Supporting women whose lives have been touched by breast cancer

Skin Sparing Mastectomy with part silicone part expander implant reconstruction and Mastopexy (lift/symmetrisation) to other side.

by bl

Even though I knew I was going into hospital for a necessary mastectomy for 2 invasive lobular cancers in different areas of my right breast, when I received the letter from the hospital the week before the surgery I felt very scared. This was it and there was no going back. I had to be there by 12.00 noon and could not eat or drink anything from 9.00 am.

I woke up at 5.00 am on the morning of my admission worrying if I was doing the right thing. I wasn’t worried about the mastectomy; I really had no choice over that, but it was the reconstruction that bothered me. I had not wanted an implant because I was concerned about complications and rejection, but I was not a candidate for DIEP due to previous abdominal surgery. Nor did the surgeon think they could harvest enough tissue from other areas for a free flap reconstruction and told me I would still need an implant. He was concerned about fat necrosis and infection in someone of my age (60) and with a congenitive hole in the heart and suggested my best options were a Latissimus Dorsi flap with implant to match my remaining breast or an implant only with symmetrisation of the other breast, which could mean a reduction or just a breast ‘lift’.

I have muscle weakness due to an underactive thyroid plus I have osteoarthritis of the knees and rely on my arms to get me out of the bath or up from the floor and I was concerned that using the muscle flap would make both these tasks more difficult for me. Also, if I had to have an implant as well and that failed I would have used the muscle for no gain. For me I knew that psychologically I needed to have a reconstruction no matter what, as I didn’t want an external prosthesis and would not be comfortable being lopsided. After several discussions with my surgeon I decided on the implant only with a mastopexy on the left side.

The surgeon explained that the implant would be inserted under the pectoral muscle and be part silicone with an expander attached to a port through which he would inject a saline solution over a period of weeks to gradually stretch the muscle to accommodated the implant and I could then decide whether I wanted it replaced by a permanent silicone implant and have nipple reconstruction, which would give me a better cosmetic result, or I could keep the first implant and just have the one operation. I knew that my decision had been made rationally, but that did not stop the doubts creeping in that morning and I was concerned that I might not be happy with the result. Eventually I rationalised that my body had changed a lot over the past 60 years. I had not been born with breasts; they developed and had changed after the effects of breast feeding and gravity and I must just think of this as another change and be grateful that I would have 2 breasts and no cancer after surgery.

I felt very nervous and shaky as we left for the hospital and quite sick by the time we got there. I was admitted onto the ward and changed into my hospital gown when Sister arrived with a student nurse. She asked if I minded if the nurse was present throughout my operation and recovery and between them they did the usual blood tests, pressure, pulse, temperature, urine sample (well I did that bit, not them) and put the sexy TED stockings on me.

I was then shown the gown I would be going to theatre in. It was called ‘Bair Paws’ and was made of paper with Velcro fastenings down the back and on the shoulders and would be connected to a device similar to a hair dryer to keep my body temperature up. (For those of you old enough to remember the walk around hairdryers attached to a hood, it was a similar set up.) I would also be wearing ‘footsies’ when I came round, a sort of wrap around slipper connected to a machine that pulsed and was designed to prevent blood clots. Sister asked me how I was feeling and if I had any concerns. I explained my doubts that morning and that I was concerned how I would react to my changed appearance and she advised that I have an open mind and take things slowly and that what I would see the next day would not be the final result. She also warned me I would have to sleep propped up on my back to encourage drainage from the wound sites.

The surgeon arrived and went through the op with me again, drew all over me with permanent marker pen in a standing and lying position, which my husband said made me look like an African tribal woman! Apparently on the perfect breast the nipples are 19 cm from the top of the breast bone (bet you didn’t know that either!). When I commented on the effects of gravity he replied I hadn’t done badly, which made me feel quite good. He explained what I could expect to see in respect of stitches, swelling, drains (3), drips (2, Hartmanns and antibiotics) etc and he would see me in theatre around 4.30 pm and the surgery should take about 2 to 2.5 hours and I should not expect to be any more uncomfortable than I was after the lumpectomy.

Next the anaesthetist arrived and went through a few things, prescribed anti nausea tablets that the nurse brought to me and then we were left alone to wait. I felt much calmer, but as 4.30 approached I started to get nervous again. Sister popped back to say that the previous surgeon had overrun in theatre so my op would be a little later and not to clock watch – easier said than done! We went for a short walk and then they came in to put me into the ‘Bair Paws’ gown and connect me to the hair dryer. I was given a remote control to regulate the temperature, but told to keep it on. At 5.10 pm I said goodbye to other half and walked to a little ante-room just outside theatre with Sister. I climbed onto the table and they inserted a cannula into my left hand and put a blood pressure sleeve on my right arm. Sister insisted they take it off and put it on the left arm opposite to the mastectomy side.

