Never agree to plastic surgery if the doctor's office is full of portraits by Picasso... - tweet by M2CTR

Sept 17, 2015

I knew I was sinking, and did try to improve things. Phil and I decided to throw a ‘post ride’ celebration party. The Ride had made me come alive and I thought that by having a party, it might help things. It did. Temporarily.

It’s very strange to me how you can be so completely deflated and then be instantly 10 feet tall just by the company you keep. Having that party was like sharing a piece of the Ride again. It was a great night with our whole deck packed with teammates, their spouses, and their kids.

We decided then and there that it would be an annual tradition.

Although it didn’t magically make everything ok, I think that party helped to make me look forward to my reconstruction consult that was coming up a few weeks later.

When we initially pushed the consult out to September (from the original July date) I was relieved. I wholeheartedly jumped into the “out of sight out of mind” mentality and thoroughly enjoyed the time I had to not think about another long, scary surgery. I was ok at the time without breasts, and not emotionally ready to think about such heavy decisions, so delaying the appointment was the right choice for me.

By the time September rolled around though, I was in a very different place. I don’t want to say I was obsessed with breasts – because really that sounds creepy – but I was certainly hyper aware of breasts. Like all breasts. Or lack of breasts. For the first time I noticed – really noticed – how many models look like they have no breasts in the clothes they wear. That was oddly comforting (I ignored the fact that they were skin and bones…) But I also noticed how everyone has breasts – even if they are little. And I was envious of them. In my eyes they could wear any shirt and it would look ok because their chest wasn’t concave. Even those with barely an A cup looked healthy and whole to me (ha the person not the breasts…)

I suddenly longed to be whole again.

So the appointment was strangely well timed for where I was emotionally. I was still nervous though. The consult would result in decisions needing to be made, that regardless of which option I chose, would mean another surgery(s), a painful recovery and all the risks that come with surgery…

But my need to feel whole again was greater than my fear of what it would take to get there.

So my mom and Phil, and I walked into the doctor’s office like some movie star and her entourage. (ha even more so given we walked into a plastic surgeon’s office!) They offered us tea or coffee and the waiting area was quite luxurious with stylish black leather sofas that we sat on to wait until we were called in. We didn’t have to wait long. We followed the assistant back and she sat us down in the consult room and asked me a bunch of questions. She told me we needed to go to the room next door and take some pics. Now I know where the “before” pics come from when you see before and after pics…I had to undress to my underwear line and she took different pics from different angles. I wish I could say it was like a model shoot, but if felt more like a mug shot shoot. That is if they took mug shots from your neck to your pelvic bone…I had to let my tummy “hang out” so they could see what they potentially had to work with…it really didn’t do much for my already rock bottom self esteem…

The assistant was so nice though and tried to distract me and agreed that these were not the most flattering for anyone but how it would really help the surgeon.

Then there were more questions (medical history) and she left us to wait for the plastic surgeon, Dr Humphries.

I was nervous. I had heard from one friend who said she had met with him and his bedside manner wasn’t the greatest. Given how “fragile” I was, I was worried I might end up in tears before we even got through the whole thing. Ug.

But I have to say he was really fantastic. Phil and my mom liked him too.

Although when he first walked in I remember thinking “but he’s so young! How can he be good if he’s so young??” Apparently I had forgotten the hero worship of my  “Kinda Handsome Surgeon”, who is also young and also my favourite medical person on my breast canser team.

He asked a few questions basically about my past and then got right to business. I felt fairly comfortable with him right off the bat. A good sign.

He started by saying that breast reconstruction is sort of like how you can look at your canser treatment. You are walking down a road, and you have choices along that road. Different medicines, different treatments that you need to decide on etc. Reconstruction is sort of like that too. First choice as you walk down this road is reconstruction vs no reconstruction. He talked about prosthetics and what he hears from women as the reasons they decide to get reconstruction – the main one being “to feel normal”. I was nodding along like a bobblehead on a bumpy road. I was liking how he approached this whole discussion – it was easy to follow, directly applied to me and he was very knowledgeable. It was also helpful for my Mom I think because he started right from the decision process and moved forward methodically.

He continued by saying the next decision is whether you use a man made product or your own tissue.  Both have pros and cons. He would go through each option and the pros and cons, and then we could discuss what option I was hoping for and if he thought that would be a good fit, given the radiation I had received.

Before I go on, I should quickly explain about radiation. Radiation was used for me to make sure any canser cells that might have been lurking after surgery and chemo were zapped. Once a canser cell is damaged, it cannot repair itself. (so much for canser being all powerful eh…) Aside from the potential blistering, colour changes or other outward damage you can see, radiation can take away the elasticity of the skin. So even if it feels soft and smooth (as mine does), it still loses elasticity – which means it loses its ability to stretch like normal skin. This is pertinent for the first option he got into which was using the man made option( implants.)

