Reconstruction - Why and How

I realized while rereading the blog today that I had forgotten to post about reconstruction. A little back story first. When I was first found out that I had to have a mastectomy, my first thoughts were so what, I don't care about the cosmetic outcome. To this day I still feel that way. I don't care that without my cloths I look nothing like a "normal" woman. I don't even care that with my cloths on I do look like a "normal" woman. Every decision I made during my surgeries and treatments was about my health and keeping life normal for my daughter.

After the mastectomy I waited only 3 weeks before getting my prosthetic breast. It is recommended that you wait at least 4-6 weeks to allow all the swelling to go down. I had a family Bat Mitzpah to attend and I wanted the prosthetic for purchasing a dress for the occasion and attending. This event also delayed the start of my Chemo since I wanted very much to attend this event and have my extended family see me looking good and healthy. I was hoping that this would ease their minds and reduce their worry. I have to say I was indifferent about the prosthetic. I got it in February when it was cold in New England where we live. I know this seems an odd statement but temperature played a huge part in my decision to have reconstruction.

After I got the prosthetic I wore it everyday for 3 months. Then it was May and it started to get warm. The prosthetic is a hunk of rubber strapped to your chest. It doesn't matter if it is in a pocket inside your bra or has a cotton covered protective pad on the back and Velcros into your bra. When it gets hot the prosthetic is hot, sweaty and itchy. My prosthetic was in the shape of a breast with "flaps" that filled in the area missing under my arm and the divot in my chest where the muscle was removed. It had 2 Velcro strips on the front and 2 on the back. The 2 on the back were used to attach a protective foam pad with a cotton cover which was suppose to keep the prosthetic from resting directly on your chest. While the pad helped, I ended up with a rash on my chest and under my arm in the shape of the prosthetic from the edges of it. I ended up never wearing it in the summer. I never purchased a swim prosthetic I just wore a suit without it.

I have to state that I was and still am a D cup. Therefore the missing breast was very noticeable. I didn't care, comfort was so much more important. Neither my husband nor daughter ever asked me to wear it. I even left it at my father's house once. If you can't see the humor in having to call your father and have him send you your breast, then you will never understand me. I thought this was one of the funniest things that happened. I also have a story about a friend who left hers at a hotel and the hotel called her and had to ask her if she had left a breast there. When I went out of the house sans the boob, people stared at me and so idiots even made comments. It began to have a negative effect on my daughter.

The long and short of it is the prosthetic was inconvenient and uncomfortable. No one should be forced to be uncomfortable simply to have people not stare at them. It turns out either way I was uncomfortable and my daughter was uncomfortable. That is what really made the decision for me. As with everything else maintaining normalcy for Sarah was my driving factor.

Once I had decided to have reconstruction the next step was two-fold. Did I have the second breast removed prophylacticly and what type of reconstruction do I have. I will address each of these issues separately. The decision about the removal of my second breast was definitely the harder of the two choices.

Prophylactic Remove

This was a hard decision. If I removed the breast I almost bring my recurrence chance to 0%. But, in doing so I am further mutilating my body. Chemo and Tamoxifen had pushed me into menopause (or very close to it). I had all the physiological changes associated with menopause. Some of these changes are sexual. Your sex drive drops and you have vaginal dryness. It is kind of nice to say this; my husband was worried that If I had my other breast removed he wouldn't be able to please me when it came to our intimate relationship.

Given all this I had pretty much decided to get rid of the breast. The final decision was made by my surgeon who told me I didn't have enough belly fat to make one large enough breast much less two. I had definitely decided against implants. I could have had two A cup breasts or two C/D cup breasts. This wasn't a vanity thing. Because my breast would be getting so much smaller I would be unable to have skin sparing surgery on the second breast and I might end up losing the nerves under my right arm as well as the ones missing in the left arm. In the end I decided not to have the breast removed. I have some days where I regret this decision (mostly when I have to get my mamogram).

Reconstruction Options

I want to be very clear about this. Consider having mastectomy and reconstruction done at the same time using skin sparing surgery. You will probably need to delay surgery in order to coordinate a general and plastic surgeon. You need to find surgeons who will do this and work with you. If they won't consider your needs do you really want them operating on you? Skin sparing surgery can be used with each of the different types of reconstructive surgery. I have been told that if you are having radiation after mastectomy that implants may not be an option.

There are surgeons who will tell you you can't have reconstruction before radiation because it will damage the implant or implanted tissue. This is an opinion not a fact, here is a link to a site about radiation after reconstruction. Once the chest area has been radiated the skin is much less pliant and reconstruction is more difficult. There are some women who were completely unable to have reconstruction because the skin was so damaged.

There are several different types of reconstructive surgery. I by no means know about all of them. There is a great article here about reconstruction. My choice for reconstruction was a DIEP Flap procedure. Most woman have implants or TRAM Flap procedures. For me each of these had major drawbacks.

TRAM Flap - the tissue and muscles in your abdomen are folded back and brought out where your breast(s) used to be. A protective mess is placed in your abdomen to protect your organs.

PROS
There is very little change for the transplants to die because their blood source is never disconnected.
The transplant is your flesh and blood.

CONS
You lose your abdominal muscles.
You have a foreign substance placed in your body.
This is major abdominal surgery and your recovery time is weeks maybe months.
You need to protect your abdomen after the surgery.
You have a greatly increased risk of a hernia after surgery.

Implants - If skin sparing surgery is not done, having implants put in will require the skin on your chest to be slowly stretched with an expandable implant that will later be replaced with a permanent one. This implant is the same type used for breast augmentation although silicone can be used for reconstruction.

PROS
No abdominal surgery is needed.
Has the least amount of time under anesthesia.
If done after mastectomy can be done as an out patient procedure.

CONS
You end up with a foreign object in your body.
Implants do not feel or move like real flesh.
Implants may have to be replaced over your lifetime.

DIEP Flap - Abdominal tissue is remove along with blood vessels for reattachment. This tissue is transplanted to the breast area attaching the blood vessels to other in the chest area.

PROS
Implant is your flesh and blood.
Little to no muscle is removed from your abdomen.
This is abdominal surgery but it is much like a tummy tuck and not major surgery.
No foreign items are placed inside you.

CONS
Longest operation of the 3.
There is a chance that the implant will not take because of the reconnection of blood vessels.
If the implant is on the left side this may restrict future heart surgery.

As you can see all 3 have pros and cons. I never considered implants since I didn't want something place in my body. I didn't chose the TRAM Flap for two reasons, 1) I had given up enough why should I now have to give up my abdominal muscles and 2) I didn't like the idea of a 4-8 week recovery period where I would need to protect my mid section. I suggest you read as much information as you can and make the decision the best suits you. Finding a good surgeon is imperative. My Plastic Surgeon was Dr. Hooman Soltanian. He is currently practicing in Ohio at Case Western Reserve and if I had to do this again I would travel to Ohio to have him work on me insurance be damned.

I will post more on the actual reconstruction experience but it is getting late and this has gotten very long.