Celebrity Plastic Surgery, News, Gossip

By David M. Amron, M.D.

As a physician and surgeon, one of my main responsibilities is to honestly guide, educate, advise and protect my patients. As liposuction surgery is the only major cosmetic surgery I perform and I have done this procedure for 14 years for thousands of patients, I have a lot of opinions and insight into the nuances of consistently achieving a great result and making my patient happy. I have spent years fine tuning my approach and have a particular philosophy on what constitutes a good candidate for liposuction. It is so much more than sucking out or melting as much fat as possible. Despite what a patient may want or the mistaken goal of a surgeon, this approach will commonly lead to a poor result.

One of the most important points I want to emphasize is the importance of choosing the honesty, integrity, artistry, eyes, hands, skills and good judgment of the surgeon over the machine. The machine is only a paint brush in the artist’s hands. Despite interesting technology and aggressive marketing hype, it will not guarantee a great result in a trusting patient. A concerning trend I have seen in the last few years with the introduction of some of this interesting technology is the mistaken tendency of the patient to choose or ask for the machine instead of spending time to find the right surgeon. Unfortunately, companies, the media and sometimes even doctors themselves contribute to this when there is competition for dollars. Like I say on my radio show (and you are doing so by reading this article), please do your homework and spend time educating yourself. Do not be impulsive, continue to learn and hopefully the truth will come to guide you to a great result.

Presently in the United States, liposuction is still the most common cosmetic surgery. It also has one of the highest revision rates approaching 25% in some studies. It is much more difficult than most patients and even many naïve surgeons realize to consistently get a beautiful result. There are many reasons for this as we will start to see. I feel it is extremely important to “get it right” the first time. Every aspect of this procedure from clear honest communication with the patient, to complete evaluation, to meticulous technique should be directed toward this end. If a patient is not a candidate, e.g. they are simply overweight, maybe out of shape but not disproportionate, then I may have no role in their improvement and honestly tell them they are not a candidate for liposuction.

Unfortunately, approximately 30% of my surgeries are revision liposuction where I am using techniques to improve a bad or less than optimum result by another physician or possibly non-physician. In my evaluation of this patient, I can always tell why a bad result has occurred. A bad result occurs for two reasons: either poor evaluation (including poor communication) or poor technique. The surgeon may have been too conservative, been too aggressive (too common), been uneven in his contouring, poorly blended areas, placed his incision points in strategically poor locations or thrown a patient out of balance and proper proportion. And once again, unfortunately no new technologically advanced machine can or ever will prevent any of these problems. Like a perfect haircut or a beautiful sculpture, it goes back to the skills and artistry of the person doing it.

With liposculpture surgery, as with any procedure, a great result begins with a complete honest evaluation as to who is a good candidate. Simply stated, liposuction is all about targeting areas of genetic disproportion and balancing a body. It has virtually nothing to do with being overweight, underweight or normal weight. It is about focusing on stubborn areas that can’t be taken care of with diet or exercise. This is one reason why it is so important to be fully evaluated from your neck to your ankles by someone with a good eye and ability to determine where you are out of balance if at all. It is a mistake to perform liposuction on someone who is simply overweight or out of shape but not disproportionate. Once again, unfortunately this does not uncommonly occur and the result will be a person thrown out of proportion. This is why we hear of cases of people who had lipo and the fat “went” to other area. The surgeon created disproportion. In addition, make sure that the person who is evaluating you for surgery is actually the surgeon and not somebody else. I have heard of patients who met their surgeon for liposuction in the operating room for the first time. Be wary of places that seem like factories and do not truly care about comprehensive individualized care.

With regard to my own approach to liposculpture, I strongly feel that local anesthesia is the gold standard and offers many advantages over general anesthesia for liposuction specifically. This is called “tumescent” liposuction which was developed by a dermatologic surgeon. I like to call this pure tumescent liposuction to differentiate it from other types where they maybe combining it with general anesthesia. Tumescent liposuction has essentially three major benefits. To begin with, studies show it is far safer, especially if compared to liposuction done with other procedures under general anesthesia. The second benefit is easier recovery. The tumescent fluid which is infiltrated into the fat helps hydrodissect (separate with water) and allows much more pure fat removal with decreased bleeding. This results in far less bruising and generally much faster recovery with less post operative discomfort. I only trust myself to do all the local anesthesia as there certainly is an art to infiltration so that the patient feels as little as possible. However, the greatest advantage of local anesthesia is that I have a patient that can always be positioned optimally, so that I can meticulously sculpt without ever jabbing the muscle or poking the skin. This allows me to stay only in the fat layer where I only belong. Jabbing the muscle (which could never be tolerated with a conscious patient) significantly increases bleeding, bruising and postoperative pain. On the other hand, jabbing, poking or tenting the skin with the cannula at the wrong angle is one of the main causes of indentations and irregularities (as we will soon discuss).

