Boob Shopping

On Tuesday, I had my first consultation with the plastic surgeon, Dr. Samson.  This was where I would learn about the various options for breast reconstruction after my mastectomy.

I knew this was going to be an interesting experience right from the start when one of the forms they gave me to fill out in the waiting room was a photo release!  Eeks.

Sure enough, after they called me, Dr. Samson's physician assistant took my patient history and then asked me to change into a hospital gown (from waist up only, thankfully).  After a few minutes she came back and that's when the photo shoot began.  I had to stand in front of a wall with a black curtain while she photographed me with a digital camera from every angle (8 shots in all).  Every patient is photographed, for "before and after" comparison purposes, and they don't include any identifying features (i.e. the shots are taken from the neck down).

This was actually the second time I was photograhed, as Dr. Sara had taken a couple photos before my first treatment so they could compare my progress with how I started.  Of course, I completely trust my doctors and everything was entirely professional, but it's still a little unnerving to know those photos exist!  I just hope I never see them on the Internet...

After the photo shoot, Dr. Samson came in and introduced himself and then did a physical exam.  First he took some measurements, calling out the numbers while the PA wrote them on my chart.  Then he did the typical breast exam, which I'm pretty used to by now.  And then he started pinching my belly.  I knew this would probably happen because I knew beforehand that one of the reconstruction options is a surgery where they take fat from your belly and make a boob out of it, so I figured he would have to examine my abdomen to try to assess how much fat I have there.  But still, this was one of those times when I had to step out of my own body for a minute because if I concentrated too much on what was happening, I would probably burst out laughing.

He also examined my back, pinching my back fat to see how much was there, since that's another "donor site" they can use to get fat for the reconstuction.

After all the pinching, I was able to get dressed and then learn about all of my options.

Dr. Samson started out by saying that one thing that can potentially complicate my reconstruction is the fact that I will need radiation following surgery.  Radiation damages tissue, and so I do need to consider that no matter what method I choose, there could be complications down the road due to the radiation.  For that reason, some people choose to delay reconstruction until after radiation therapy, but Dr. Samson said he didn't think that this was necessary, especially since that would mean that I would have to live for probably 6 months or so without a breast at all, which can obviously be very emotionally difficult.

The simplest and most common reconstruction is an implant.  After the mastectomy (literally, right after - they do it in the same surgery), Dr. Samson would insert a temporary "tissue expander" in my breast.  Even though Dr. Rosenbaum-Smith (my breast surgeon) would perform a "skin-sparing" mastectomy, I would still lose some skin in the mastectomy, so the tissue expander is designed to stretch the skin so it can contain an implant that matches the left side.  During a series of visits, fluid would be inserted into the tissue expander, until we get to the desired size (i.e. until it matches the left side).  Then, I would need outpatient surgery to replace the tissue expander with the permanent implant - either saline or silicone.  I didn't even know they still did silicone, but it turns out they do.  Since the saline vs. silicone implant isn't a decision I would have to make for awhile, he didn't get too into the pros and cons of those yet.  First I need to even decide if an implant is right for me... one step at a time!

The implant surgery is pretty quick - only one hour (in addition to the mastectomy of course), and would require only one night in the hospital and just a couple weeks recovery time.

The other option is something called a TRAM flap surgery, which stands for something really long and medical-sounding which I can't remember.  The gist is that, instead of using an artificial implant, they use tissue from your own body to reconstruct the breast - most commonly from the abdomen, but they can also take it from your back.  This is why Dr. Samson had examined my abdomen and back.  He said I don't have much fat to work with (I guess that is a good thing?) but that if he used it all he would probably have just enough to reconstruct a breast that matches the left.

At this point, I asked him, "What if I ate pizza every day from now until the surgery?  If I fatten up would you have more to work with?"  He said it doesn't really work that way because the tissue is still living tissue.  It doesn't know it's in your breast and not your abdomen anymore, and so it reacts the same way it would if it were still in my belly.  So when I went back to my normal diet, it would shrink just as my belly would.  He didn't go so far as to say I would be lopsided, but that's the image that floated through my head!

This is a much more involved surgery, since there is not only an incision in the breast, but also a (very big) incision in the abdomen.  There are different variations of this surgery which can take from 4 to 10 hours.  I would need to stay in the hospital for 4-5 days, and the recovery time is several weeks.

So what is the advantage to this surgery over an implant?  Some believe that it results in a more natural look and feel to the breast, since it uses your own tissue.  Also, women with a natural "hanging breast" (yes that is the term he used) tend to prefer this option because it's easier to achieve this look with the TRAM surgery vs. an implant which tends to sit high on the chest.  Some women are also freaked out by the idea of having a foreign object in their body, so they are more comfortable using their own tissue.  I suppose some people also see the advantage of the free "tummy tuck" aspect, though Dr. Samson said he always downplays that part.