The anaesthetist appeared, administered the anaesthetic and the next thing I knew I was coming round and the clock registered 9.45. My first thought was that the surgeon had lied: it hurt. I felt as if a tight band was round my chest and my left breast felt very painful and sore, but as soon as I let them know that they gave me some morphine (I was only on iv paracetemol). I could hear them saying that my pulse and heart rate were very low and the ward would not have me back like that. I wondered if it meant I would be going to ITU or HDU or would be left in the car park!

The anaesthetist administered frusemide and it must have worked because I was wheeled back to my bed at 10.15, still on oxygen and still in quite a bit of pain from my left breast, but the mastectomy side was virtually pain free. I didn’t know at that time my husband had been waiting for me to come back to the ward since 9.20 pm. The surgeon had rung him at 9.00 pm to tell him all had gone well and I was in recovery and would be back on the ward in 20 minutes! As I was still drifting in and out of wakefulness he didn’t stay long.

I drifted in and out most of the night. I was wired up to a machine that kept beeping, not because of my condition changing; there was something wrong with it apparently. 2 nurses seemed to be there most of the time, although I think in reality it was every 15 or 20 minutes they checked on me. When I woke around midnight, one of them said they were still concerned about my pulse and oxygen levels, which were low. When I replied that I had a low pulse rate normally, she said ‘not 39 though!’ I was aware of my pulsating slippers, which if the pulsating coincided with the precise moment of falling asleep jerked me awake again; very frustrating. I was very thirsty and drank lots of water.

The pain had gone now and I just had a little discomfort. It only hurt when I reached forward to pour more water out. They kept asking me if I needed the loo, but I didn’t. I wanted to see what was under my gown, but didn’t want to look on my own in case it upset me. I got my chance when the nurse said she wanted to check the wounds and drains for any swelling or hardening. Both sides looked much flatter than I thought they would and at first I thought the implant hadn’t been inserted. I had clear dressings over the whole chest area with steri strips over the stitches.

On the mastectomy side there were steri strips over the vertical incision that ran from the top of where my nipple had been to join the stitches in the crease under the breast. On the mastopexy side there were steri strips around the nipple, the vertical incision that ran from the nipple to under the breast and under the breast as well. It was quite bloody around the nipple, which may have been the reason for the pain and soreness immediately post op. There was 1 drain in the top half of the left breast and 2 drains on the mastectomy site. As well as the Hartmann’s solution and antibiotics I also had iv paracetemol. It was only later that it occurred to me that because you’re lying down when they operate and put all the dressings on your breast(s) are squashed and spread out. I felt as if half my breast was on the side of my body under my arm and the remainder much higher on my chest.

By 9.00 am I was off oxygen and breakfast appeared. I was not in the least hungry, didn’t eat much all day and really struggled to keep awake all morning. I couldn’t really face food and they offered me the light post-op menu, as nothing on the usual one remotely appealed. I finally managed to have a wee at 10.00 am to the nurse’s relief. It was a bit of a palaver getting to the bathroom, having to be disconnected from 3 drips, my pulsating slippers and carrying 3 bottles that fell over when I put them down. She then helped me have a bedside wash and change of gown. Medication appeared in the form of anti inflammatory tablet and blood clot prevention injection into tummy. Tablet made me feel woozy and sick and I had to go back on oxygen for a while.

The surgeon arrived and was very pleased with progress, checked wounds and told me I didn’t need to look yet if I wasn’t ready. I told him I’d already looked, but didn’t mention I was a bit disappointed with the flatness. He pointed out the outline of the implant, but to be honest I couldn’t see it. He told me it all looked just as it should; the swelling above the breast would diminish and the breast might appear a little square, but would round out. There was not much fluid draining, but he wanted to leave the drains in because of the bruising. I could come off the drips though and go onto oral painkillers.

The physiotherapist arrived to go through some exercises with me, left a sheet for me to refer to and told me to try and do them every hour. After lunch I had a couple of visitors (husband and brother) and when they left I went for a walk with the nurse complete with drains in 2 bags; she held 1 bag and I held the other and her arm. When we got back the Breast Care Nurse was waiting to measure me up for a compression bra she wanted me to order from Amoena and wear for at least 6 weeks; she left me all the details.

I’d been a 34E before the op, but was now 36D. She also checked all my wounds and drains, asked how I felt etc, if I had looked and if I had any questions. I mentioned the flatness and she said it looked like that because of all the swelling above the breasts, but as the swelling diminished fullness would return (strange that neither she nor the surgeon mentioned being squashed because of lying down) and the compression bra would help with reshaping the breasts.