With regard to my technique of sculpting, it begins with a good eye for the contour, balance and proper proportions for the male and especially the female body. Each body has its own differences, nuances and limitations. Good surgical technique also encompasses excellent judgment for not only where to target but also how aggressive to be. There must always be respect for skin tone as well as knowing how to deal with looser flabby tissue (flab is the term I use which is loose skin and muscle. Many people confuse flab with fat.)

Where I have learned to place my incisions in each part of the body I approach is extremely important. The goal is not only to place few incisions in places that hide well, but to strategically place them to be able to completely and evenly approach each area without jabbing the muscle or skin. My incisions are small nicks in the skin between two-three millimeters in length. I feel that not suturing the sites allows faster recovery by drainage of fluid postoperatively.

With regard to how I sculpt, this is a little more difficult to convey in words. The fat is embedded in a fairly dense connective tissue framework so it certainly is not just sucking fat out. One must tunnel very precisely in the fat and this is why liposculpture is truly a more accurate name then liposuction. I always start deep in the fat with small round cannulas to debulk the deeper layers of fat. I almost always approach an area from two or more directions and crisscross my tunnels. As I move up in the fat layer, I progressively go to even smaller cannulas and finish in the superficial fat layer with a flat tipped small cannula I had designed for myself many years ago to make sure my surface is smooth. It is how I approach this superficial fat and how aggressive I choose to be with regard to rasping the dermis from underneath that controls how much skin tightening I choose to achieve. Liposculpting is a very tactile procedure and this is one of the main reasons why I do not prefer laser assisted liposuction or ultrasonic liposuction as I lose the “feelings” or vibrations which convey to me exactly where I am and how much I am bringing an area down. Remember, the goal is not to always be aggressive and just suck all the fat out. This is a very amateur approach and bad results will commonly occur. For a more detailed description of how I approach each particular area of the body, please consult my website www.expertliposuction.com in the section entitled “area by area.”

Now, with regard to alternative liposuction procedures, I will group them into internal and external modalities. With regard to the internal modalities, I will begin with mesotherapy (also known as lipozap or lipodissolve) as it will be the quickest to dismiss. One of the deceitful marketing tools is that mesotherapy many times is advertised as being better than liposuction. I find this not only inaccurate but insulting. Mesotherapy is the multiple injections of a nonstandardized solution of phosphatidylcholine into the fat. Now, I am not saying that it won’t ever dissolve fat because it might. But remember when I said that the fat is embedded in a dense connective tissue framework? Well, how do you control the dispersal of the fluid and trust you are going to dissolve everything evenly? Remember how particular I was in how I sculpted each area of the body? There is so much more involved to great liposculpting then just dissolving fat. And, not that this is the most important thing, but mesotherapy is not FDA approved, is not supported by any of the major cosmetic surgery societies and furthermore, no one that I know who specializes in body sculpting has chosen to incorporate it in their practice.

Laser assisted liposuction (eg. Smart lipo, cool lipo) and ultrasonic liposuction (eg. Vaser) are newer quite popular alternatives to more traditional forms of liposuction. The argument here goes that they melt fat and tighten skin, whereas traditional liposuction either does not tighten skin or makes your skin looser. Very alluring, but it’s not that simple or truly accurate. I sometimes call this liposeduction vs. liposuction. There are many surgeons that have embraced these newer machines. Personally, I do not trust simply melting fat and feel I can get as much tightening as I choose by how I deal with the area just under the skin. I prefer this because it gives me more of a feel. With regard to the laser sealing blood vessels, remember that with properly done tumescent anesthesia one gets very little bleeding due to the hydrostatic pressure and epinephrine vasoconstruction. One well done study in a major peer reviewed journal (Plastic and Reconstructive Surgery Sept. 2006) failed to demonstrate any clinical advantages of laser assisted lipoplasty.

