No, I haven’t had my FLAP reconstructed (snort), I’ve had a flap reconstruction. The medical term for the whole operation is a mastectomy diep flap reconstruction. For the car-crash rubberneckers, the surgery curious, the people who slow-mo the worst zombie scenes in The Walking Dead just to relive the horror again and again (me too), this is for you. Oh, and family and friends who haven’t yet had the privileged experience of me walking you through my surgery deets, blow by blow. I lay it all out on a plate for you right here, just like my mastectomy specimen before it was sent off to pathology.
If you’re a bit on the squeamish side, this one’s probably not for you, especially if you have a belly button phobia (people do, you know).
I am just going to begin with the top-line, the nut shell summary, if you will. I’ve had the nipple (and a bit of extra skin) and all the internal breast tissue, including the cancerous tumour, removed keeping most of my breast skin. That’s the mastectomy bit. The volume of my breast, and the skin that needs to be replaced to cover the hole where the nipple used to be, comes from fat and skin from my abdomen. That’s the reconstruction bit. To ensure this skin and tissue survives in its new home, it goes with its own blood supply.
Here’s a diagram of the procedure, drawn by my surgeon.
The first thing to explain is that, unless you choose to delay the reconstruction ’til later, the mastectomy and the reconstruction happen in the same operation. One team, different surgical specialties coming together around the operating table. Mrs Adwani, my Consultant Breast Surgeon performing the mastectomy, and Miss Petrie (Nicky), Consultant Plastic Surgeon performing the reconstruction. And the rest! Registrars, med students etc etc.
Here’s a pic of everyone in action on the day of surgery.
In our pre-op meetings and physical examinations, Nicky has ascertained that she can make up the volume of my breast from my abdomen. This is by a simple process of grabbing, pulling, pinch-tests and measuring. She was trying to make a hand full which is pretty much what I have. She checked my back, and my inner thighs (nope. Pleasing). She also works out where the incisions are going to take place and what happens with my belly button. I’ll come back to this later.
Her job, on the day of surgery, is to locate a specific mass of tissue, as fat or muscle or both, that has a good blood vessel running through it.. The decision is made once she goes in and sees what she sees and finds what she finds. She does however go in with some knowledge, gleaned from a blood vessel MRI scan that took place before hand.
I am going to explain this in steps, but actually quite a lot is going on simultaneously with different teams working at different ends of my torso. (Torso. Eugh, Weird. Sorry).
On the day, shortly before the surgery, Nicky does a drawing on my body to map out where they are going to cut. Now, funnily enough, the girls were around for this part. She didn’t blink an eye as she sailed from meeting the children, to “would you like to see what I am going to do?” all delivered with warm eyes and a completely reassuring tone as she “drew pictures on Mummy”. The girls were riveted.
OK, now to the operating table. Step 1 is the Mastectomy. A 5cm hole around my nipple is cut, and a bit of extra skin in my case, is removed. All the breast tissue is removed through that 5cm hole, I imagined, with tablespoon, but it probably isn’t. It seems physically impossible to get all the boob tissue through the hole but it does because skin stretches (Vom face. Sorry)
The breast tissue is weighed so Nicky knows what volume she needs to replace. In my case, the ‘mastectomy specimen’ weighed 222g.
Now onto the next bit.
If you look at the diagram below, you can see where the incision lines are. Nicky found a layer of usable fat and didn’t need the muscle. She described it as fish-shaped. Long and flat and thin, that ran across the surface of my belly. Like a “fillet of red snapper”, she clarified, when I asked specifically, “which kind of fish?”, with some extra fat coming from the two bits either side of my belly button, as shown.
That elliptical fish shape, the flap, but let’s stick with fish, is effectively what was taken out, hip to hip.
Importantly she found “a loooovely big blood vessel” (me, smiling, like I just won something) running through it. She removes the fillet, and the blood vessel, cauterising and sealing off blood vessels in my abdomen as she goes.
There is some pretty serious microsurgery going on at this stage. The surgeons do everything using a powerful microscope, peering down through it, with their hands doing the work underneath.
My fillet of red Snapper (can’t say flap) is then literally walked across the room in cupped hands to the scales to be weighed to double check comparable volume, and then the breast reconstruction begins.
Now, this is where Nicky is ‘the bomb’ and has a reputation for creating the right shaped boobs. I asked, “how do you take a long flat thing and make a rounded plump thing?”.
Once in, she takes the fillet and suspends it with small stitches to the top corners (see diagram up there, marked ‘stitches’). Eventually, the stitches will dissolve and a natural adherence will develop with my own tissue. Tummy morphs to boob. There’s enough thickness in the fillet there to create the downward sloping ‘padding’ for my breast to reflect its natural shape, but she also does some shaping. To get the curvature for ‘side boob’, she effectively curls the ends of the fillet and tucks it under. I mean, wouldn’t you?
The big juicy blood vessel she found (I am so amazing) is then plumbed into the internal mammary artery and vein. To get to it, a small section of rib cartilage is removed.