He first went into the advantages of implants. First: fairly easy, straight forward operation, little down time (recovery). For people who have had bilateral mastectomy (like me) fairly good chance at getting them symmetrical. Here he added that as much as surgeons might think they are God’s, they are not. God makes breasts, they make something that simulates a breast, and helps you feel “more normal”. His goal is to give you something that when walking down the street, no one would look twice or know that they are not real. Sounds good.

The downside to implants, especially in my case, is with regards to radiation. He explained that with any foreign object, the body creates scar tissue. With some people, that scar tissue can become hard. They don’t know why it happens to some and not others, it just does. For people who have breast augmentation (boob job) their chances are under 5% of this happening. For those who have reconstruction without radiation, it’s about 5%. For those with radiation like me, it’s closer to 50% chance... The problem is that the scar tissue can get so hard that it can make the breast feel hard, as well as change the shape. If it gets hard enough, it can cause pain. It can affect daily life – like sleeping on your stomach could become painful. He told me he has performed this operation in women with radiation and gotten reasonable results. But he has also had patients that ended up losing one or both implants. One patient’s implant opened and was leaking, and had to be removed. Man made options are exactly that - man made, so can fail.

As for the process, you can imagine the doctor  trying to put implants in me right now. Despite people thinking getting implants for reconstruction is the same thing as a boob job, it is NOT at all like a boob job. Women who get boob jobs already have “sacs” to put the implant in. They also have breast tissue. It just augments the size and shape of the breast. In my case, there are no sacs. I have zero breast tissue. It was all cut off remember?

So if I choose implants they would start with an operation to put in an expander. An expander does exactly what it sounds like.  It looks like an implant but is more rigid. It is inserted under my chest wall muscle and is used to stretch the skin (or expand it), in order to create a sac to put the implants in. The operation takes about 2 hours. I may or may not stay the night (2/3 stay, 1/3 of his patients go home same day) .The skin of the expander is made of a thick layer so that when they put a needle into it to fill it with saline, it re-seals itself (pretty cool actually). It also has a metal pin like thing that is a magnet. They use a device not unlike a stud finder (ha I had to bite my tongue on that one) after it’s been inserted into you, to find the spot where they put the needle in when you get “fills”. That by the way is how they stretch your skin – every few weeks you go in for “fills” where you get a needle in the expander (which is also a needle through your skin…) and more saline is added to keep stretching the skin. During the initial operation, he would fill me up as much as he could, but with the radiated skin, it can be tricky to get very much in. Then I would go back every few weeks for the fills.

Once I was at the size I wanted, they would take out the expander and put in the implants. (another operation…) Takes about 1 ½ hours for the 2nd operation. Perhaps this helps to highlight how very different just the process is for implant reconstruction vs boob jobs…And that’s just the process difference, never mind the emotional difference…

Anyways, he explained that during the initial operation (to put in expanders) he would cut out the mastectomy scars. What they do is send the mastectomy scar tissue away to the pathology on the off chance that there are any abnormal cells there. Just a double check because I have heard canser can come back in your scar tissue.  He said in all his years he’s only had 1 patient where it came back that she had had a local recurrence and that was 10 years ago and she was doing fine! I was going to ask about this so I was glad when he brought it up. A friend of mine who had reconstruction had this done by her surgeon, and I wasn’t sure if it was common practice.

I asked how long implants last. He said the manufacturers  show the 10 year fail rate is less than 1% . After that it goes up 1% per year. They use ultrasounds to check to make sure that the shell is still intact etc. But given my age, I was likely going to need new implants at some point in my life. I was very impressed he gave us such detailed info.

I started to wonder if he was going to talk me into implants. Before coming, after doing some reading and talking to people who have had reconstruction, I was leaning towards using my own tissue from my stomach. He made the implants sound so great that I was starting to wonder what he was going to say about the other option…

I relaxed when he said “the other path is using your own tissue, with what is called a TRAM Flap procedure. It’s a good operation”. I can’t tell you how nice it is when you are faced with a big decision, and both are considered “good options”.

The advantage is you’re using your own tissue. Once it’s moved there and alive, you don’t have to do anything else (ie no “upkeep” like fills and checking to see if they are leaking or failing down the line). They also change size with you (if you gain or lose weight). I briefly wondered if Phil would try to sneak high protein powder into my food….

The down side is it’s a big operation. He compared it to front loading your stock (if you’re into investing). You pay everything up front and once it works, you’re all set.

