Mastectomy, breast recontruction and tummy tuck

I have just come back from a month with my best friend. Two years ago she had a double mastectomy and chemotherapy. A few weeks ago she went back into surgery to have a breast reconstruction.

I must say that I was against my friend having this operation. It worried me that her body had been so traumatized with the mastectomy and chemo. I was so glad that she was alive and the thought of more surgery and more drugs really frightened me. It was a 13 hour operation and that in itself worried me. The fact that her immune system had already been so greatly compromised with the previous treatments really worried me. She had been so sick and weak and tired and depressed for so long that that worried me. All surgery and anaesthetic is risky. The fact that it was non essential surgery also worried me. She could die! That is what really worried me.

I felt like I had been holding my breath for 2 years; praying and willing her to live through the cancer side of things and now she was putting herself at risk for what amounted to nothing more than cosmetic reasons.

Breasts are after all not much more than lumps of fat. Breast cancer is probably the best cancer to have –they are not vital organs. Cosmetically and psychologically, I can understand that a young woman would be more devastated by a mastectomy, but surly being alive and healthy should be more important than girly self esteem.

Intellectually, she would agree. She tried to explain how she felt but no one really understood. We all love her so much – we had all had to face the prospect that she might die of cancer and the fact that she had come through it was all we could think of. We love who she is - not just her chest!

It wasn’t until I was really and seriously looking down the barrel at having a mastectomy myself that I understood what she was feeling. No, it’s not really about lumps of fat. It’s about amputation – not just the loss of a body part but a deep sense of grieving for “The Me” part of me. I felt it as soon as they said I had cancer.

Anyway, we could rationalize or debate this endlessly but the bottom line is that it is her life, her body and her choice to make for herself. I had played devils advocate but finally conceded that her decision had been made and I needed to get on board and get rid of my own fears and doubts. Focusing on what could go wrong was probably the worst thing we could do.

We wanted her body to accept the changes; to heal quickly and perfectly. We visualized and affirmed and expected her body to be stronger and healthier than ever before. She went into surgery blessing the doctors and all of the hospital staff and asking God to work through them. She spoke with her body and asked it to be receptive to accepting that the operation was necessary to repair and rejuvenate and she thanked her body for assisting.

According to the doctors the marathon operation was a success. She was sore, uncomfortable, drugged and plugged into drains when she finally woke. She was kept in hospital for 10 days. The surgery itself had gone well – very well, but recovery depended on the tissue taking and keeping a close eye on any sign of pneumonia or infection. She was poked and prodded every hour and very carefully monitored. It was impossible to sleep for more than 30 minutes at a time. She was encourage to move as much as she possibly could but it was difficult and painful as she was propped up with pillows into a V shape and had 4 drains attached to her wounds as well as the oxygen nose hose, catheter and cannula.

There was a big smiley face cut from hip to hip just above the pubic bone. They had taken the skin, tissue, muscles and vessels from her pubic area to above her belly button and stretched the skin together which had her pretty much doubled up. (This is what they refer to as the flap) The flap is then cut into two parts and inserted into the original mastectomy scars. Her breasts looked pretty good really, especially the top half as the fatty tissue had pumped up into a decent looking cleavage. The scars ran across the nipple area and underneath the breast with a small line vertical – like a dart in a dress. This gave a pretty good shaped mound and will later be contoured properly and evenly when the tissue and swelling has settled. A nipple will also be tattooed on. Oh, did I mention that they also made her a new belly button?

When she came home she looked like the number 7. It will take many weeks or maybe months for the skin to stretch enough for her to stand up straight. He lower back ached terribly as she could not lift of hold herself due to the cuts and the loss of muscle. She needed to sleep on the sofa with pillows under her shoulders and knees and she also came home with a drain hanging from her hip wound. The drain was really frustrating, cumbersome and ugly as she had to get around with a transparent hose and bag filled with blood and fluid.

Luckily the hospital has provided some home help and people come to her house to help with housework and some transportation. This is fantastic and fully subsidised – apparently this service should have been available when she had the two mastectomies but someone let her fall through the cracks of the system and she really had a hard time as she was on her own at the time.

Last week was week 5 and finally the drain was taken out. The scars have healed beautifully although she did get nasty blisters due to an allergy to the tape used. She had to take additional antibiotics. She is almost ¾ straight now and able to sleep in her bed and on her side. It will take some time before the scars fade but even now they are quite discreet. When she has the final adjustments in about 6 months I think it will all look quite natural. The skin needs to stretch some more but ultimately her stomach will be flat and her breasts will be natural looking, firm and nicely shaped.

In the near future she will also see an osteopath to help her realign and regain her posture.

Below is an excerpt from: http://www.cancer.org/docroot/CRI/content/CRI_2_6X_Breast_Reconstruction_After_Mastectomy_5.asp which details this operation (click the link for a more complete explanation.)

