Just another woman doing bog standard breast cancer, y'know the one where you discover your treacherous ovaries have been feeding oestrogen to that uninvited carcinoma. It's here I get things off my cancery, now post-menopausal chest. It's definitely not funny, most certainly sweary. Sometimes a bit cry-ish.
As I type, it’s nearing on five weeks since surgery and people have been asking how I’m doing ‘down there’. The following notes are thank you letters to my surgical team which will explain the situation best.
I quite literally feel like I won the surgical lottery. Hit the jackpot. I know it wasn’t quite like that. You were chosen for me. But I feel so damn lucky to have been your patient.
Even past the bruising and the swelling, I see a breast that looks just like mine. It IS mine. I have my own skin. I have my freckles. I have the same shape, and I also know that what is inside is mine, and is me.
So, I don’t feel at all like I’ve had a mastectomy in a funny old way. It just takes a little re-framing of the situation – I’ve had something really really horrible taken out of my breast, and a bit of me from somewhere else popped back in – a re-org, as it were, a tissue re-shuffle.
My boob is fabulous and SO ARE YOU.
Thank you. You are, actually, the best.
An edited version of the thank you letter penned from my hospital bed to my Consultant Breast Reconstruction Surgeon.
It can’t be easy being registrar when the consultant surgeon gets all the damn credit for the boobs. I wanted to write and say thank you for the bits you probably don’t get thanked for very often. Like the belly button bit.
I’ve always had what could be conservatively described as a prominent outy. An ‘out there’ outy. An extroverted, flamboyant outy verging on body-political ambitions for abdominal take-over.
Then with two pregnancies, dear GOD, my belly button grew to such grotesque proportions it cast its own shadow across my abdomen at high noon.
And so I resigned myself to one piece swimsuits.
Then came breast cancer-reconstruction surgery. Once I’d gone home and the swelling had settled in my abdomen, I did not, in a million years, expect to wake up one day, lift the sheets and look down to ‘New and Improved Shiv’. Not only a svelte new abdomen but what appears to be a new and improved belly button. HELLO YOU!
And perfect neat scars, healing nicely thank-you-very-much due to some mighty fine stitch work at the tail end of a long and exhausting surgery sesh on nothing more than bean stew.
For the new and improved me, I salute you Sir. Your belly buttons ROCK Dan. Thank you.
My draft letter to Dan, the registrar who played a key part in my surgery.
So people, really, don’t feel sorry for me. I am going to wang on and on about the unexpectedly fabulous new me thanks to awesome surgery by awesome people who work for the NHS, all in the name of ridding me of the cancer and putting me back together again. I will go so far as to say I may become intolerable. I may even resurrect that belly button ring from my late teens. Hold the phone, I might even wear a crop top this summer.
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.
This post is dedicated to Jane Quinlan, my wonderful Consultant Anaesthetist. She’s not dead by the way, I just wanted to dedicate it to her even though she’s alive and unlikely to read it.
Jane, apart from being bloody brilliant at what she does, is proper funny. In meetings with her, there were times I was mentally panning back with a camera and thinking. “You could script this. She’s good!”. On the day of surgery, I told her how much I appreciated her humour during what was essentially a pretty dark time. She admitted, shortly before I went under, that it really depended on the patient and sometimes she had to tread very carefully. This in itself, to me, was hilarious. So much potential! Imagine the scenes of the anaesthetist taking dark humour a bit too far? It’s just so British comedy TV!
As with my surgeons, I took a photo of Jane “the funny one” to show the girls. “And this is Jaaaane, Mama’s anaesthetist” (maybe one day they’d like to be an anaesthetist?) Daisy: What’th an anaeththetitht (tough, if you have a lithp) Me: Hmm. Anaesthetists put people to sleep. Jane will give me an injection to put me to sleep before the operation. Daisy: Silent, but with a face that said. “That’s a fucking stupid job”.
Sorry Jane, it’s a tough one to explain to a 6 year old. I should have said more about the pain management side of things.
Anyway, back to you people, this next bit wasn’t funny but it was really really helpful and came in handy yesterday.
Yesterday, Monday, I was DOG TIRED. Weak. Just felt “not well”. Couldn’t do. I occasionally made it downstairs, but then crawled back upstairs just to collapse and disappear into my bed. Bed was the only place I wanted to be.
It was in stark contrast to Sunday. Sunday was home-day. I got up early. I showered. I dressed. I EVEN PUT PANTS ON (first time since Tuesday. As I write, it’s just occurred to me that I went IN to pre-op with them on, and came out with them off. I won’t think about that now). Tom and the girls helped me pack up my room and we all trundled home. It was a seriously happy day. As soon as we got back, we all made a bee-line for the garden and I sat in the sunshine and had a cup of tea and a cup cake.
Jane had previously warned me, that when I wake up from the op, I might feel like “I’d been hit by a truck” (BRILLIANT bedside manner). I didn’t really feel like that when I woke from the op, but I REALLY felt it yesterday. The truck had hit me six days later. I woke with it. I wasn’t in pain, but I ached. I couldn’t stand for long and could only walk small distances. Everything was effortful and less than I could do the day before.
But I didn’t feel pathetic or down on myself because wonderful Jane (#anaesthetistcrush, now there’s a new hashtag) had drawn this for me.
