Tag Archives: plastic surgeon

Nipples, pecs, bras, OH MY!

I visited my plastic surgeon again to get a few more questions answered. Among them: what are we going to do with these nipples? I’m still waffling over keeping them and doing nipple reconstruction later. The reasons this is so difficult for me are many.

If they stay:

Will they die? Will they be in the right spot on my reconstructed breasts? What will the proportion be to my new breast size? Will I have any feeling left? Will I have permanent headlights? Basically, keeping the nipples intact leaves a few things up to chance. If the surgeon does a spectacular job and doesn’t snip any nerves or vessels that are essential to survival, we’re good; if something goes wrong, more surgeries will be needed.

If they go:

How much bigger will the scars be? Will I miss them? Will my husband be put off? How long until I can get some nipples back on these babies? Will the breast shape lose some projection and look a bit flat? Will I get 3D tattoos or something more creative? This seems like the less complicated route and nipple reconstruction is an option.

So what’s the verdict?

I don’t know. I’m still undecided. (See Let’s give them a chance for the update)

The plastic surgeon and I discussed these concerns and options. He did note that for each woman that undergoes a mastectomy as a preventative measure, about 30 are doing it after a cancer diagnosis. Saving the nipples is not a very safe choice once there are cancer cells in the body, therefore some surgeons don’t have much experience with nipple-sparing mastectomies. Out of the patients my plastic surgeon has worked with, there have been zero nipples lost. However, he is not the one that will be wielding the scalpel when the incisions are made. That lies in the hands of the other surgeon. When I recently met with him (see Speed Bump), he didn’t seem too keen on the nipple-sparing route. I am withholding making the call until I meet with him again and discuss this in more detail.

QuestionsOther questions from this visit with plastic surgeon:

  • Do we really need to snip the pec nerves?  NOT doing it isn’t really an option. It is done to create the pocket, but also for optimal projection. If the pec major remains completely intact (not sure this is even possible), this can cause “jumping boob” when you shake hands, reach for things, or even have a conversation, if you talk with your hands.
  • Will I have to wear a bra (ever)? No. I just want to take a second here and say “woo hoo!!! There will be an ace bandage wrapped around the chest for at least a couple of days post-surgery, but long-term a bra is not needed. Side note: As women age, they typically gain weight and the different types of tissue that make up the breast lose elasticity, so everything starts drifting south due to gravity. All of that tissue is removed during the mastectomy. Also, a piece of AlloDerm is implanted under the skin and acts as a sling for the breast implant (check out this 2 min video on YouTube – NSFW). Want a laugh? Check out this lady whose boobs sagged so low she just tucks them into her pants!
  • Should I use BioOil before and after surgery to soften tissue and minimize scars? Maderma and other products that help reduce scars are a waste of money. The most effective way to do this is to stimulate the tissue by applying pressure to it. One hour each day, take some “me” time and massage the scar tissue on the breasts.
  • Will you be performing the entirety of the reconstruction? Meaning: will any medical students/residents be practicing on me? Residents may be present to watch the surgery, but they do not participate. A surgical assistant will the stitching after everything is done.
  • When do you submit for insurance pre-authorization and does the general or the plastic surgeon complete the disability paperwork? The breast surgeon does his pre-authorization first, then the plastic surgeon submits the paperwork. Disability paperwork is completed by the plastic surgeon about three weeks out. By the way, the Women’s Health and Cancer Rights Act of 1998 (WHCRA) requires insurance companies covering the mastectomy to provide coverage for all stages of reconstruction of the breasts and  treatment of physical complications of the mastectomy (doesn’t matter if prophylactic). Note: this is IF the insurance company covers the mastectomy.

Breast Reconstruction Guidebook Table 18.1

Source: Steligo, Kathy. Breast Reconstruction Guidebook: Issues and Answers from Research to Recovery. Maryland: The Johns Hopkins University Press, 2012. Print, third edition.

