Supporting women whose lives have been touched by breast cancer

Implant Exchange and Nipple Reconstruction

by bl

I had a skin sparing mastectomy and reconstruction with a permanent expander (part silicone, part saline) and was given the choice of keeping the expander or changing it for a permanent silicone implant. Initially, I was against the silicone implant, mainly because of the bad press it had back in the 90’s, but my surgeon said they had improved vastly since then and there were many different options of implant, the ‘gel’ inside was now cohesive so even if the implant ruptured the gel would not leak into the remainder of the body. I figured that the expander still had silicone in it so the risk of rupture was probably the same and because I still had one ‘natural’ breast, the expander failed to offer sufficient symmetry. I hoped by having the expander changed for a permanent silicone implant, the resulting reconstruction would be less like a cricket ball, not so hard and give me a better symmetry between the 2 breasts. It was just as well I made that decision because 1 week before my surgery the implant deflated. I found out later it was because the connection between the port and expander had come adrift, which was rare, but probably due to the fact that the surgeon had expanded it to its limit before the exchange (to give the reconstruction some droop) combined with me rolling over on to it in the middle of the night.

I was not at all nervous or worried about the procedure and was admitted to hospital at mid-day for an overnight stay. On arrival I had the usual pre-op assessment, was given anti-sickness and antacid tablets and struggled into my TED stockings. The surgeon arrived and drew a line under each breast and marked where the new nipple would be. He explained that he would cut where the scar was under my breast to remove the expander and insert the new implant; the nipple would be made from existing tissue, which would mean an additional scar. They make 3 incisions rather like flower petals, or if you visualise a sycamore seed with the third petal hanging down from the centre and fuller and shorter than the other petals it will give you some idea, twist them round with a piece of fat whilst leaving the skin still connected to the reconstructed breast at the top of the new nipple and stitch it in place. The ultimate size of the nipple will depend on the viability and shrinkage of the fat.

At 1.30 pm I was taken to theatre, an oxygen mask was put in place and the next thing I knew I was in recovery with the clock showing 3.45 pm. I still had the oxygen mask plus a drain in place and was connected to a drip containing liquid paracetemol. There was some discomfort around the drain, which was where the port had been previously, but no real pain as such. It was certainly a whole different experience to the mastectomy and a walk in the park by comparison.

Back on the ward the oxygen mask was removed. The nurses were concerned that my heart rate and pulse were very low (which they had been after my mastectomy) and the surgeon and anaesthetist came to see me. The conclusion was that it was just how I reacted to the anaesthetic and I was obviously very relaxed about the whole thing (!).

In spite of the anti-sickness tablet given pre-op, I was very nauseous, drowsy and could not face food when it arrived. I was given an anti-nausea injection that helped and an injection of fragmin, an anti-coagulent, because I was taking tamoxifen. I was also given a course of antibiotics to prevent infection. The surgeon explained that the biggest cause of implant failure is post-op infection.

I was advised to sleep as upright as I could, as this would aid drainage, and I could go home in the morning providing there was less than 100 ml in the drain bag.

By morning there was 90 ml in the drain bag, my heart and pulse were back to what they had been on arrival and I was told I could go home. There was a large foam pad round my new nipple, which I could just glimpse through the hole in the middle, with a cling film dressing over the top so that I could shower. I was told that it was imperative the foam pad stayed in place and if anything happened to it to contact his secretary immediately. I was advised to wear my compression bra for 6 weeks day and night , but I didn’t need to wear it all the time, by which I assumed he meant the odd evening out I could dispense with it and wear something more attractive.

The nurse came to take my drain out, which was a little uncomfortable, but quite painless. There was still ‘soreness’ in that area; it felt very much as if a rib had been bruised – the same feeling I had when it felt as if the port of the expander was pressing against a rib. I was advised to wear the TED stockings day and night for a week because of the higher risk of clotting whilst on tamoxifen. I declined the painkillers they offered me to go home with, as I really couldn’t see the need for anything stronger than paracetemol.

I had a little discomfort over the next 2 days, which was soon resolved with paracetemol or ibuprofen. My new breast was much softer than the expander and felt more natural. It still seemed smaller, not as full underneath the nipple as my natural breast and slightly higher, but it was fine in a lightly padded bra. I was told I had been between sizes so they used the smaller size, the swelling would reduce in the upper part of the breast and it should drop slightly over the next 3 – 6 months.

