Choosing surgeon

ODPmom

Hello. Diagnosed last week with DCIS and supposedly small IDC. Hormone + waiting on fish results. I’ve been followed closely for the last 10 years by dr Rosenbaum-smith in NYC (mt Sinai). The last few years I switched to screenings locally at a Breast center (Monmouth medical) Nj. After receiving initial labs immediately saw a local dr (kohli)who was actually trained by my NYC dr! She is fellowshiped trained, numerous accolades and certified in skin nipple sparing and hidden scar. Nothing but good reviews but only has only 5 years in practice. My ny doc obviously has 20 years More experience. However she and her ps shy away from direct to implant and are not advocates for pectoral nerve block.

Any advice on how to choose? Should I get a 3rd opinion from MSK or Cornell?

Thank you for any input. Trying not to decide on convenience alone. I have 3 small children and I need to get to the other side of this quickly hopefully!

Anonymous

Hi ODPmom,

When I was ready for my BMX/recon surgery, I interviewed a local surgeon who did my lumpectomy and a plastic surgeon in my smallish city. We don't have breast surgeons available....just more general ones.

Then I went to MD Anderson in Phoenix, and interviewed a breast surgeon. MD Anderson has a great reputation for all cancer related txs and I already got a second op from them before I began chemo.

I found out several things:

1) the MD Anderson guy also didn't recommend immediate reconstruction even though I am small breasted and wanted to stay small-breasted. Did not want to do nipple sparing surgery either. He didn't even consider my request for more than a min before saying he wouldn't operate that way. I asked him how many surgeries he had done and found out he'd only been in practice a few years, making me believe he just wasn't experienced enough to feel comfortable with what I wanted.

2) I interviewed my local surgeon and ultimately went with him. He had over 20 years experience and had done nearly 100 surgeries working closely with my plastic surgeon, who also had over 20 years experience in my type of surgery, so even though he wasn't from a big hospital or a specialist, I chose him. My surgeon didn't bat an eye when I requested nipple-sparing and immediate recon. He did a biopsy of the nipple tissue first, when he "lifted" the nipples, and then did a great job on the immediate recon and did fat-grafting a year later for better symmetry.

Point is, sometimes those who are specialists aren't necessarily the best, if they don't have a lot of experience. I'd interview two of each (plastic surgeon and general), and ask them how many successful surgeries they've done, how comfortable they are doing what you want, and if they've ever had any problems.

Hope that helps; others will weigh in I'm sure.

Claire in AZ

Moderators

ODPmom, welcome to Breastcancer.org! We're sorry you have to be here, but glad you've found us and decided to post!

We know it's not an easy decision, but you may find some helpful information on this page fro our main site too: Finding a Qualified Plastic Surgeon

We hope this helps and we look forward to hearing more from you soon!

The Mods

ODPmom

Thank you! My NY doc definitely has more experience so that’s where I’m having trouble deciding.....

Anonymous

Hi there again,

....sometimes it's nothing more than trying to find out what your intuition is saying, and then listen to it.

I thought MD Anderson would be the much better treatment place for me, and it didn't work out that way. I think for me it was which docs gave me the most confidence in their ability as a skilled surgeon--that was what helped me make my decision.

Hugs

Claire

beach2beach

Hi, did they say why they don't like direct to implant? I'm curious. When I was dx'd I had been seeing my breast surgeon for over 10yrs for yearly check up due to family history of bc and my having previous benign lumps. I decided on a bmx rather than a lumpectomy. She recommended a PS who i saw within a few days after being dx'd. I was also small breasted. The PS had told me since I did not have much fat, my skin was also too tight that I was not a candidate for DIEP and he did not think expanders would be the right way to go. He was afraid with my skin. I went nipple sparing and direct to implant. So I'm not much bigger than I was before, I'm probably a low end B right now but when I last saw him he said I could swap them out for a little larger one,,my skin has some room. I doubt I will do that.

My dr's were both located on Long Island. You have a history with your dr, that's certainly something to consider, but ultimately you have to go with your gut and consider what you would want the end result to look like. Sometimes many years of experience isn't everything if they are not progressive with what is going on now with options.

dtad

Hi everyone...IMO years of experience isn't the most important factor when choosing a surgeon. I would be more concerned about the physician's educational background and the facility at which they practice. I do believe that breast surgeons are a better choice than general surgeons. I also believe that being treated at a major university teaching hospital is paramount. We all have to make our own informed treatment options. Good luck to everyone navigating this complicated disease!