It’s a whole day in the operating room. (minimum 10-12hours but can go longer)

It’s a 5-7 day stay in hospital, on pretty strong IV pain meds. Most people are 6-8 weeks  getting back on their feet, just doing normal day to day life stuff (like walking around, getting out of bed, walking up stairs…sigh). 2-3 months off work but everyone is different (15-16 weeks minimum to start and then see) 6 months to get back to “life”. Yikes.

Then he got into the actual operation, which is called a TRAM. Original way this was done was to take the rectus muscle and move it up to the chest. I found a quick summary of what this entails on the breastcancer.org website:

“TRAM stands for transverse rectus abdominis, a muscle in your lower abdomen between your waist and your pubic bone. A flap of this skin, fat, and all or part of the underlying rectus abdominus (“6-pack”) muscle are used to reconstruct the breast in a TRAM flap procedure.”

The tissue/muscle from your tummy that is moved needs a blood supply so that it doesn’t die. Each muscle (one on left side, one on right side) has a blood supply or vein/artery feeding it.

That brings us to the 2 ways of moving the tissue up to your chest: FREE vs PEDICALED (or attached). I thought I’d also use the definitions from the same site as they are easy to follow (Dr Humphries explained it well but drew it as well so we understood and I don’t think I’d summarise as well as he did):

•  Free TRAM flap: In a free TRAM flap, fat, skin, blood vessels, and muscle are cut from the wall of the lower belly and moved up to your chest to rebuild your breast. Your surgeon carefully reattaches the blood vessels of the flap to blood vessels in your chest using microsurgery. There is also what's called a "muscle-sparing" free TRAM flap. This means that your surgeon tries to use only part of the rectus abdominis muscle for the flap, instead of a large portion of the muscle. Because only a portion of the muscle is used, women may recover more quickly and have a lower risk of losing abdominal muscle strength than if they had the full width of muscle taken.

• Pedicled (or attached) TRAM flap: In a pedicled TRAM flap, fat, skin, blood vessels, and muscle from your lower belly wall are moved under your skin up to your chest to rebuild your breast. The blood vessels (the artery and vein) of the flap are left attached to their original blood supply in your abdomen. (The artery and the vein are the "pedicle.") Pedicled TRAM flaps almost always use a large portion of the rectus abdominis muscle and are known as "muscle-transfer" flaps. Recovering from a pedicled TRAM flap can take longer than recovering from a muscle-sparing free TRAM flap because more muscle is used.

In the pedicled the blood supply is left attached. You basically slide the new tissue under the skin up to the chest. Although the surgery is usually about 7-8 hours, it’s a little more straight forward.

With the Free flap, they cut the blood supply and have to re-attach it to a blood vessel in your chest – this surgery is typically longer than the pedicled because they have to use microsurgery to attach the blood supply.

They both have pros and cons (of course!) When you have a unilateral reconstruction, meaning when you are only reconstructing one breast, they would essentially take the muscle on one side from your belly button out to your hip and move it up. You’d still have the other muscle on the other side. He mentioned that studies show that for women who can do a full on sit up before the surgery, 80% can do a sit up afterwards (once you’ve healed of course) with 1 muscle on the other side. From a structural integrity perspective you still have 1 muscle on your stomach wall giving you strength.

When you have to reconstruct two breasts, and they have to use the muscles on both sides, that number goes down to 5%. So only about 5% of women who could do a full on sit up before, can do one after surgery. So instead of sitting straight up, you strengthen your obliques and kind of roll sideways to sit up.

The advantage to doing a FREE tram (as opposed to pedicled or attached) is they can try to save some of the muscle so it’s not all removed. (pedicled they rotate the full muscle up) The disadvantage is they are cutting a blood vessel that is about 1mm thick, and have to re-attach it to another vessel equally as small (ie micro surgery) Because I would be reconstructing 2 breasts, there would be 2 blood supplies needing to be attached– one on each side. Dr Humphires said they basically use 20 stiches for each side (ie each blood vessel) to attach the blood supply– and that each stitch is smaller than a human hair! This is one of the main reasons the FREE tram surgery can go “long into the night”. The micro surgery is tricky, and they have to make sure they have not clogged or otherwise impeded the blood supply, otherwise the tissue (ie my reconstructed breasts) would die. If the tissue dies, it has to be removed. Removing it means losing the reconstructed breast (or both if the tissue on both sides die) You can only have this surgery once. So if it fails, it’s not an option for “round 2”.

Yikes.

Worldwide, 16% of people will have a problem with that blood vessel clotting. Of the 6% that go back into surgery to get it unclogged so the tissue can get blood supply, 50% of the time the tissue can be saved. In Calgary, the rate of losing the tissue is 1% which is better than world average. He mentioned how 99% success rate is great, if you’re part of the 99%. If you’re the 1%, it’s very difficult.