Tissue flap procedures
These procedures use tissue from your tummy, back, thighs, or buttocks to rebuild the breast. The 2 most common types of tissue flap surgeries are the TRAM flap (transverse rectus abdominis muscle flap), which uses tissue from the tummy area, and the latissimus dorsi flap, which uses tissue from the upper back. These operations leave 2 surgical sites and scars--one where the tissue was taken and one on the reconstructed breast. The scars fade over time, but they will never go away completely. There can also be complications at the donor sites, such as abdominal hernias and muscle damage or weakness. There can also be differences in the size and shape of the breasts. Because healthy blood vessels are needed for the tissue's blood supply, flap procedures are not usually offered to women with diabetes, connective tissue or vascular disease, or to smokers.

In general, flap procedures behave more like the rest of your body tissue. For instance, they may enlarge or shrink as you lose or gain weight. There is also no worry about replacement or rupture.

TRAM (transverse rectus abdominis muscle) flap
The TRAM flap procedure uses tissue and muscle from the lower abdominal wall (tummy tissue). The tissue from this area alone is often enough to shape the breast, and an implant may not be needed. The skin, fat, blood vessels, and at least one abdominal muscle is moved from the abdomen to the chest area. The TRAM flap can decrease the strength in your abdomen, and may not be possible in women who have had abdominal tissue removed in previous surgeries. The procedure also results in a tightening of the lower abdomen, or a "tummy tuck."

There are 2 types of TRAM flaps:
A pedicle flap leaves the flap attached to its original blood supply and tunnels it under the skin to the breast area.

In a free flap, the surgeon cuts the flap of skin, fat, blood vessels, and muscle for the implant free from its original location and then attaches it to blood vessels in the chest. This requires the use of a microscope (microsurgery) to connect the tiny vessels and takes longer than a pedicle flap. The free flap is not done as often as the pedicle flap, but some doctors think that it can result in a more natural shape.

Latissimus dorsi flap
The latissimus dorsi flap moves muscle and skin from your upper back when extra tissue is needed. The flap is made up of skin, fat, muscle, and blood vessels. It is tunnelled under the skin to the front of the chest. This creates a pocket for an implant, which can be used for added fullness to the reconstructed breast. Though it is not common, some women may have weakness in their back, shoulder, or arm after this surgery.

DIEP (deep inferior epigastric artery perforator) flap
A newer type of flap procedure, the DIEP flap, uses fat and skin from the same area as in the TRAM flap but does not use the muscle to form the breast mound. This procedure results in less skin and fat in the lower abdomen, or a "tummy tuck." The procedure is done as a free flap, meaning that the tissue is completely cut free from the tummy and then moved to the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels. The procedure takes longer than the TRAM pedicle flap discussed above.

Donor tissue site for DIEP flap
After DIEP flap
Gluteal free flap
The gluteal free flap is another newer type of surgery that uses tissue from the buttocks, including the gluteal muscle, to create the breast shape. It is an option for women who cannot or do not wish to use the tummy sites due to thinness, incisions, failed tummy flap, or other reasons. This procedure is much like the free TRAM flap mentioned above. The skin, fat, blood vessels, and muscle are cut out of the buttocks and then moved to the chest area. A microscope (microsurgery) is needed to connect the tiny vessels.

Nipple and areola reconstruction
You can decide if you want to have your nipple and areola (the dark area around the nipple) reconstructed. Nipple and areola reconstructions are optional and usually the final phase of breast reconstruction. This is a separate surgery that is done to make the reconstructed breast look more like the original breast. It can be done as an outpatient under local anesthesia (drugs are used to make the area numb). It is usually done after the new breast has had time to heal (about 3 to 4 months after surgery).

The ideal nipple and areola reconstruction requires that the position, size, shape, texture, color, and projection of the new nipple match the natural one. Tissue used to rebuild the nipple and areola also is taken from your body, such as from the newly created breast, opposite nipple, ear, eyelid, groin, upper inner thigh, or buttocks. A tattoo may be used to match the color of the nipple of the other breast and to create the areola.

In a newer procedure called nipple-sparing mastectomy, the nipple and areola are left in place while the breast tissue under them is removed. Women who have a small early stage cancer near the outer part of the breast, with no signs of cancer in the skin or near the nipple, are better candidates for nipple-sparing surgery. Cancers that are larger or nearby may mean that cancer cells are hidden in the nipple. Some doctors give the nipple tissue a dose of radiation during or after the surgery to try and reduce the risk of the cancer coming back.

There are still some problems with nipple-sparing surgeries. Afterward, the nipple does not have a good blood supply, so sometimes it can wither away or become deformed. Because the nerves are also cut, there is little or no sensation left in the nipple. In some cases, the nipple may look out of place later, mostly in women with larger breasts. This type of surgery is not yet widely available, but is getting more popular.

Saving the nipple from the breast that has been removed to use it later (called nipple saving or nipple banking) is no longer favored by most surgeons. The tissue can be injured by the way it is stored or preserved, and there have been other problems with this surgery.