Lula73

one thing I have not seen mentioned is insisting on seeing before & after pics of the surgeon’s work on women who had the same procedure as you are. That is also very important. If you’re not happy with what you see in those pics for yourself, keep looking for the right surgeon. No pics? Keep looking. And note that if a PS says they do/recommend/get the best results from a certain type of procedure it’s usually because they are not trained in how to do it/haven’t done enough of that type of procedure to feel comfortable offering it. Additionally, they often will say you’re not a candidate for certain procedures (like over the pec implants or a natural tissue reconstruction) simply because they don’t do those procedures and they want your business. So always ask if they do/have the training to do that particular type of procedure before accepting their word as gospel when it comes to your candidacy for that particular surgery.

Another thing I keep seeing on the boards is everyone wanting the quickest option without a lot of downtime. As a full time mom & wife & Mimi who aspires to be Superwoman, and who works in a high stress full time career that is extremely sensitive to being present, I get it, I really do. On the flip side, quick does not always equal best for you, personally. Quick with poor results/results you’re not happy with/results that are not comfortable is not typically quick at all when we look at the long term issues that ensue. You have to do what’s best for you and only you as an individual - not necessarily what’s best for the family because it’s quick. When the kids are grown and out of the nest you are left with you. Whether recovery is 2 weeks or 8 weeks, 1 surgery or 2 or even 3 is just a blip on the screen for the kids. A few weeks if daddy (or another caregiver) feeding them cake for breakfast, pizza for lunch and fish sticks for dinner and dressing them in totally mismatched clothes isn’t going to hurt them. It may even be fun for them. I know my kids have a blast with their dad making spaghetti pizza, not having to do their hair just so, etc when i am out of town for work or in the bed recovering from surgery. It’s great bonding for them. Examples on quick not always being best: Ex: you chose the quickest option but because the results are not great you no longer get in a bathing suit to play with your kids at the Beach/pool. Or your recon path left you with pain/discomfort that keeps you from doing the things you do like to do with your family. The quickest option isn’t always quick in the end either. Ex: 1) lumpectomy is quickest surgery option....but at the least, weeks of daily rads appointments, and more frequent mammo/mri appointments following. 2) mx w/ TEs/under muscle implants...but have to go for weekly fill appointments, and later exchange surgery. You have to look at the whole picture. I’m not advocating for no recon or a particular type of recon. I’m just advocating for more than choosing an option because it’s the quickest. You matter just as much as those you’re taking care of. You would research thoroughly and choose the best option for them, why not for you? Don't you think they would want the best for you too?

Anonymous

beach2beach, I never heard the answer as to why he didn't like immediate reconstruction or wouldn't do them. After I found he had only done less than 20 reconstructions overall I kind of decided he wasn't comfortable yet with his work...

When I talked to the doc I ultimately chose, he didn't bat an eye when I told him immediate recon is what needed. He knew because I was small-breasted, and wanted to stay small, that it would work. I had to wait a year for the surgery to let my skin calm down after 6 weeks of rads, and I saw my surgeon a few times over that year so he could monitor my skin. My surgery was successful and really mostly a non-event. I stayed in the hospital I think only 1 night and was doing yoga poses in the hospital hallways the next morning.

Speciality surgeons are great if you feel confident in them and they are conveniently located. MD Anderson and the specialty doctor that was fairly new to the practice (who I ultimately didn't choose) were 3 hours driving one way from my home, meaning that if there was a problem post-surgery, I wouldn't have my doctor near to treat it. I'd have to stay in a hotel for 2 weeks or so near the hospital.

I do think, contrary to a previous poster, that years of experience count--a lot.

Anyway, as to another poster reminding us to see the before and after shots--yes, that is a great reminder and I did review both docs portfolios. My general surgeon's portfolio was a lot more extensive, and he could show me photos of direct to implant, which the other specialty MD Anderson doctor couldn't.

My 2 cents. We all have different reasons for choosing who we do, and how we choose. I think gut intuition counts a bunch with these types of serious decisions.

Claire in AZ

InnaB2018

Hello. I interviewed 2 breast surgeons: a local Overlook Medical center surgeon and an MSK surgeon. I chose an MSK surgeon then and there. ODPmom, did you know that there is an MSK office in Middletown? It’s amazing, and so far everyone I dealt with impressed me immensely. They still do mastectomies only in NYC, but for everything else I don’t have to Travel to the city, which is great. If you are interested, I’ll give you the names of my surgeons, I love them both, especially my breast surgeon. She is an angel. Talking to her have helped me more than daily Lorazepam pills and psychologist visits.