Again, more microsurgery. The blood vessels we are talking about here are about 2mm in diameter. Nicky is literally using tiny tiny stitches to stitch two blood vessels together. Here’s an image of that looooovely blood vessel up on screen, clamped and in the process of being stitched.
Right, back to my flap (snort). The skin of my abdomen, of our snapper fillet, then partly becomes the skin of my breast, replacing what was removed during the mastectomy, and is stitched in place. This also becomes the foundation of my new nipple, which will be reconstructed at a later date. And so my tummy skin, is now my breast skin.
I am so grateful I don’t have a hairy tummy.
OK. Now to the belly button piece. Now, if you look at the diagram below, the top line of the elliptical fish fillet needs to meet the bottom line (Left)
Consider that if the surgeon takes the skin from the top and stretches it down, my belly button is going to be dragged down and therefore potentially in the wrong location in my torso (TORSO TORSO TORSO. Sorry, just desensitising that one). Consider, too, that one’s navel is in fact attached to you on a sort of fat stalk from the inside and it can’t stretch very far. SO, the surgeons need to cut around my belly button to release it, drag the skin down to meet the bottom line, stitch up the base line, which traverses my pelvis, PLUS stitch up the old tummy button hole (image right)
Then, a new hole is cut further up where my tummy button ought to be, and my belly button popped through that and stitched up. My tummy button hasn’t been relocated, but the skin around it has.
And that, my friends, is the full story on my surgery – tummy tuck and boob job in a oner. Not forgetting we just got rid of that fucking tumour which is why this is all happening in the first place.
Any questions? I thought you might. If I haven’t covered them below then feel free to ask me in the comments (btw, after you’ve commented once, the system remembers you and you don’t need to add your details in again).
How long did the operation take?
About nine hours. I arrived at the hospital at 7am. I was under by 8.30am and the op started at about 10.30am and finished at around 7.30pm.
I too, am wondering about those two unaccounted hours.
Bloody hell, that’s a long time! Did they stop for lunch?
Yes. But briefly. Nicky had a grapefruit. I think she’s on the Grapefruit Diet but I didn’t ask.
Dan, the Registrar, had some kind of bean stew and ate in in about 3 minutes. Punchy choice for a small room and a lot of people, I thought. Especially not mindfully chewing for easy digestion (I actually thought all these things).
Basically, as far as I can gather, these surgeon types are super humans and work the whole way through, stopping only briefly to eat on the fly and go to the loo. The med students are probably napping on the floor.
Why did you have to lose your nipple?
Too risky. The cancer originated in the milk duct which is linked to the nipple. It’s the same reason the surgeons decided to take some extra skin as it felt like the tumour was quite close to the skin.
Did you get a gander at the tumour?
No. Although I did ask. The entire mastectomy specimen is sent off to pathology in tact for further examination.
Who took the photos?
A med student who attended surgery took them. I keep wondering if they got the med student to shave my lady garden too. It’s what I would do to an intern, just for shits and giggles.
Do you have MORE photos? Like really gory ones?
More were taken, and yes, I have seen all the key stages of the entire procedure. Nicky went through them with me. I decided not to keep them owing to what I anticipate to be the next global crisis. Cloud storage. We can’t keep everything people.
What about boob after care?
My flap was checked every 30 mins for the first 24 hours, decreasing to every hour for the next 24hrs and then every two hours etc. They are specifically checking blood flow to the breast to make sure that all the pipe-work is connected up properly. They check with a mini doppler, much like the midwives use to check the baby’s heart beat during pregnancy.
What’s the recovery time?
Six weeks off driving and running. About three months all in from surgery back to full recovery.
That’s a big op and big recovery time for someone who works, has two small children, a dog, and leads an active life-style. Why put yourself through it?
It’s really because of all those things. An implant, although a much simpler operation and much shorter recovery time, would require on-going maintenance and eventually more surgery as they do have a ‘use-by date’ of sorts.
Also, a tissue reconstruction gives a more natural result and is much easier to match up to the other breast. Lastly, it will also age naturally in line with my other boob so I don’t end up with ‘Little Miss Perky’ on the left and ‘Little Miss Droopy’ on the right in years to come.
I could have course had lefty clean off and stayed flat, which I did strongly consider and it was initially what I wanted to do. I do however run, swim and do yoga a lot and I just thought dealing with funny bras and chicken fillets and god knows what else would be a pain in the arse and a painful reminder of what I’d lost (imagining a chicken fillet half way down my wetsuit during a triathlon)
I just wanted to have one operation and be done with it forever. No maintenance, no faffing, no thinking about horrible cancer and the impact it’s had.
So, how are things now?
As I type, it’s one week three days since surgery. Boob is going great guns. Apart from the fact that it looks like it’s been involved in its very own car crash (bruising and swelling), there is no pain in the breast area and all as it should be. I am thrilled with the results and most importantly, glad the tumour is a goner.
My abdomen is really tight, I can’t stand straight and this where I tend to feel any pain. There’s a helluva lot of healing going on, inside and out, and it’s pretty tiring all told. I can’t stand for long periods or walk far. Progress is, quite literally, baby steps.