Reconstruction after Mastectomy - A Very Personal Choice
In some cases of breast cancer an immediate reconstruction following mastectomy may be offered to suitable patients but this article is an account of my personal decision and experience of a delayed reconstruction. I did not have the choice of an immediate reconstruction as I needed extensive radiotherapy following surgery and then a further 18 sessions of Herceptin and I had always said and indeed believed that only having one breast did not define me and I had, in my mind, gone through enough.
When I had my 3 month follow up appointment in October 2015 my oncologist suggested that I discuss and explore the reconstruction options with the breast care nurse, obviously with no obligation and with some reluctance on my part! I spent a most informative and enlightening hour with Jackie, the nurse, which was not without its humorous moments especially when given a rather large silicone implant (porn star size) to examine which reminded me somewhat of a transparent rugby ball. I was really quite relieved when I was told that because I had had 6 weeks of radiotherapy and my skin integrity was not good I was NOT a suitable candidate for an implant and so resigned myself to living the rest of my life with a prosthesis. Quite smugly I thought to my self 'Told you so'. Jackie, bless her, was using reverse psychology by showing me what I could not have and then informed me that the technique of using the patient's own body tissue to do the reconstruction had a very good success rate and produced some very impressive 'before and after 'photos of women who had undergone this procedure. I was intrigued and was sent home with all the literature to go and think about it and call her when I had made a decision.
The following days were mostly spent reading the literature and going on line to gather more information on 'Flap' reconstructions as they are called but I became increasingly aware in a change in my perception of my body and began to view myself in an almost clinical way. Whereas before I had looked at the mastectomy sight wth a bewildering array of feelings, ranging from pity to distaste and a perverse pride in what I deemed to be my battle scars, I had fought and hopefully won the hardest battle that any woman can fight, now I was comparing myself with the women who had fought the same fight and yet looked 'normal'. I realised that they also had struggled with the same feelings but had chosen to reclaim their lives and their femininity by opting for reconstruction and starting a whole new chapter in their lives. That was exactly what I felt I needed to do, put all the trauma of the past 4 years, my husband's illnesses, stroke and suicide, the loss of the business and cancer with all its many ramifications, and move on and live again.
The decision was made, I called Jackie and she arranged a meeting with the oncoplastic surgeon. There was some trepidation on my part and I was asked by some well meaning friends whether I knew what I was doing, but I told them firmly, this is my body and my decision, and I have to say they then supported my whole heartedly.
My meeting with the oncoplastic surgeon took place just before Christmas and my daughter came with me for moral support and also as an extra pair of ears in case I missed anything! As expanders then an implant was not an option for me he explained in great detail, with diagrams, the types of Flap reconstructions used but because I had had 2 C section deliveries many years ago a stomach flap was ruled out so the LD flap reconstruction was advised. The surgeon, Mr G, went through the procedure and explained all the possible problems but reassured both of us that the operation had a very high success rate. He also stressed that in no account must I think that I was being vain, after all if I had lost a limb I would expect the most realistic prosthetic limb available, and the ethos of oncoplastic surgeons is to give their patients the most 'normal' appearance possible whether it is visible to the outside world or not!
I left Mr G's clinic knowing that I had made the right decision and with the full knowledge that the start of the new chapter in my life was literally in the hands of the most empathetic and highly skilled man whose ability to communicate his passion for bettering the lives of those blighted by cancer filled me with confidence and I went home to wait for my appointment scheduled for 5 to 6 months later. I made it my mission to use the intervening time to get fitter so that I would be in the best possible shape for surgery so determined was I that nothing should go wrong and mean the surgery had to be delayed!
The Big Day
When I was offered my surgery appointment in April for a date 5 weeks hence I had no hesitation in accepting although it was stressed to me that I could change my mind at any time by ringing them. There was no chance of that happening, I knew what I had to do to be able to move on. I had my pre-op assessment, packed my bag and waited for the appointed day. I was so excited but I managed to sleep, got up early and was at the hospital for 7a.m. accompanied by my son and the next 90 minutes were filled with visits from the surgeons and the anaesthetist and at 8.30 said good bye to my son and went down to the anaesthetic room and by 9.a.m. had drifted off into a peaceful sleep!
I came round about 8 hours later at 5pm, feeling very comfortable and cocooned in a warm air blanket in the recovery ward and 30 minutes later I was drinking a very welcome cup of tea and sitting up chatting to a nurse that I knew! Within the hour I was back on the Surgical ward and waiting for my family and by 10pm I was out of bed and walking around complete with my 2 little pink carrier bags containing the 3 drains that I needed but I was happy that it was over and I had no pain and very little discomfort.