Speed bump

I have been seeing the breast surgeon since the spots showed up on the ultrasound in March. I expected to work with him and the plastic surgeon I chose. Well, that will not be so. During a recent screening appointment he threw a wrench into it. He doesn’t have regular operating privileges at the hospital the plastic surgeon operates in and vice versa. He thought he would, but with his current patient load, there just aren’t enough weeks in a month for him to do whatever has to be done in order for a hospital to grant those privileges to an “outside” surgeon.

That’s just peachy! Now what? Do I pick one of the other two plastic surgeons or do I find another breast surgeon? He suggested that I stick with the plastic surgeon and meet with another breast surgeon – one he highly recommends. So off to another appointment!

I met with Dr. K and discussed most of the specifics of what has been going on with me and where I stand now.  He’s available to do the mastectomy on the 22nd, he seems like he knows what he’s doing, he does think that this is a good idea, we got along just fine, and he’s originally from Jersey (good or bad – you decide). I feel like I don’t have much choice at this point, as it doesn’t look like the other surgeon can do it, but I know I don’t have to “settle,” so I’ll think about it and see if I’m good with this arrangement or not.

Going under the knife

So what’s actually going to happen?  How does this work?

The prophylactic bilateral mastectomy is serious business.  The operation can range from four to over 12 hours – depends on what type of mastectomy (skin-sparing, nipple-sparing) and reconstruction (direct, delayed, implant, DIEP, TRAM, other flap, fat transfer) are planned.  It requires at least one night’s stay in the hospital and has a lengthy recovery (multiple-week’s-worth, not just a few days).  During a mastectomy the surgeon removes all of the breast tissue leaving little or none behind.  The breast reconstruction can happen or begin at the same time the breast tissue is removed: the breast surgeon removes the tissue and hands off the scalpel to the plastic surgeon who does his magic.

After consulting with both surgeons, I chose to have a skin-sparing mastectomy and go the two-stage implant route for reconstruction.  Sadly (or not – depends on how you look at it) I do not have enough extra tissue and fat to spare for some new boobies.  I’m still undecided on whether or not I want to keep my own nipples, but more on that later.

This whole procedure scares the crap out of me.  Even though I’m still two months out, I’m already nervous!  There are so many things that need to be considered and so many unknowns.  A few things are still up for discussion with the surgeons.  I have another list going and will be meeting with both of them again to get some more info to help me decide (updated a couple of answers post-appointment).

  • QuestionsDo we need to biopsy the sentinel node to see what’s going on there? Original verdict was no, but to be re-discussed with new surgeon (see Speed Bump). The answer is still no.
  • Should I keep my nipples? Eventually decided that I’m going to keep them.
  • Do we really need to snip the pec nerves? It is done to create the pocket, but also for optimal projection. If the pec major remains completely intact, this can cause “jumping boob” when you shake hands, reach for things, or even have a conversation, if you talk with your hands.
  • When do we do insurance pre-authorization? Breast surgeon does it first about a month before surgery. Plastic surgeon submits after that is granted.
  • How long will I be unable to shower, open my own water bottles, high-five, do the nasty, drive, work, etc.? Timetable for Healing is one of the sections in the Breast Reconstruction Guidebook and details the first four weeks post-mastectomy. You are back to most of your normal routine during week four.

Breast Reconstruction Guidebook Table 14.1

Source: Steligo, Kathy. Breast Reconstruction Guidebook: Issues and Answers from Research to Recovery. Maryland: The Johns Hopkins University Press, 2012. Print, third edition.

Aside from worrying about infections and other surgery complications, the thing that bugs me most is long-term limitations on physical activity.  During the procedure, the surgeons snip some of the nerves that are attached to the pectoralis major to create a pocket for the implant.  Because of this, the pec major atrophies and loses some of it’s function.  The pec minor learns to pick up the slack, but doesn’t fill the shoes.  Does this mean that I won’t be able to go rock climbing again?  How about wake boarding?  Eek!  Anyway, another topic to research and discuss.