Meeting with the Plastic Surgeon...

Pema Chödrön posing as "Rosie the Riveter"

We had our first meeting with a plastic surgeon today. It had been awhile since we had thought about surgery and we needed to brush up on the breast cancer books we devoured early on in this journey to come up with pertinent questions. (It is a good idea to have an idea of what is going to be covered before you meet with a surgeon. One, so you are not surprised as to what will inevitably come up and two, because surgeons are usually very knowledgeable people and you want to make sure to have your questions ready -- the next time you see them could be in the operating room or immediately beforehand.)

A bilateral mastectomy sounds scary. And it is. This is the recommended surgery by Laura's general surgeon to remove as much of the cancer in her right breast and the remaining breast tissue to reduce the chance for recurrence. We've known this for some time. It is more common to have this type of radical surgery when a woman has a large tumor (check!), it is aggressive and fast growing (yep!), and the patient is young (we have a winner!); all because there is a higher chance for the cancer to come back. Put bluntly, the procedure permanently disfigures a person, which is why we were meeting with the plastic surgeon to discuss options for reconstruction. 

Laura, Linda, and I arrived at the office and were taken to a nice meeting room and waited patiently for the surgeon. There were implants on display which we played with and Laura found a three ring binder that had about 50 pages of pictures inside with women who had breast cancer and were proceeding through various phases of reconstruction. The photos were graphic and not easy to look at. This would definitely not be left in the room if you were there for a typical "boob job" (i.e. without cancer). You need to have a lot of backbone to look at those photos and know this is something you will also go through.

One of the more ideal situations for reconstruction after a mastectomy is to have "expanders" inserted into the breast at the same time the breast tissue is removed. The expanders have a large metal port and are injected periodically with saline to slowly stretch the skin. Following an additional surgery, the expanders are exchanged with a proper silicone implant. This is probably more similar to the typical "boob job," but breast cancer patients have to work with a lot less, since a lot of stuff (skin, fat, and tissue) is removed along with their cancer.

Along with breast tissue, fat and sometimes the outer skin on the chest will need to be removed depending on how the cancer has spread. In Laura's case, the cancer is near the surface and all around her right breast, which will make reconstruction difficult at best.

The goal of the general surgeon who will perform the double mastectomy is to get rid of all the cancer, including in the lymph nodes, and she will also be removing as much breast tissue as possible, to limit the possibility of recurrence. It only takes one cell of breast tissue to allow the cancer to come back and although it isn't always possible to get rid of it all, less is definitely better. It's important to have clean margins which will be determined through pathology tests post-surgery.

Unfortunately the goal to be cancer free sometimes comes in direct conflict with what the plastic surgeon would like for great reconstruction results. They want lots of healthy, supple skin left to work with. The other big negative Laura faces for reconstruction is that she will be undergoing radiation after her surgery. The radiation will lower the statistics of a recurrence, but also will likely change her skin. Radiation can tighten the skin, discolor it, and may rule out the possibility for using expanders. The plastic surgeon said it is likely that the left and right breast will not match exactly if the effects of radiation are severe. By massaging and moisturizing the irradiated skin, we can hopefully help keep the remaining skin supple and prepare it for reconstruction.

Without going into too much detail with regard to the many surgical options for reconstruction, the best option for Laura will be to wait one year following her radiation therapy before doing anything. This means Laura would not have breasts for a year. That is a tough pill for all of us to swallow, but we are ready to smile at fear.

Although there is a small chance that she could have enough skin left for expanders post-mastectomy, and that the skin would stretch after radiation, she is much more likely to have to undergo an additional surgery to have muscle pulled from her latissimus dorsi or tunneled from her abdomen to make up the reconstructed breasts. The loss of the muscle from this surgery is permanent, although patients can resume activities they did before, like lifting things and swimming, after many months of physical therapy.

Whether the type of reconstructive surgery be a DIEP flap, whereby only a few muscles are taken along with arteries and are then transplanted into the breast area, or one of the myriad of other surgeries is unknown at this point. We can only educate ourselves and meet with other plastic surgeons to get multiple opinions. Much of what will happen is dependent upon the outcome of the mastectomy and the ensuing radiation treatment/its effects on Laura's skin.

This was definitely a hard appointment for us all and throws cancer right back in our faces with all of its force and might, particularly for Laura. She lives with her cancer every day, without escape, and will likely do so for the rest of her life, until a cure is found.

We all look into the future sometimes thinking on a time when all of these surgeries will be behind us and Laura will be without the big C, but right now all we can and need to muster is to be in the moment. It is too easy to get sucked under and into the depths otherwise. Being in the present is the greatest lesson we are learning through this experience. All we have is right now. Be thankful for this moment, and that one. We are and so can you.

"In our sleep, pain, which we cannot forget

falls drop by drop, upon the heart,

until, in our own despair, comes wisdom,

through the awful grace of God."

— Aeschylus (Oresteia)