“People Don’t Get Better in Straight Lines. It’s a wavy line with some good days, and the next day may be not so good, but ALL progress”
Jane had told me this verbally, but I had asked her to scribble it in my book (to be fair, I didn’t think she’d ACTUALLY scribble). Yesterday, I clung to it. I really didn’t anticipate feeling this awful. Instead of thinking, “fuuuuuuuck, this is shiiiiiiiit” all day, it allowed me to just move through it knowing tomorrow might be a better day.
Today so far is a really good day and I’m listening in. I woke up FULL of beans and am now back in bed for my afternoon nap. It’s a good thing because today is hubby Tom’s birthday. We’re going to make cake together (me reading the recipe and directing from the sidelines, probably).
So thank you Jane, your little scrawl in my book got me through a tough day and will get me through every subsequent post-surgery dip. This morning I remembered your parting words to me last week. “And remember. Strictly no washing dishes or vacuuming for two years”*. If you get sick of putting people to sleep, you could always try your hand in comedy.
*I hope I haven’t ruined that line for you by publishing it. You might need to work on a few more. Always good to have fresh material to pull out the of the bag.
It was around midnight Wednesday. There was definitely a rumble of sorts. It feels like the troops are mobilising. Oh my god. There’s no mistaking it.
I need to poo.
I haven’t ‘been’ since Monday. We came in early Tuesday for ‘op day’ and i drank coffee on the way in to help, well, ‘move things along’. I thought it would be optimal to go into theatre ‘empty’.
We meet Jane, my wonderful anaesthetist. She goes through a few things.
“Any questions?”, she asks.
“Well.. there is one thing. I haven’t done my morning ‘constitutional” I say with meaningful eyes.
“I won’t… you know… On the… during the…??”
“Oh no don’t worry, everything will grind to a halt”
“Like when you go camping?”, I suggest.
“Exactly” says Jane, parting with “right then, see you later and erm, good luck with your wee slash poo situation”.
No more to report.
Back to midnight last night. I am now post-op so let me put this in perspective for you. I’m lying in a hospital bed. I have two drain pipes attached to my insides on the left hand side of my body (one for my breast, one for my left abdomen) with accompanying bottles for post-op body fluid to drain into, one drain on the other for right abdomen. Also a catheter and accompanying ‘wee bag’. Intravenous pain blocker direct to my newly constructed breast on the left, and a cannula /morphine feed, the latter two attached to a lamp-post-machine thingy on wheels to the right of my bed.
All this needs to come with me.
I call for the nurse. She arrives, takes one look at the situation, and calls for another nurse.
We all exchange a look that says, “ok. Let’s do this”..
We start with what we need to do to get me out of bed. I have intermittent pneumatic compression devices velcroed around my legs (to prevent blood clots) which need to be removed. My bed clothes include the ‘Bear Hug’ an inflatable plastic blanket with warm air being pumped through it 24/7, sheets and blankets. I am physically ‘plumbed in’ to everything so, as the bed clothes etc come off, we need to give clearance to the wires on both sides of the bed as I ever so slowly bum-shuffle down, taking some weight into my right arm, and get myself to sitting position on the edge of the bed.
The intravenous lead from my right arm to the not-a-lamp-post on wheels is short so it needs to be wheeled from the right hand side of the bed to the left, with my arm following it.
Nurse A, let’s call her Romana, because that’s her name, brings a drain bottle and my catheter bag. Nurse B, Shirley, is holding the other two drain bottles. In the end we decide all the drain bottles can go in a ‘Chipping Norton Literary Festival’ tote bag to make it easier to carry them.
The door to the loo is two metres away as the crow flies. I inhale, and stand on the exhale. This is big people.
I have effectively had a tummy tuck to create the volume for my left breast from my abdomen. It’s really tight down there and I can’t stand straight. It’s a slow, decrepit, old-lady-like shuffle to the loo. I’m wearing a backless hospital gown which is the only remotely convenient thing about my set up in that moment.
Once I get there, we all need to go in. Because of where the nurses and the wheely thing are in relation to me, we need to walk in , reverse, and de-rotate so I am not entangled in wires and everything is on the correct side. This happens in the small space between the sink and the loo.
Sitting is an effort but a relief. We bloody made it!! It feels massive. But not as massive as what’s backed up inside me and threatening to come out any second. It suddenly feels very crowded. You know that scene in Ghost, when Whoopie Goldberg is in the room with all the ghosts and she does the, “right, EVERYBODY OUT, OUT OUT OUT!!!”. That happens.
Aah, privacy. I close my eyes and wait.
Eventually, I fart.
[SOME TIME LATER: I’m pleased to report a ‘happy ending’ to this crushing disappointment. I had aimed for Everest and only reached Basecamp and it was a difficult blow at the time. Tom and the girls came to visit me the following morning. Tom brings coffee and beetroot juice. A familiar rumbling kicks in toward the end of their stay. I ignore it for a while. By the time I slam that nurse button we are ALL SYSTEMS GO. I make it to Basecamp AND Everest! Thanks for bearing with me as I got my poo story out. The poo is a big step in recovery. It means my insides are back on track. It means, I can get from the bed to the loo. That means they can take the catheter out. That means I am one ‘lead’ down in being plumbed into ‘the system’ and one baby-step closer to getting back home. And THAT my friends, is a worth a standing ovation].