Back to the radiation risks - there are risks of damage to the reconstruction no matter which option I choose, but I guess the risk is slightly higher with an implant.  There are two things that can happen - infection, which is very rare, and something called capsular contracture.  Whenever a foreign object is inserted in the body, a protective tissue develops around it - this is the body's natural defense.  This is normal, but if this tissue gets too thick, it can distort the look of the breast and even become painful.  There is a risk of capsular contracture with any kind of breast implant, but the risk is higher in radiated tissue.  It's not a life-threatening condition - it would just mean additional surgeries to fix or replace the implant.

Radiation can also damage TRAM reconstruction, and if that tissue gets damaged, there is no fixing it - most likely if it was bad enough it would have to come out and an implant would have to go in (i.e. I would have had that big surgery for nothing).  TRAM flap reconstruction cannot be repeated - once you take tissue from the abdomen or back, you can't go back - it's a one-shot deal.

After Dr. Samson went through each surgery and the pros and cons of each, he brought out the photo book.  Yes, my first thought was "oh geez, am I going to end up in this book one day with countless people looking at photos of my boobs?"

Then he showed me before and after pictures of women who've had the various surgeries we discussed.  As we looked through the photos, I got a little overwhelmed with all the boobs and scars, and I started feeling a little nauseous.  I didn't say anything but I was thinking "how embarrassing would it be if I had to excuse myself right now to go barf?"  What a wimp!

The pictures weren't gory by any means, but some of the before shots were a little upsetting (some had had previous mastectomies with no reconstruction, and others had biopsy scars and other abnormalities from the cancer).  The after shots were much better, but I have to say I didn't like the looks of that giant abdomen scar on the women who opted for the TRAM flap surgery.  It was huge - from one side of the body to the other.

I came away from the meeting leaning heavily on implant surgery.  For me, I just don't see the advantages to the TRAM.  I do not have a problem with a foreign object in my body; I'm not going after the "hanging breast" look; and I'd really rather not have a big scar on my belly if I can avoid it.  The complexity of the TRAM surgery is also a disadvantage, but honestly, I tried not to take that into too much consideration because I need to make the decision that is best for me in the long run.  If the advantages of the TRAM outweighed the fact that it's a much more involved surgery, then I would choose it.

One concern I did have with the implant is what happens 15 or 20 years down the road when my left breast might start sagging as I get older?  Dr. Samson said that he didn't think I had to worry about that but in any case, thanks to breast cancer lobbying groups, insurance companies now have to cover any future procedures I might need to ensure that both sides are as even as possible.  So, if I need a breast lift or something in the future, it should be covered.  That was reassuring to hear.

The other thing I really have to think about is whether I want a single or double mastectomy.  There is nothing wrong with my left breast, and I do not have the breast cancer gene (in which case I would almost certainly have a bilateral mastectomy as a preventative measure), but many women in my place still choose to have both breasts removed as further assurance that they won't have to go through this again.  But I need to talk to Dr. Rosenbaum Smith and Dr. Sara about what my risks are for a recurrance before I make this decision.

All in all though, it was a very interesting meeting and Dr. Samson gave me a lot to think about!

Hair Update

As of Friday, I have become a full-time wig-wearer (at least in public).  My new short haircut was quite a hit, but all week I kept losing a significant amount of hair in the shower every morning (and really, every time I touched my hair) and it was getting thinner and thinner. 

You would think that having short hair would shorten my getting-ready time, but it didn't really because I'd spend just as much time examining my thinning hair and wondering if I could get away with it for one more day as I would styling my normal hair.  I would inspect the back of my head every morning for bald spots with a small compact in the mirror before leaving for work, and then when I got to work I'd have my co-worker Corey do a check just for good measure (she never saw any that I missed, thankfully!).  I guess I'll have to wait until my hair starts growing back before I can fully enjoy the advantages of short hair.

But by Friday morning, I felt like an old man combing my hair every which way to try to disguise the thinness (I have a new sympathy for men, and women for that matter, who start losing their hair as they get older), but it just wasn't working so I decided to "wig it up."

I wore the long-haired wig (the one I call my "weekend wig") to work and got lots of compliments!  I was a bit worried that wearing it all day would start to get hot, itchy or uncomfortable, but it didn't really - it was fine.  Although at home I've taken to wearing hats as they're a little more comfortable.

So now I can choose from my two looks - short or long - each morning.  Who do I want to be today?  I think it will be kind of fun!