The Reconstruction Procedure
This is the procedure as explained to me, obviously I was oblivious to any of it! Once safely anaesthetised the original mastectomy scar was opened and the uneven scar tissue was removed and the site made smooth and the incision was then clamped together, I was then rolled on to my right side and the left arm was strapped to a board which was fastened above my head - this is necessary so that the left underarm area is exposed. My reconstruction, an LD Flap reconstruction, uses the large muscle from the back, the latissimus dorsi muscle,
The surgeon first makes an incision approximately 6 inches (15 cm) long across the back and removes the muscle, tissue and skin but leaving it connected to the blood supply under the arm. I believe (but not exactly certain) that the blood vessels in the back are then cauterised to stop bleeding and the flap which has been removed is then tunnelled under the skin to the mastectomy site. Once the drains (2) are in place the incision in the back is then glued together and held with steri strips and covered with a dressing. The incision is so placed that when the patient is wearing a bra no scar is visible
The mastectomy site is then unclamped and the surgeon reconstructs a breast from the tissue and in my case a small implant was placed against the chest wall as there was deemed to be insufficient fat from my back (which was a great surprise to me!) to achieve symmetry with the other breast. The flap is then glued in placed, a drain inserted, and held with steri strips and covered as before. The appearance at first is similar to a pair of lips as the flap is elliptical in shape and the skin is of a different colour. It is very important to keep the site warm so that the transplanted tissue does not die and this is where the warm air blanket came into its own as it covered me from head to toe and even shaped to fit under my chin! Thankfully I had no problems whatsoever and whole experience exceeded my expectations.
The First View
Although I was out of bed and walking around on the same evening, I waited another full day before venturing into the shower. A student nurse was asked to come with me to help me to take off my gown and hold the pink drain bags and off we went to bathroom. She was in her first year at university and it was her first placement so I asked her if she was OK with wound sites, she was quite excited to get the chance to view an LD Flap reconstruction as it is not a very common procedure where we live. We stood in front of the mirror and took off the gown. I was transfixed and speechless, I must have stood staring at my reflection for 5 minutes and then the tears came (from both of us). To me a miracle had happened! Where once there had been puckering, lumps and ridges which I hated every time I saw myself in the mirror for it reminded me of what had happened, now there was this breast with beautiful smooth skin (the dressing had only covered the steri strips) and I even had a cleavage! I knew and understood that there would be some swelling and possibly some bruising to come out later but that was a small price to pay. I was elated and so grateful for the skill and dedication of all the staff at the hospital and I could now finally see the end of a very traumatic period and get me back to being me. I had the back drains out before I went home on day 5 and the front drain was taken out on day 7 when I was at home. Yes, I was tired but I had no pain and a remarkable range of movement in my back and shoulder and my scars healed well and I took every opportunity to admire the handiwork of the surgeons and marvel at what they had done!
Work In Progress
It is now almost 4 months since surgery and I am feeling so well both physically but more importantly psychologically. I have closed the chapter, moving on with my life and welcoming the return of my creativity, enjoying a very good social life and very happy with my new figure. There is some 'titivation' yet to be done when it has all settled in another 2 to 3 months. There is some dissipation of my own flesh back into my body and so there is a small hollow which will be sorted about by lipomodelling, a fairly new procedure where the fat is taken from my midriff and channelled into the reconstructed breast. As breast tissue is naturally lost due to age the volume in the other breast is also given some lipomodelling if necessary to achieve the symmetry which both the surgeon and the patient desire. As there is no nipple on the reconstructed breast it is the choice of the patient whether to have a prosthetic nipple, which are very realistic, or to have a nipple reconstruction and tattooing, both of which under the circumstances only count as minor surgery!
I understand that reconstruction may not be for every woman who has had a mastectomy but I know that for me it was absolutely the correct decision. The surgery ,which in my case lasted for 7 hours, is major surgery but the pain management meant that I had only a little discomfort needing 4 paracetamol in all. My self esteem is restored with my femininity and only now do I realise what a negative impact the loss of my breast meant to me but I think I was probably in denial, so to all the ladies out there (not just the younger ones, I am 72) who have suffered breast cancer and mastectomy I urge you to explore the possibility of reconstruction. I hope you have enjoyed reading this lay person's first hand account of an LD Flap and if there are any medical/surgical inaccuracies pleased bear with me, I was under anaesthetic!