Lumpectomy vs skin-sparing mastectomy for cosmetic purposes

That is pretty dismal of your PS to tell you that unequivocally you will be "smaller" after skin sparing MX.  As NATS stated above, with tissue expanders and, depending on your skin integrity, it is very likely you will be able to exchange out to an implant which will give you symmetry with your augmented native breast.  A "B" cup is not that far of a reach for expansion purposes.  I see you are in Canada - I think you need to get a second opinion.  I have seen a number of Canadians who come from MX with larger breasts than they had prior to MX.  So it can be done.  Perhaps this PS was inferring that he would perform a "one-step" - which is to state, skin sparing MX with immediate implant placement, rather than using tissue expanders.  You need further clarification if this is the case.  I do not think you want a "one-step" - because yes, your end result would be smaller than the augmented native breast. 

I had a similar situation- my tumor was sub areola- did they say the nipple would have to go? That was heartbreaking for me.I like my nipples. I am so sorry you are having to deal with this. I read somewhere that lumpectomies in the center of the breast don't give very good cosmetic results, esp after radiation, the skin can contract in odd ways and the results can be pretty awful looking.  So I opted for a skin sparing mast with free TRAM reconstruction, tho I wish I had found someone who could do DIEP instead (less muscle used). I found this article that does a pretty good job at discussing issues in reconstruction in lumpectomies, you might find it helpful. If you have any questions , please feel free to PM me.

 http://www.plasticsurgerypractice.com/issues/articles/2009-05_05.asp

Cat, there is a lot more to the lumpectomy vs. mastectomy decision than just cosmetic results.  And even from the standpoint of cosmetic appearance, while most of us end up reasonably happy with our reconstruction, it often takes a while to get to that point.  The fact is that no matter how good your plastic surgeon is, there is no guarantee of what the cosmetic results will be.  When it comes to reconstruction, often our bodies have minds of their own and react in ways that can't be predicted.

I recently posted this list of questions/considerations for someone else who was making a Lumpectomy vs. Mastectomy decision; this individual was also considering whether to go all the way and have a Bilateral Mastectomy.  This is a good starter list of things you should consider as you make this decision:

• Do you want to avoid radiation? If your cancer isn't near the chest wall and if your nodes are clear, then it may be possible to avoid radiation if you have a mastectomy.  This is a big selling point for many women who choose to have mastectomies, however you should be aware that there is no guarantee that radiation may not be necessary even after a mastectomy, if some cancer cells do happen to be found near the chest wall or if it turns out that you are node positive. 
• For most women, a lumpectomy is a relatively easy surgery and recovery.  After a lumpectomy, radiation usually is given for 6 weeks.  A mastectomy is a longer, more complex surgery and the recovery period is longer.  How do you feel about going through a longer surgery and recovery period? Also be aware that reconstruction, even "immediate" reconstruction, is usually a long process - many months - and often requires more than one surgery.  Some women have little discomfort during the reconstruction process but other women find the process to be very difficult - there is no way to know until you are going through it. Are you prepared for that?
• How you do feel about your body image and how will this be affected by having a mastectomy? Reconstructed breasts usually looks fine in clothing but may not appear natural when naked (this is particularly true of implant reconstruction). They may not feel natural. You may have lingering side effects (muscle pain or spasms, etc.) on one side or both. Will this bother you? If you have a mastectomy and you have complications with reconstruction and/or require a revision (which is not uncommon), how will you feel? How will you feel if you have some ripples or some indentations/unevenness? Will imperfections like this cause you to regret the decision to have a mastectomy or are you prepared the imperfections that often occur with implant reconstruction?  Or what about if you don't end up with symmetry (i.e. each of your breasts look or fall differently)?  Be aware that with a single mastectomy, while you may be able to get good symmetry of appearance, the feel and movement of your reconstructed breast might be very different than the feel and movement of your natural breast.  And even if you have a bilateral mastectomy with reconstruction on both sides, symmetry is not a sure thing. Our bodies aren't symmetrical, so the exact same implant might sit differently on one side of your chest vs. the other, or your chest muscle might be tighter on one side and as a result, the shape of your breasts might appear to be a bit different.  These differences sometimes can be fixed with a revision surgery but you need to be aware that these things can happen. 
• How do you feel about losing the natural feeling in your breast and your nipple?  Is your nipple important to you sexually?  Remember that a mastectomy will change your body for the rest of your life.  Are you prepared for that?
• How will you deal emotionally with the loss of your breast? Will you be glad that it's gone because it was the source of your cancer, or will you be angry that cancer forced you to lose your breast?   Don't just consider how you feel now, as you are facing the breast cancer diagnosis, but try to think about how you will feel in a few years, once this diagnosis is well behind you.  A lot of women don't really feel the loss until quite some time has passed.
• Will removal of your breast help you move on from having had cancer or will it hamper your ability to move on? Will you feel that the cancer is gone because your breast is gone? Or will the loss of your breast be a constant reminder that you had breast cancer?
• Appearance issues aside, do you know your recurrence risk if you stick with just a lumpectomy and radiation?  Is this risk level one that you can live with or one that scares you?  How would you deal emotionally with this risk level?  Will you live in constant fear or will you be satisfied that you've reduced your risk sufficiently and not worry about it (except when you have your 6 mth or annual screenings)? If you would always worry, then having a mastectomy might be a better option.  Be aware however that a mastectomy doesn't completely eliminate your risk of a local (in the breast area) recurrence and has no impact whatsoever on your risk of a distant recurrence (i.e. mets).
• Do you know your risk to get BC in your other (the non-cancer) breast?  Is this a risk level that scares you and or one that you can live with?  If you are considering a bilateral (and I don't know if you are), this is something to consider. 
• If you have a lumpectomy and get BC again, either a recurrence in the same breast or a new BC in your other breast, will you regret your decision and wish that you'd had a bilateral mastectomy? Or will you feel that you made the best decision at the time with the information that you had?
• If you have a mastectomy or bilateral mastectomy and aren't happy with the reconstruction results, will you question (either immediately or years in the future) why you made the decision to remove your breasts? Or will you be satisfied that you made the best decision with the information you had?

I hope I haven't scared you; that's not my intent.  But before heading into a mastectomy or bilateral mastectomy, it's important to know what's ahead and what may happen.  Now, for some better news.  To your question about breast size, I had a single mastectomy with an expander and implant reconstruction and I ended up slightly larger than I started out.  To achieve this, I had a small implant added into my 'good' breast.  I started out as a full "A" or small "B" and ended up as a full "B".  That's not much of an increase but it was all I wanted - my PS was willing to go quite a bit larger, if I'd wanted.  So if you are a "B" now, there is no reason why size should be an issue. And I'm in Ontario too.  I had my surgery done at Princess Margaret Hospital.

I hope that this helps.

If there are other factors involved it's a different story, but personally, I would NOT have a mast for cosmetic reasons alone! It is major surgery, and like all surgery carries risks of unintended complications, not to mention the loss of sensation, and the extra time/expense/pain of reconstruction. I had a 3 cm tumor, and had a lumpectomy. Although the shape was not great a first, the fat moved around and filled in the breast quite well. This is terrible to think and say, but the more extreme measures one takes, the more money the medical establishment makes...which can influence their advice to patients.

Cat - My tumor was a little smaller than yours but also involved the nipple and aerola. My surgeon warned me that lumpectomies where the nipple is lost are more "disfiguring" and that my breast would be "flat" on the front after losing the nipple and unlying tissue.   Despite that, she encouraged me to go the lumpectomy route because it is definitely less "disfiguring" and decidedly easier than an MX with or without reconstruction.  She also indicated that while radiation is mandatory after a lumpectomy,  it may also be indicated after a MX, particularly one where the aerole/skin is involved, so that shouldn't be a consideration in the decision.   I almost went for the MX, but decided on the lumpectomy after she told me that a MX was always an option if the lumpectomy result bothered me a lot.

 As it turned out, I'm completely happy with the lumpectomy.  My breasts are still equal in size (C cup) and although one lacks a nipple, I've come to like my "smoothie".   With a lightly padded bra, you can't tell the difference.  And since the scars are now invisible it even looks fine in the raw.

It's a hard decision and one you can only make for yourself.  Do what feels right...and you'll do the right thing for you.

Patty

one option you might consider is to go ahead with the lumpectomy and if it turns out poorly, then you could opt for a masectomy with reconstruction later. I don't know if you are doing chemo or not, but as I posted before having chemo a few weeks after such major surgery was like being kicked when I was already down. I asked my PS about delaying reconstruction and he told me the results wouldn't be as good (but we were talking about immediate mx, not lump). I really felt an urge to just have surgery and get it all over with. I did not intend to do chemo before surgery - that was also a factor in my decision, then I had a positive node and that changed my mind.

Latte,

its a hard decision.   My insurance at the time of dx wouldn't pay for BRCA testing, tho i am considering having it now that I have different insurance. I have asked myself what I would do if the results came back positive. I'm not sure. My sex life plays heavily into my decision personally- this is probably TMI, but my remaining nipple is very important to my sex life, I'm not sure if I could adjust to not having any functional nipple at all, so personally I would not remove the other one unless it was cancerous.

I have often wondered if there was anyway I could have saved the other nipple had I done neoadjuvant chemo, I know even if it was still there physically, having surgery so near to it might have severed/altered sensation anyway. My tumor was small enough neoadjuvant chemo was never discussed as an option- I only opted for the mx instead of lump bc of tumor location.

thanmks for the input Alyad and Cat.

I have been looking for photos of lumpectomies that also removed the nipple that still look good but haven't managed to find any (I was looking on TimTam's site). MSMPatty - you said that yours looked good - any chance that you have posted a photo anywhere i could see? or anyone else who is happy with their nippleless lumpectomy?

thanks cat and akab!

glad to hear that cat. my lumpectomy also turned out fine, clear margins, and managed to keep the nipple. am dealing with a post surgery infection and seroma, but otherwise all is fine.