My second night post op I had to ring for the nurse 3 times to go to the loo (making up for lost time). I would have attempted it on my own, but for the pulsating slippers that had to be disconnected first. I slept better although I was wide awake by 5.00 am. It was much easier moving around and it had only been 36 hours since surgery. The cannula was removed that morning along with the pulsating slippers and I was only on oral paracetemol and diclofenac plus the anticoagulation injection in the tummy. I managed to get to the bathroom and wash myself (have drains, will travel). I had to keep the hospital gown on because I didn’t have any PJ’s with buttons (I have a button phobia, so a no go for me; pathetic really).

I had taken in a couple of baggy t-shirts and a zip up top, but the nurse decided the hospital gown would serve better. Surgeon arrived and was still pleased with progress and look of things. It still looked a bit flat to me, but he’s the expert. He authorised removal of the drain on the left side and one on the mastectomy side, but the third needed to stay in. He told me the nurses would ring him in the morning as he would be at a different hospital operating and he would let them know if it could come out and I could go home.

I was a little nervy about the drains coming out, especially when I was told they went in about 4 inches. The nurse was very gentle though. She removed all the dressings, cleaned the skin, cut the stitch holding the drain in and gently pulled it out. The one on the left hurt a little coming out, possibly to do with the bleeding I had, as the nurse thought it had probably adhered to some tissue. She said it was unusual for it to hurt when it had only been in a relatively short time. I’m glad to say the one on the mastectomy side didn’t hurt at all when that came out.

Towards the end of the day the mastectomy side started to feel more uncomfortable; my right side seemed stiffer and it was more uncomfortable to do the exercises; Sister thought it might be due to the drain being removed, but said it was still soft and hadn’t hardened so not to worry. I had a rotten night’s sleep that night, just couldn’t get comfortable sleeping on my back. If my right side was comfy, my back wasn’t and vice versa. For the first time I wanted to go home and have my own bed and be able to get up and wander round in the middle of the night if I wanted to. The next morning I was a little emotional, probably to do with being tired, although 2 days after surgery seems to be the time when that hits me. It didn’t help when the night nurse said that there was too much in the drain bottle for it to come out and it was unlikely I would be going home.

When the day staff came on duty Sister explained that it was often the case patients felt low on the second full day post op because the anaesthetic drugs and iv painkillers were wearing off and it was likely to be more uncomfortable plus the initial euphoria of getting past surgery was gone. She rang the consultant who agreed the drain could come out and I could go home (joy of joys!). I was told not to bath or shower, but just to have strip washes (blast!).

It felt so good to be home and I slept much better in my own bed, plus I could lie down properly instead of being propped up and even managed to lie on my left side. It was more uncomfortable than painful and I had been advised to take both paracetemol and ibruprofen regardless of how I felt, which I did. The worst thing was getting up from lying down when I experienced something akin to needles being stuck in me (nerve pain perhaps), but a few deep breaths and it was gone. That only lasted a few days after which the only discomfort I had was from the expander port that was just under my breast, which felt as if it was pressing too hard against my ribs and making them sore.

The afternoon after my discharge from hospital I developed a ‘leak’ from the mastopexy site and had to go back to hospital to have it redressed twice over the next 2 days and have it checked by a doctor to make sure there was no infection. My surgeon was contacted and he asked them to reassure me that this did happen and he knew it would be the T junction between the stitches, as that was always the weakest point. He was right!

My compression bras arrived in the post, not the most attractive bras I have to say. They fastened with about 10 hooks and eyes at the front and the shoulder straps also adjusted by hook and eye at the front, so very practical. I found vest tops were the best thing to wear over them with a zipped top zipped halfway, as this seemed to disguise the difference in breast size (I don’t do buttons remember).

I saw the consultant after the weekend and because there was still a slight leak plus I had an adverse reaction to the dressings in the way of blistering on the left breast he decided I should have a course of antibiotics, as he did not want any potential skin infections to get into the wound. He decided it would be better to let air to my skin, but I told him I wasn’t ready for Brighton beach just yet! All the dressings were taken off the mastectomy site and minimal dressings left on the mastopexy site; steri strips around the nipple and an iodine dressing on the site that had leaked.

Unfortunately, this meant I still could not bath or shower. He confirmed that the expander port could be uncomfortable, but may be less so once expansion started and he could always remove it once the expansions had finished. I had to go back a week later for the dressing to be changed by a nurse and the following week saw the consultant for the first expansion.

The Expansion

Implant Exchange & Nipple Reconstruction

Nipple Tattoo