After Breast Cancer Diagnosis

General Questions

  • After you have been connected with a certified breast surgeon, you will be given several options. These may include:

    • Lumpectomy (breast conservation surgery)

    • Nipple-sparing mastectomy

    • Skin-sparing mastectomy

    • Radical mastectomy (rarely seen)

    • Prophylactic mastectomy (for those with increased risk of breast cancer)

  • Dr. Goyal works with all health insurances to ensure that your procedures are covered. By law, if you have undergone a mastectomy, your insurance company must cover reconstruction on the affected breast and symmetry procedures on the contralateral breast.

    Read more about this law here.

  • If you are out of network with Dr. Goyal, she will work with your insurance company to make sure you are not slammed with large out-of-pocket expenses.

  • Some patients require chemotherapy and/or radiation therapy depending on the type of cancer, size of the tumor, grade of the tumor and degree of cancer spread.

    Generally, if one undergoes lumpectomy (breast conservation surgery), this is accompanied by a sentinel lymph node biopsy (performed by the breast surgeon) and adjuvant radiation therapy.

    Sometimes chemotherapy is offered before the lumpectomy or mastectomy surgery, and sometimes it is offered afterwards. Radiation therapy is almost always offered after surgery.

  • Yes, breast implants are safe.

    It is important to consent to a procedure only after being adequately informed.

    Here is more information regarding the risks of implant-based breast reconstruction.

  • Autologous breast reconstruction involves using your own tissue to reconstruct your breasts. Most commonly, Dr. Goyal utilizes abdominal tissue in the form of a DIEP flap. This is a procedure that spares the abdominal muscle to reduce morbidity of your donor site. Other options include inner thigh or back tissue.

    Learn more about DIEP flaps from the Mayo Clinic here.

  • Now that surgical technique has evolved, you can do way more following breast surgery than in the past. There are no range-of-motion restrictions following a breast cancer reconstructive surgery; however, you cannot lift heavy weights until cleared by your plastic surgeon.

    Sometimes physical therapy is recommended if you are having trouble with strength and range of motion following surgery. Please do not hesitate to mention any of these symptoms to your surgeon so that you may be referred to therapy if indicated!

  • If you have any additional questions or would like to further speak with Dr. Goyal, you may schedule a consultation with her by calling (804) 270-3333 or email her at drgoyal@rva-plasticsurgery.com.

Lumpectomy/Oncoplastic Reduction

  • A lumpectomy is a procedure performed by a certified breast surgeon to remove your breast cancer tumor with appropriate margins. It is not always possible depending on the size and number of tumors. This is generally accompanied by a sentinel lymph node biopsy to determine if there has been any spread in your lymph nodes.

  • If you are a candidate for a lumpectomy, a plastic surgeon can help you achieve optimal aesthetic results. In this oncoplastic approach, both breasts are lifted and reduced to account for the removed cancerous tissue, to best achieve symmetry.

  • Generally speaking, an oncoplastic reduction will look very similar to a breast lift or breast reductions. Incisions will be located around the areola, at the midline on the bottom half of the breast, and underneath the breast fold (like an anchor or upside-down T). Because patients who undergo oncoplastic reductions will likely need radiation, there will always be a degree of asymmetry (the radiated breast will stay higher than the nonradiated breast).

  • If you are diagnosed with invasive breast cancer, you will need radiation in addition to a lumpectomy/oncoplastic reduction procedure. Radiation therapy would follow the procedure after the breast has healed (approximately 4-8 weeks) and will last approximately 4 weeks.

  • Lumpectomy with oncoplastic reduction is usually an outpatient procedure and you can expect to go home the same day. You will often have drains following surgery, which will be removed at your next appointment with Dr. Goyal. You should keep your surgical bra on at all times but may remove it on postoperative day 2 to shower (replace it afterwards!). You should not lift more than 10 pounds until you are cleared by Dr. Goyal. In most cases, this is at 4 weeks following surgery. Radiation therapy does not commence until all of your incisions have healed.

Mastectomy with Implant-Based Reconstruction

  • A mastectomy involves removing all of your breast tissue. This means that you will lose sensation to your overlying breast skin (but you should regain sensation over time, sometimes after several years). If you are eligible for a nipple-sparing mastectomy, your nipple will no longer function to produce milk and will no longer have any erotic sensation.

  • Nipple-sparing mastectomies involve saving the nipple. This is usually only offered to women with breasts that are grade I ptosis (i.e., the nipple position has not fallen too low). The tumor must also be smaller than a certain size and its location must be far enough from the nipple to be eligible for this procedure.

    If you are a candidate for a nipple-sparing mastectomy (determined by both the breast surgeon and the plastic surgeon), you will likely have an additional procedure before your mastectomy called a surgical delay. This is a procedure to enhance the blood flow to your breast skin and nipple to reduce the incidence of complications following your mastectomy.

  • If you are a candidate for a nipple-sparing mastectomy, the most common incision is underneath the breast, similar to (but longer than) an incision used for a breast augmentation.

    If you are undergoing a skin-sparing mastectomy, where the nipple is not spared, there are several options. Sometimes Dr. Goyal utilizes a transverse incision, which consists of a horizontal scar across the center of the breast. For larger breasts, she often uses a Wise pattern incision, which is shaped like an upside-down T. This removes excess skin from the horizontal and vertical planes to best round out your breast.

  • There are several options for breast reconstruction. The most common options in Dr. Goyal’s practice are implant-based reconstruction using smooth round silicone implants and autologous reconstruction using your abdominal tissue.

