NOTES FROM PLASTIC SURGEON APPOINTMENT

Prior to making an appointment with a plastic surgeon, Judy had done extensive research from legitimate medical resources and through the American Cancer Society as to the options available for breast reconstruction and had learned that breasts can be rebuilt using implants or expanders + the tissue remaining after the mastectomy – or – with flaps of muscle or with muscle and skin obtained from the abdomen, back or buttocks and then transferred to the chest wall. She was leaning towards a procedure using muscle and skin from her abdomen because even though it is a more extensive procedure (longer surgery by 3 hours, longer hospital stay, longer post surgery recovery time) and leaves you with weakened abdominal muscle (unable to do sit ups, risk of possible abdominal wall hernia in the future), it is a more permanent procedure as it is done with your own tissue, it ages as you age, sags when you sag, gains or loses weight as you gain or lose weight, and looks and feels more like your own breast. She had learned that the implants, while a less invasive procedure, require frequent follow up visits to the plastic surgeon for expansion of the tissue expander, followed by a final outpatient surgery to have the implants actually placed. The implants carry the risk of leaking, rupturing during follow up mammograms which are necessary to detect breast cancer recurrence, result in poor quality mammograms which may not detect cancer recurrence and run the risk of something called capsular contractions (a firm fibrous scar that forms around the implant which can cause pain and can affect the shape of the breast). She learned that implants can last from a very short time to many years but should not be considered “life time” devices. 1) On first impression, the office was very business like, the staff not warm and friendly like in the Breast Center where Judy had the biopsy or in the surgeon’s office. There were signs up and brochures all over about botox treatments to reduce wrinkles, and face lifts, and breast reductions, and facial hair removal. (As a side note, there was a TV on which we didn’t look at initially but could hear someone talking about the skin of the breast. We both assumed it was an educational video about some breast procedure until we looked up to see someone basting a turkey on a cooking show.) Judy said to me, or maybe I said to her “I don’t like this office”. 2) Judy was asked to fill out pages of information on medical history, allergies, medications etc. After a short wait, we were ushered back into a consultation room by a woman who might have introduced herself by name, but did not identify herself by title or role, i.e. nurse, receptionist, etc. She then asked Judy many of the questions which Judy had answered on the paperwork she had filled out and noted her answers. She then proceeded to go into a prepared speech all about breast implant procedures, how they are done, length of hospital stay, recovery period, follow up visits, etc. I finally interrupted to ask if Dr B. performs reconstruction procedures using a woman’s own tissue like the one that uses the abdominal tissue & muscle called a TRAM procedure. She said that “I don’t know you’ll have to ask Dr B” and then returned to where she had left off in her prepared speech. She next had Judy initial some forms indicating that she (whoever she was) had explained to Judy all about the implant procedures and then said that Dr B would be in to see us shortly. She gave Judy literature to read which covered different types of breast reconstruction procedures (the literature was produced by the companies which manufacture the implants) – no bias there! 3) Dr B came into the room and introduced himself. I think he asked Judy how she had been diagnosed and asked us if we had brought the pathology report (which we had not). Every other appointment we have, the office has contacted us and told us exactly what we needed to bring. No problem because I know the pathology report by heart. Dr B. then asked Judy many of the same questions she had first answered on the forms and second answered to the woman (no one ever looked at her paperwork, or at the previous person’s notes.) Dr B. then proceeded to talk all about the breast implant procedure. I again interrupted to ask if Dr B. performed the procedures using a woman’s own tissue, specifically the TRAM. He told me that he indeed did do this procedure, that in fact he had performed the first TRAM ever in the whole Chicago land area in 1990 something, but that he now does very few of them because they are such a major procedure. He said that when people go on the internet to look up these procedures they read all about how wonderful they are and how the TRAM is esthetically superior, as it is, but they do not read about all of the downside to the TRAM. He proceeded to tell us how invasive of a procedure it is, long surgery time, long recovery time, weakens the abdominal muscle, risk of hernia, all of the things we already knew. He did tell us that it is a “one time deal”, that if she should subsequently need a mastectomy on the left side, the TRAM could not be done a second time and an implant would have to be done on the left and the implant and the TRAM would not match. This was new and useful information which we had not previously considered. He then went back to talking about the implants. He never mentioned any of the risks or downsides to the implants until I specifically started asking questions. What is the risk of leakage? Dr B. “Rare, I can’t say never, but now the implants are filled with a gel which is self healing.” What about the lack of permanence of implants? Dr B. “Not true, they are just as permanent as your own tissue”. What about the fact that your own tissue ages, gains & loses weight, etc better than implants? Dr B. “Not true, neither the implants nor your own tissue age, or gain/lose weight”. What about the issue with mammograms with the implants? Dr B. “Not a problem”. At this point I stopped asking questions. He next took Judy into an exam room where he determined that she did not have enough fat & tissue in her abdomen and was therefore not a candidate for a TRAM. Judy’s reaction was “Really?” Lastly he discussed when he would be available to do the implant procedure, for the week of Thanksgiving his only availability would be Friday, but he said that he really didn’t see it happening for a couple of weeks. 4) As you can probably tell from these notes, there is a little bit of a trust issue with Dr B. He comes highly recommended by people I know and trust, as far a technical skill and good surgical outcomes. We thought we were going for a consultation in which we would be presented with ALL of the options for reconstruction which include 4 types using your own tissue and then the implants. We expected that we would be informed of the pro’s and con’s of each of the procedures and then after exam, Judy would be advised about which procedures she would be a candidate for. We felt we were being sold a “bill of goods”. It felt like Dr B was getting a “kick back” from the implant company. I know that all of this is likely not true, I know that procedures using a woman’s own tissue are MUCH more lucrative procedures for a Plastic Surgeon, so there is no financial incentive for Dr B to push the implant procedure over the TRAM procedure. I know that it is very likely possible, maybe even probable that Judy is not a candidate for the TRAM procedure, but I also know that she did not get her needs met at this appointment. This is something she will have to live with for the rest of her life, and she needs to KNOW for sure that the implant was her only option. 5) This is all very discouraging also because on top of the sense of urgency to have this “bad breast” removed, everything now needs to be delayed for a second opinion Plastic Surgeon appointment. Also this is one more physician’s bill. Should she not have immediate breast reconstruction at the time of her mastectomy and just proceed with her mastectomy? Everyone seems to recommend immediate reconstruction if possible (one less surgery, one less time under anesthesia & with delayed reconstruction you run the risk of scar tissue developing which can interfere with the reconstruction). A lot to think about, a lot of decisions to make, a lot of stress to be under. Judy has an appointment with a second plastic surgeon on Tuesday afternoon 11/25. In the morning of the same day she has an appointment with a genetic counselor.