InnaB2018

By the way, my plastic surgeon is not a fan of direct implants either. He told me that a two step reconstruction offers much better results in the long run, so I didn't question himfurther. All my BC friends received the same consult from their doctors (different ones)as well.

moth

Is lumpectomy not an option for you OP?

My GP was referring me (I'm in Canada) and her opinion regarding the breast surgeons she knew helped. But ultimately we went with the surgeon who could do my surgery the fastest. I had my surgery on day 8 after receiving biopsy results.
My surgeon is young, quite fresh out of an oncology surgery fellowship at a cancer research center in the USA. I think young doctors have many benefits - they're usually keen, up to date on the latest techniques and eager to do well.

ODPmom

Hi! Yes please send me your recs - thank you! I was kind of waiting to see if I needed any further treatments after surgery as right now still looks possible I may not. I used to work for a hospital in the city and have heard mix reviews on MSK for surgery.... crazy that some people love it and others so unhappy. Although not ruling out getting an opinion. I’m definitely sending my pathology after surgery for them to review and would absolutely consider having adjuvant treatments at their satellites.

Thanks again

InnaB2018

ODPmom, My breast surgeon is dr. Kirstein, my plastic surgeon is Dr. Cordeiro. My surgery experience was impeccable, I think. They give their best single occupancy rooms to mastectomy patients at no extra charge. There is a comfortable couch for the loved one to stay with you, if they choose to do so. A nurse sits right outside the room and takes care of only 3 patients at the time. So far, the techs and nurses who saw the end result of the surgery were pretty impressed with it. It’s hard for me to say whether it’s really good or just average, since I can’t compare it with anything, but what I can tell you is that I felt good enough to take a walk in the park the morning after the surgery. Then, of course, I collapsed into my recliner for a couple of hours 😜. I like my oncologist at the MSK as well. Communication is very good. Everybody calls back within hours, all my questions and concerns are addressed in a timely manner. I have absolutely nothing to complain about. I am starting chemo on Thursday in their Basking Ridge clinic, so will be able to comment on that as well.

dtad

InnaB....IMO yon made the right decision! Overlook is a community hospital that is NOT associated with a university. They just don't have the resources to compete with a major NYC facility. People come from all over the world to be seen at these hospitals. We should definitely take advantage of them since we are close by. Good luck to all

InnaB2018

Dtad, that’s what I thought too.

Anonymous

Further info about direct to implant (aka immediate reconstruction) surgery, from a 2012 article, NCBI:

"Implant-based breast reconstruction is the most common means to restore the breast following mastectomy for breast cancer treatment or risk reduction. Many patients chose implant reconstruction secondary to the advantages of a shorter operative time, lack of donor-site morbidity, and quicker return to normal life activities. A single-stage direct-to-implant (DTI) breast reconstruction offers an ideal reconstructive choice in select patients by replacing loss of the breast at the time of the mastectomy in a single operation. In the past, DTI reconstruction was largely abandoned secondary to issues with pectoralis muscle retraction, implant malposition, and contracture. The advent of acellular dermal matrix products (ADM) offered a solution to these problems by holding the released pectoralis muscle on stretch and forming a complete pocket around the implant in the desired position (1). By off-loading stress on the inferior skin envelope, and by changing the interface of the skin envelope with the implant, it is thought that ADM-assisted reconstruction may be associated with lower contracture rates than reconstructions without ADM. A DTI procedure has obvious appeal to patient and surgeon alike, but not everyone is a candidate for single-stage reconstruction. The key to success is in patient selection, technique, and intraoperative decision-making".

Key words: "shorter operative time, lack of donor-site morbidity, quicker recovery, patient selection, technique, AND not everyone is a candidate". I was lucky, was a good candidate, had a skilled surgeon, and I wanted less surgery and less hospital time/less exposure to anesthesia and potential for infection.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4115696/

ODPmom

Thanks everyone! This is all so overwhelming and I’m so afraid to make a wrong decision. In the end I think I have to accept I’ve done my due dilligence and as all the candidates are exceptional surgeons have to go with my gut and pray for the best. Right now my preference is for a prepectoral direct to implant. I’m really athletic and cutting into my pec muscle does not sound ideal. Although I realize things found out during surgery may throw that plan out the window. I guess my only concern with prepectoral placement is future monitoring but ps says there is no imcreased risk. My BS say that I’ll have to fall into a very specific category for her to agree to pre vs post pectoral. All at once I’m feeling I just want this surgery over and also scared of what I will wake up to ...