    A very useful brochure from MD Anderson’s cancer center can be found here to help navigate the many choices you have for breast reconstruction.

  • Yes, breast implants are safe.

    It is important to consent to a procedure only after being adequately informed.

    Here is more information regarding the risks of implant-based breast reconstruction.

  • Sometimes patients are candidates for direct-to-implant procedures, i.e., when implants are placed at the time of mastectomy. Dr. Goyal screens each patient to ensure they are a candidate for this procedure. This is usually based on current breast size, desired breast size (not offered to patients who want to be larger), stretchiness of the skin, blood flow to the skin, asymmetry of breasts, and general health of the patient.

    Dr. Goyal uses her judgment and clinical acumen on the day of surgery to determine whether a direct to implant procedure is a safe option for you.

    If you are not a candidate for direct-to-implant breast reconstruction, you will undergo breast reconstruction in two stages via breast expanders. Often at the time of your expander to implant exchange, you can have symmetrizing touches along with fat grafting to optimize your results!

  • Mastectomy with implant-based reconstruction is usually an outpatient procedure and you can expect to go home the following day. You will have drains following surgery, which will be removed after a minimum of 2 weeks by Dr. Goyal. The drains are removed after the output has fallen below a certain level. You should keep your surgical bra on at all times but may remove it on postoperative day 2 to shower (replace it afterwards!). You should not lift more than 10 pounds until you are cleared by Dr. Goyal. In most cases, this is at 4 weeks following surgery. You will need to take all of your prescribed medications, which includes antibiotics until your drains come out. If you are scheduled to undergo adjuvant chemotherapy or radiation therapy, you must be cleared by Dr. Goyal prior to undergoing these treatments. This is usually 4-8 weeks following your surgery.

  • You have the option to undergo nipple reconstruction, should you desire.

    If you are a candidate, a new nipple “nubbin” can be created using your local tissues. You will need to have the areola tattooed afterwards by a certified tattoo artist.

    Otherwise, you can undergo a 3D tattoo. These tattoos look like real nipples but do not have any projection since they are tattoos.

    I recommend my patients to consult with a certified tattoo artist, such as Amy Black.

    Do these tattoos hurt? Usually they do not, because following a mastectomy, the nerve endings to the breast skin do not transfer messages of pain to the brain.

Autologous Reconstruction

  • Autologous breast reconstruction involves using your own tissue to reconstruct your breasts. Most commonly, Dr. Goyal utilizes abdominal tissue in the form of a DIEP flap. This is a procedure that spares the abdominal muscle to reduce morbidity of your donor site. Other options include inner thigh or back tissue.

    Learn more about DIEP flaps from the Mayo Clinic here.

  • Mastectomy with autologous reconstruction with DIEP flaps is usually an inpatient procedure and you can expect to go home three days following surgery. In the hospital, your flaps will be checked hourly by the nursing staff at the hospital, and you will have monitors that Dr. Goyal can check virtually. You will have drains following surgery in your abdomen and breasts. The drains are removed after the output has fallen below a certain level. You may shower when you go home. You should not apply any pressure to your chest to avoid any injury to your breast flaps. You should not lift more than 10 pounds until you are cleared by Dr. Goyal. In most cases, this is at 6 weeks following surgery.

  • Do not try to gain weight! Many patients erroneously try to “increase their donor site tissue” by eating more and purposefully gaining weight prior to the procedure. When the abdominal tissue is more distended after weight gain, the abdominal closure becomes tighter and sometimes less skin is able to be removed at the time of surgery.

    You also do not want to try to lose unnecessary weight - just keep doing what you are doing. Focus on your nutrition and improve your core strength through exercise directed at your abdominal muscles.

    You will need to have a CT scan performed prior to surgery for Dr. Goyal to plan out the incision and surgical dissection for your procedure.

    If you are having both breasts reconstructed, you will meet with Dr. Goyal’s co-surgeon before surgery. It is important that you meet your team before your procedure to optimize your comfort level!

  • Autologous reconstruction is an excellent option for patients who have undergone or plan to undergo radiation therapy. It is considered a salvage option in patients who have had significant radiation damage and are no longer candidates for implant-based reconstruction. It also is a salvage option for patients who have had recurrent implant infections.

    If you have had radiation therapy, your DIEP flap may be used to replace damaged radiated skin on your chest wall. If your oncologic plan includes receiving adjuvant radiation therapy following your mastectomy, your DIEP flap will be performed after several months following the completion of your radiation therapy.

  • Although autologous reconstruction involves a surgical site in addition to your breasts, the recovery is generally well tolerated. Many patients report that the pain following DIEP flap reconstruction is less than that following the original mastectomy.

    Dr. Goyal achieves excellent pain control with the use of exparel, which is liposomal bupivacaine. This medication is injected into your chest wall and into your abdominal muscles as a TAP block at the time of your surgery. It provides anesthetic relief for 72 hours following surgery and diminishes the use for opioids significantly. Read more about exparel here.

  • You have the option to undergo nipple reconstruction, should you desire.

    If you are a candidate, a new nipple “nubbin” can be created using your local tissues. You will need to have the areola tattooed afterwards by a certified tattoo artist.

    Otherwise, you can undergo a 3D tattoo. These tattoos look like real nipples but do not have any projection since they are tattoos.

    I recommend my patients to consult with a certified tattoo artist, such as Amy Black.

    Do these tattoos hurt? Usually they do not, because following a mastectomy, the nerve endings to the breast skin do not transfer messages of pain to the brain.