lymph node removal. He says he wouldn't operate me himself because someone who knows how to construct should do it. I will get an appointment next week with plastic surgeon and also ask about photos, that is a good idea, thanks. Plastic surgeon in C's network isn't in the hospital but in a private clinic outside. I am not sure how that works but will ask that too.

@Threetree: they don't give me any lumpectomy option and I am not comfortable living lopsided.

@abigailj: It would be nice if surgeon B & plas. surgeon did the surgery together. I will ask but not sure if it is possible. After all mastectomy and lymph node removal is an easy OP, my onc told me plastic surgeon should be able to do it. I don't feel good about it though, he knows to remove tumor with right borders? Not sure.


DIagnosed at 43, Hodgkin's Survivor (at 33) Dx 9/8/2021, IDC, Left, ER-/PR-, HER2+ Targeted Therapy 9/24/2021 Herceptin (trastuzumab) Chemotherapy 9/24/2021 Carboplatin (Paraplatin), Taxotere (docetaxel) Targeted Therapy 9/24/2021 Perjeta (pertuzumab)
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Jan 15, 2022 12:00PM Dancemom wrote:

in my case, my oncologist breast surgeon made recommendations. I went with her top choice after I left my PS consultation confident in PS work. The surgery is a team effort after all.

My treatment involves such a big team and I know I am discussed at every multidisciplinary conference, so it is important to me that all my Drs have confidence in each other. I don't take their recs blindly, but I do approach them as "who makes the team stronger". It's not just how competent is an individual dr. It's also about the ease and flow of communication and discussions on diagnostic decision making.

Dx 3/16/2021, IDC, Right, Stage IV, metastasized to other, Grade 2, ER+/PR+, HER2- Hormonal Therapy 3/28/2021 Femara (letrozole) Targeted Therapy 4/20/2021 Ibrance (palbociclib) Surgery 1/3/2022 Lymph node removal: Sentinel; Mastectomy: Right
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Jan 15, 2022 12:05PM MinusTwo wrote:

Sarah - Usually a surgeon (maybe a breast surgeon) does the mastectomy and a plastic surgeon does the reconstruction. In my case - the mastectomy was done by a breast surgeon and the plastic surgeon was waiting to step in, finish the surgery & close. As others have said - a plastic surgeon has the expertise you probably want, so personally, I'd listen to my oncologist.

2/15/11 BMX-DCIS 2SNB clear-TEs; 9/15/11-410gummies; 3/20/13 recurrance-5.5cm,mets to lymphs, Stage IIIB IDC ER/PRneg,HER2+; TCH/Perjeta/Neulasta x6; ALND 9/24/13 1/18 nodes 4.5cm; AC chemo 10/30/13 x3; herceptin again; Rads Feb2014
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Jan 17, 2022 08:47AM Sarah_78 wrote:

I just talked to the plastic surgeon. He said "let one of the oncology/gyn get you flat, I can reconstruct after, no problem."

He also checked my tummy and thighs, said both would work but tummy needs to go in twice, with some fat grafting as second step but with PAP-Flap he would be able to do my left breast at one single time, then I'd probably need a matching surgery for right later.

Anyone who had PAP-Flap? I am reading it might be a little easier to recover.

DIagnosed at 43, Hodgkin's Survivor (at 33) Dx 9/8/2021, IDC, Left, ER-/PR-, HER2+ Targeted Therapy 9/24/2021 Herceptin (trastuzumab) Chemotherapy 9/24/2021 Carboplatin (Paraplatin), Taxotere (docetaxel) Targeted Therapy 9/24/2021 Perjeta (pertuzumab)
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Jan 17, 2022 09:04AM MinusTwo wrote:

Sarah - make sure they know to leave the extra/loose skin for the PS to use later.

2/15/11 BMX-DCIS 2SNB clear-TEs; 9/15/11-410gummies; 3/20/13 recurrance-5.5cm,mets to lymphs, Stage IIIB IDC ER/PRneg,HER2+; TCH/Perjeta/Neulasta x6; ALND 9/24/13 1/18 nodes 4.5cm; AC chemo 10/30/13 x3; herceptin again; Rads Feb2014
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Jan 17, 2022 09:12AM Sarah_78 wrote:

Plastic surgeon says he doesn't need the skin.... weird.

My onc was thinking he'd put a small implant to make sure skin doesn't collapse.

DIagnosed at 43, Hodgkin's Survivor (at 33) Dx 9/8/2021, IDC, Left, ER-/PR-, HER2+ Targeted Therapy 9/24/2021 Herceptin (trastuzumab) Chemotherapy 9/24/2021 Carboplatin (Paraplatin), Taxotere (docetaxel) Targeted Therapy 9/24/2021 Perjeta (pertuzumab)
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Jan 17, 2022 09:49AM RatherBeSailing wrote:

Sarah, my plastic surgeon said the same thing about just letting the breast surgeon get you flat and he would make it work.

I'm a little confused that you say skin will be removed during mastectomy, yet surgeon is saying he might be able to insert an implant?

If you do end up going through radiation, the skin may not be suitable anyway. I had a skin-sparing mastectomy and radiation, and the plastic surgeon ended up tossing the skin because of the degradation due to radiation. He used the skin from the stomach flap, and the insert is an elliptical shape. Looked odd at first, but as scars have faded it's okay.

You need to be comfortable with your PS, as it is a complicated operation both medically and aesthetically. If you like her/him, I would follow their advice on what they feel is needed to make it work- and ask them to consult directly with your breast surgeon. You can also ask them to show you photos of what it would look like using skin from stomach.

Finally, if you do have radiation, a temporary implant can affect what the radiation oncologist can do. Usually not a problem, but something to consider if there are other factors at play. Usually it is a tissue expander that is slowly filled with saline to stretch the skin in preparation for the reconstruction. But, again, if the PS says they don't need it maybe you want to skip that. And... my PS would not do reconstruction until at least six months after radiation, in order to give time for tissue to heal.

Good luck, and keep asking questions!

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Jan 17, 2022 10:16AM Dancemom wrote:

This is all very interesting to me to have each procedure considered separately. My doctors are all in direct communication. RO actually said she would negotiate with PS about how much to fill the expander. And SO and PS surgical coordinators worked together to schedule me for the masectomy. PS inserted the expander, closed it all up and is in charge of my drains. I have a friend who (i found out later) had a lumpectomy by my SO directlly ahead of my surgery, and the PS was in an adjacent OR. When it was my turn, they each came in to do their thing.

I think I am saying that communication is key.

Dx 3/16/2021, IDC, Right, Stage IV, metastasized to other, Grade 2, ER+/PR+, HER2- Hormonal Therapy 3/28/2021 Femara (letrozole) Targeted Therapy 4/20/2021 Ibrance (palbociclib) Surgery 1/3/2022 Lymph node removal: Sentinel; Mastectomy: Right
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Jan 17, 2022 01:16PM - edited Jan 17, 2022 01:17PM by MinusTwo

Yes to communication - directly by the docs. If it were me, there are enough questions thatI would get a second opinion.

2/15/11 BMX-DCIS 2SNB clear-TEs; 9/15/11-410gummies; 3/20/13 recurrance-5.5cm,mets to lymphs, Stage IIIB IDC ER/PRneg,HER2+; TCH/Perjeta/Neulasta x6; ALND 9/24/13 1/18 nodes 4.5cm; AC chemo 10/30/13 x3; herceptin again; Rads Feb2014

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