One week later I returned for the surgeon to remove the dressings. The nipple matched my other one for size and was stitched in place with bright blue ‘hair like’ stitches that extended about 1/2” either side. I was told just to cover it with gauze to prevent it rubbing against my bra.

The weekend before my next appointment a week later to have the stitches removed I decided to try some of my old ‘pre-mastectomy’ bras on to see how they fitted. With hindsight it was probably not the best thing to do. There was still a gap between me and my bra on the reconstructed side. The reconstruction still seemed to be higher and I was not convinced it would drop. The lower outline of the reconstructed breast didn’t look round. If I drew a line under both breasts the natural one would be arc shaped, but the reconstructed one lost that arc where the vertical scar joined the horizontal scar under the breast and I realised that it was probably because of the way they had to pull the skin up to cover the area where the nipple had been. I had the fullness on the outside of the breast and a small ‘bubble’ on the inside of the breast and I could see that if I joined these 2 areas up the arc would match the one under the natural breast.

At my appointment the surgeon removed the stitches and advised that I should give the breast 3 – 6 months to settle and if I was unhappy he could ‘tidy it up’ and easily remove the ‘bubble’ on the inside of the breast. He recommended I went ahead with the tattoo, as he felt it would benefit me psychologically and take the focus away from the scars. He said that he would see me in 3 months unless I had any problems; the breast care nurse would contact me in about 6 weeks to arrange my tattoo.

There have been up and down days, days when I am quite happy with my reconstruction even though it may not be perfect and some days when it irks that I no longer have symmetry between my breasts. It does not matter how many people say ‘but most people’s breasts probably don’t match’, mine did and now they don’t. I have to remind myself that if I turned the clock back, given the same options, I would make the same decision. I no longer have breast cancer and I am still here, which is a lot better than the other options. My surgeon recommended the LD flap with implant and it was my decision not to go with that because of my arthritic knees and hips, a decision I would make again, so I can’t blame him! I know that in a bra no-one knows and that is what I wanted when I opted for a reconstruction. I didn’t want a prosthesis that would poke out above my neckline or shift around inside a bra. I wanted to have the appearance of 2 breasts in a bra or swimsuit and that is what I have. The only people who are going to see me without my bra are the medics and my husband. I am fortunate that he is fine with it and has been very supportive. I know not all men can deal with it in the way he has and I count my blessings. I think that no-one can know how they will respond in these situations until it happens. We all know how we would like to react, but when it comes down to it, it is not always that simple.

3 months on I have had my first tattoo session and I am due for a second in 10 days’ time. It has made a huge difference. Now, when I look down at myself, my breasts match and the reconstruction looks more natural with the areola colouration. The eye is taken away from the scars, which are not visible under the colouration. If I catch a glimpse of myself naked in the mirror it looks natural. It is only when I view myself critically in front of the mirror that the lack of symmetry notices and still irks on occasion.

At my 3 month follow-up appointment with the surgeon he is of the opinion that I should leave the breast to ‘settle and mature’ (sounded a bit cheesy to me) and he will see me in another 3 months. He did mention that I might need something to give me a little more projection and talked about fat transfer or collagen injection under the areola to plump it up a bit more plus a tidy up to get rid of the ‘bubble’ of skin on the inside of the breast. He has also started to use a new implant that gives a little more projection and thought that might also be an option to consider for the future. He was off to a conference on Nipple Reconstruction in Milan and hoped to learn what else might be available.

Would I do it all again? Oh yes! In all honesty I wish it had never happened. I wish I hadn’t had breast cancer, hadn’t had a mastectomy or a reconstruction, but it did happen. OK, I have scars I would rather not have, a silicone implant I would rather not have, the scars will always remind me of what happened to me, although I know they will fade with time, but even without the scars I will never forget. Life may never be quite the same, but it’s not over by a long way. I have ‘down’ days, but not that many when you put it in perspective. Sometimes I have to remind myself that if the cancer hadn’t been found when it was, the outcome might have been very different and I count myself fortunate for that. I try when at all possible to turn my thought s around, but some days it doesn’t work. Recently I tried on some of my evening dresses ready for a night out and only one was any good over my new bras. To begin with I felt quite depressed about it, but then rationalized that ‘Hey, I can go and buy some new ones now without feeling guilty.’ So, I’m off to the shops!

Mastectomy with expander

The Expansion

Nipple Tattoo