With the pedicled, the disadvantage is that I would have no structural integrity in my stomach, which could result in higher chance of things like bulges, hernias etc.

As I was absorbing this info, he went on to explain to me how the new tissue is attached. I’ve googled to try to find a bilateral Free Tram reconstruction to show you, but I can only find unilateral (ie single) so imagine this surgery on both sides (this is from Mayo Clinic websit):

He mentioned how we tend to get lighter as we move down from our face all the way down to our tummy’s (ie skin tone) Our faces are redder than our tummies. So the skin they move up to my chest will look like a patch. It will get better with time, but will probably always be lighter.

Then there are the regular surgery risks: the potential need for blood transfusion (rare, but my friend Tammy needed one after her Free Tram reconstruction…) infection (either during surgery itself or afterwards), any accidental damage caused internally (ie if something was accidentally “knicked” like bowel etc). There will also be scars. I will have a scar from hip bone to hip bone. Also around my belly button and around the breasts.

One thing that surprised me is that your belly button is attached from the inside…maybe this is common knowledge to everyone else. He mentioned how they will cut around the belly button, then pull the skin down and make a new hole. So my belly button will be right where it always was.

One really, really great silver lining, aside from coming out with hopefully 2 reconstructed breasts, is the tummy tuck that will go along with the surgery! They are cutting out all that muscle and skin to move up to my chest, so they will have to “pull down” the skin above. Hello bikini’s!!

I also have a birth mark that kinda looks like Asia on my lower left hip that will probably get cutout…but not sure if it will be visible on my breast, or will partially still be down on my hip…I was thinking about this when he then pointed out that in order to reconstruct two breasts, when It came to size, I had to keep in mind each side of the tummy would be one breast.

“You’re not a large lady” he started out with…

“Thank you” I laughed.

I asked like what size…(after my mom mentioned how I was quite busty previously) He said smaller…I said like how small? Like an A? He said ya…

Oh.

Well, small is better than nothing right???

What a strange thing to live your whole life thinking you are “stocky”  only to find out you’re too small…it was a very strange moment.

He then asked if I had any questions…which we didn’t because I think our minds were overloaded with info….

He then said if I was his wife who was 36 years old, he would recommend a Free flap. The reasons being that I’m young, and he can try to save some muscle in the tummy to avoid “structural issues”  like bulges, hernia’s or strains.

I then asked about riding…which he said I shouldn’t have issues. It would be more around strength training that I would notice it. I pressed more specifically that riding shouldn’t be an issue and he confirmed again that it shouldn’t be a problem. (I realise now he didn’t tell me how long till I could ride which is what I think I was trying to get at but my brain was shutting down so I wasn’t being very clear).

Phil then asked if he recommended a Free tram over all the options. He started to answer and I piped in that I was leaning towards a tram anyways because I didn’t want to have to deal with implants in my 50’s or later ( to get them swapped out)…He  said because of the condition of my skin, if I was someone leaning towards implants, he would have no problem doing it. But if I was leaning towards a tram, that yes he recommends a Free tram.

So if we were looking at a free tram, the operation would typically start at 8am, and the earliest I would be out would be 10-12 hours later…Sometimes if they have issues with connecting the blood vessels, it can go long into the night. Because of that, a bilateral free tram requires a team of surgeons. He recommended himself and two to three other surgeons. This is so they can change off because the surgery is so long and they get tired.

Jeeze, I’m getting more and more high maintenance…not only do I have a Kinda Handsome Surgeon I see every 6 months, now I have a whole team of surgeons who will be involved in the construction of the new pair of girls I’ll be getting…If 2 heads are better than 1 then I guess it’s fair that 6 or 8 hands are better than 2??

We ended the conversation with talking about how I wanted to go to BRA day (Breast Reconstruction Awareness day) in October  which is set up to help women know what options are out there for breast reconstruction. Phil and I had gone last year before my mastectomy and were a bit overwhelmed. This year  we just wanted to go, with our parents, to confirm that a Free Tram was indeed the right choice for me.

Dr Humphries said that was a great idea and to just give him a call afterwards and we’d go from there.

It was a lot to digest. I knew a lot of the info from friends, my own reading and BRA day the previous year. But it’s a bit different when it’s your own surgery.

It wasn’t going to be easy. 12 plus hours is a looooong time to be in surgery….and never mind the recovery….But we’d just take it like everything else – one day at a time.

As for that night, I had a date with 8 or 9 of my girlfriends and half price bottles of wine at Kildares. I don’t think I could have timed that any better if I tried…

Photo bomb...we dont know that guy

Although I think the poor bartender and all the patrons are probably still recovering from our wine loving table….

Take a Chance on Me by Abba: