Decisions, Details & Unexpected Silver Linings

Wednesday, 25th June 2025

Appointment with my surgeon - it’s another long one I’m afraid.

Today I met the surgeon who will be performing my surgery. Mr Paul Cathcart.

It was nice to be sitting in the waiting room free of anxiety for a change, as this appointment was arranged to confirm exactly what will be happening in the surgery and for the Surgeon to meet me and confirm he was happy with the plan provisionally discussed with Miss Deol the week before. 

The wait was long this time, the waiting room was packed - it was almost 2 hours from my appointment time that I got seen - I remember these from the last time round. 

The thing is, once you are in your appointment, you are grateful not to feel rushed, and able to ask all the questions you have, so I understand that the waiting time is affected by this. We had been seen relatively quickly for all the previous appointments so I didn’t mind too much. 

Fortunately as there was nothing scary about today’s appointment I had come alone so Mark wasn’t stuck waiting in the heat with me.

I also had my laptop in the car so I managed to get on with some work while I waited, which made me happy as I hate wasting time when I have lots to do. 

I finally got in to see Mr Cathcart (there were only 4 of us left in the waiting room by this point - all waiting for the same person).

He was a very lovely man. However, nothing like I had imagined. I’d literally had a dream the night before about meeting my surgeon and in my dream he was a real dreamboat - think Justin Hartley from This Is Us/ Tracker.

Sadly the (very lovely) gentleman performing my surgery was quite different. 

He got straight to business confirming everything that had been discussed in my previous appointment with Miss Deol.

Mr Cathcart asked if I was aware I could still go with the option of a lumpectomy rather than the mastectomy.

I’d confirmed that I wanted to have a mastectomy reconstruction as I didn’t want the worry that the cancer could come back again.

He explained that although they would do their best to remove all the breast tissue, this was physically impossible, due to the nature of the breast make up. The breast tissue and fat cells that lay under the skin don’t separate like marzipan and icing on a Christmas cake, more like the marzipan and cake - there will always be some cells that remain and these could still turn Cancerous in the future.

He also said that I would no longer have mammograms following the surgery as they won’t be able to pick up changes. I laughed and said that I’d lost faith in mammograms, considering that my last one didn’t pick up the lump. 

I’m not sure I said before, but I’ve seen the photos from the mammogram following my biopsy when they put the clip in. You still can’t see the lump! 

I had put so much faith in the fact a mammogram can pick up cancer up to 18 months before it becomes a problem. 

I don’t think enough emphasis has been made on the fact that if you have dense breast tissue like me, it might not pick it up.

All I keep thinking is thank goodness I felt the lump.

As a Breast Cancer survivor you possibly imagine I'm really good at checking my breast - there was only one I needed to check. But to be honest with you I didn’t. I was so confident that I had beaten it the last time round and the chances of me getting a new Cancer would be so unfortunate, I became quite blasé about it.

I think if I was more aware that the annual mammogram might not see something I might have been a bit more cautious.

He went through the reconstructive options with me;

I could have an implant or a reconstruction with a flap taken from my tummy. I explained that with the nature of my job as a Pilates Instructor, although the idea was tempting, the recovery would be too intrusive and could affect my ability to do my job post surgery.

I wanted it to be as simple as possible - he did explain that by going the implant route I may need future surgeries to replace the implants etc. I said I was ok with this.

We were still looking at w/c 28th July for the surgery, for which I questioned if a full week was required after my holiday. He confirmed a minimum of a week between my return flight from Mauritius and op was required. He said the surgery was going to be a long operation (I wish I'd asked how long - I must remember to ask next time I speak to the nurse), and the longer the better to reduce the risk of DVT.

He then took my measurements and did a brief examination.

I was offered the option to wait until the week of 11th August, when Miss Deol would be available to work with him as a joint case on the surgery, to lower the operation time, which in turn will reduce anaesthetic time and have me on my feet quicker after surgery.

At this point I just want to get it done as soon as I can after my holiday - I have a very busy August and the sooner I can start my recovery journey the better.

So he confirmed he could do it on his own w/c 28th.

When I last saw Miss Deol, she mentioned there were two ways they could do the surgery; either an incision point at the side of the breast or cutting around the nipple and going in from the centre.

Mr Cathcart asked if I had a preference - I most definitely preferred the sound of the side incision. I’ve only got one nipple left and I’d like to preserve it as undisturbed as possible. I didn't really want it to have a scar around it if at all possible. 

I did ask which was his preference and he said it’s easier for him to go through the nipple as it’s more centralised, coming in through the side was more tricky to get to the inner part of the breast as you’re further away. However he was happy to do the side incision for me. 

He explained as Miss Deol had that there is a risk of nipple loss, due to it being the furthest point from all the blood vessels and the tissue may die. I was happy to take the risk if there was a chance of preserving it.

At this point Mr Cathcart again reminded me I could still go with the option of a lumpectomy.

I confirmed I was very happy with the decision to go with the full mastectomy reconstruction.

He explained the difference between a pre-pectoral reconstruction - breast out - implant on muscle directly.

For this they put the implant inside a mesh to keep the implant in place - there are three types, an animal product, a man-made dissolvable and a man-made non-absorbable silk.

I asked how did the implant stay in place once the mesh had dissolved and he explained the scar tissue would create a pocket and this would keep it in place once healed.

I then asked what the difference was and he went through the pros - if you need a replacement further down the line - the silk will have to be dissected to access the implant. I said I didn’t have a preference and asked what he would prefer - he said man-made dissolvable would be his suggestion so that’s what we’re going with.

The other option is to put the implant under the muscle, this is harder to do but can give a better finished result with less risk of rippling.

Rippling is when an implant is visible under the skin and you can see ripples of the silicone at the top of the breast - I have a bit of this from my previous implant.

The con of this option is it can be more painful, there is also a risk of the muscle pushing the implant out to the side or of some animation as the muscle moves. I.e the boob moves when the muscle is flexed.

I had never heard the term animation before, but this is something I have always had with my previous reconstruction that was made using my Lat (latissimus dorsi) muscle from my back. The muscle still contracts when I use my lats and my boob moves - it's become a little party trick of mine.

I’m sure you won’t be surprised to hear I chose pre-pectoral - above the muscle.

He said if in a couple of years there is some rippling, I could get some lipo filling (from abs)  to inject into the breast to smooth off the ripple.

No kidding I could get a flatter stomach on the NHS, I’m almost hoping there is some rippling!

He explained how the nipple sparing reconstruction was safe in theory, they would be transecting across the ducts that go into the nipple - this means there is a risk that there will be cells left behind in the nipple that could be susceptible to cancer in the future, but as the tumour is far away this is unlikely, he said if the lump was closer to the nipple it might be different.

Diagram of where my lump is and nipple transection.

He went through how they would insert a blue dye during the operation which stains the skin for about a year. It changes to look like a bruise rather than stay blue and he promised it will fade over time.

The dye contains iron to help them identify the correct lymph node that leads to the tumor so they know which one to remove.

He confirmed he would be replacing the expander (the implant in my original reconstruction was expandable so they could stretch the skin by adding more saline, and help with sizing it to match my non-reconstruction side) - no mesh would be required as it should have a scar pocket from the implant that’s currently in place.

During the actual procedure he will do the main surgery side (Right) first, then the other side to look at symmetry. 

I asked if there was any way anything can be done on my droopy boob the one that has the lump. 

(I should say it’s not really droopy but it has had 15 years of gravity and is not as perky as it once was, the original reconstruction hasn’t had the same drop happen so is still quite high and lifted).

He said there wasn’t really anything that could be done, because although the breast has dropped, the nipple is still quite high and not pointing downwards, we’d compromise the blood supply to the nipple if we try to move it. 

He did say that the mesh around the new implant will be held higher on the chest with sutures so may actually create a bit of lift anyway.

So nothing to be done but to wait and see with that.

When I come out of surgery there will be a drain on the right side, I won’t need one on the left as it’s quite a straight forward in/out swap of implants.

The drain will be a bottle with suction, this will stay for 1-2 weeks. After 2 weeks it will be removed regardless of the output of fluid.

He warned that it will look really lumpy to start with due to the suction of the drain, but will settle down after the drain is removed, and don’t panic if it looks a little odd.

To round off the appointment he confirmed it will just be him. Although waiting 2 weeks from a Cancer point of view is low risk if we waited for Miss Deol to join him. I said from a life point of view earlier is better.

They will confirm tomorrow the exact date but at this point it is confirmed that it will be week commencing 28th July.

I had a few questions for him, to make for easier reading, I will do them as a Q&A below.

What grade is my lump?

Grade 1-2 

How do we stop the Oestrogen?

The most likely option is with Tamoxifen tablets to block the Oestrogen receptors..

Tamoxifen is generally used unless it’s not tolerated, then they usually give Letrozol

For the chemical shut down to prevent the production of Oestrogen I will take Zoladex (??) tablets - initially every month then 3 months - tablets every day.

Was it ok for me not to have this start already?

They don’t want to give me injections due to side effects and Tamoxifen has a higher risk of blood clots so don’t want to start that before surgery

It is a relatively low risk for the short time before surgery not to stop the Oestrogen.

What about eating oestrogen high food?

General rule of thumb  - have a healthy well balanced diet

What about the BRCA gene?

With my previous Cancer I had been tested for TP53 (whatever that is)

The request has already been passed to genetics to test me for BRCA1 and BRCA2 gene.

What happens if the BRCA gene is present? 

This means I would be more susceptible to ovarian cancer and Amber (my 16 year old daughter) could also be at risk of having this gene and therefore at high risk of both breast and ovarian cancer 

And if no BRCA gene present?

I am no more likely than the next person (nor Amber) at getting ovarian cancer.

Am at risk of Cervical Cancer if the BRCA gene is present?

No BRCA is only connected with Ovarian and breast cancer. Cervical cancer is linked to the HPV virus

Just to add to the list - Tamoxifen creates a higher risk of uterine cancer