However, I feel the bigger danger with many of the newer aggressively marketed machines is that they encourage the potential patient to search for the machine and forget that what is more important is the mind, hands, heart and eyes of the man (or woman) behind it. Since I do a lot of revision work to improve poorly done liposuction, I would have to say that in the past two years I have seen some of the worst disasters result from both laser assisted and ultrasonic liposuction. Once again, I don’t blame the machine but the judgment and skills of the person behind it. I am also aware that the media plays a large role in hyping up whatever is new.

Finally, with regard to many of the newer machines that are targeting either cellulite or tightening of the skin, I feel this is an interesting area as long as it is not too closely compared to well done liposculpture. There are some promising results with regard to this area. Velashape was the first FDA approved machine for cellulite and the temporary reduction of circumference (yes, temporary). There are other machines also used for cellulite. While this is a very intriguing area, I have not yet chosen to incorporate it in my practice as I am not yet sure it really works long term and is worth the cost of the procedures. There are also several skin tightening machines that are used on the body such as Titan, Thermage, which uses radiofrequency, and Affirm. Recently Thermage came out with a deep penetrating tip that penetrates over 4 mm and generates an inflammatory response in the superficial fat layer to generate tissue tightening and shrinkage. I am in the process of forming my opinion as I am starting to use this deep tissue tightening tip to further tighten skin on the body. But I have to admit that it is quite expensive and at least in my hands and eyes, the verdict is still out. But I will keep you posted.

In closing, I hope the insights and opinions I have shared help to guide you in the right direction.

Ask Dr. David Amron Questions & Get Answers

Click here to ask Dr. Amron Questions Live & Get Answers

Dr. Amron has his own message board on Make Me Heal where he answers liposuction questions live from patients.

About Dr. David Amron

Based in Beverly Hills, California, Dr. David Amron (www.expertliposuction.com) is known internationally as an expert in liposuction and revision liposuction. He has meticulously sculpted thousands of patients for over ten years and is well respected for achieving consistently outstanding results with his “pure tumescent liposuction” technique.

Learn more about Dr. David Amron

Visit Dr. David Amron’s Website: www.expertliposuction.com

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The dermal fillers market is about to get even more crowded with the arrival of Elevess, a hyaluronic acid-based injectable filler for facial wrinkles. Although it was approved in July 2007 by the Food and Drug Administration for sale in the United States, Elevess has since remained relatively unknown compared to popular competing hyaluronic acid filler brands such as Restylane and Juvederm. But now, Elevess is poised to gain more popularity with the help of Artes Medical, who has just announced a deal with the makers of Elevess to mass market the filler to American plastic surgery consumers.  Artes is the maker of Artefill, a long-lasting wrinkle filler that is popular with individuals seeking semi-permanent fillers.

Manufactured by Anika Therapeutics Inc, Elevess is the first hyaluronic acid-based dermal filler approved by the FDA to incorporate the anesthetic Lidocaine, so the filler may produce fewer side effects such as pain, itching, and tenderness at the point of injection. The prospect of less pain and discomfort should prove to be an attractive benefit to needle-averse patients.

While the pain anesthetic mixture seems to be a novel idea, Elevess is not actually the only hyaluronic acid filler to incorporate an anesthetic in its formula. Earlier this year, Mentor launched Prevelle Silk, which also mixes hyaluronic acid with lidocaine. Prevelle is also FDA approved. Mentor is one of the world’s leading manufacturers of breast implants.

The deal between Artes and Anika will take effect this year, allowing Elevess to be distributed by Artes throughout the United States.

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Pharmaceutical company giant Johnson & Johnson has big plans for penetrating the plastic surgery market that until now has been dominated by companies like Allergan and Medicis. J&J has just received U.S. Food and Drug Administration clearance to market Evolence, a new collagen injectable for reducing fine lines and wrinkles, correcting moderate to deep facial wrinkles and folds. Although just approved in the U.S., Evolence has been widely available in Europe since 2004 and in Canada since 2005.

Given the slew of injectable fillers available to consumers, what might make Evolence compelling is that it is made from naturally sourced collagen, unlike Restylane and Juvederm. Evolence uses tendons that are harvested from pigs. If you are not squeamish about having porcine-derived collagen floating under your skin, then Evolence may be for you. The advanced collagen in Evolence has been naturally cross-linked, so it closely follows the three-dimensional structure of your skin’s own collagen. This allows Evolence to integrate well and support your skin’s own existing collagen network by adding structure, strength, and volume for a natural look and feel that last. Evolence is the first collagen injectable proven to last six months, although J&J is seeking approval to claim that Evolence lasts for 12 months. The longevity behind Evolence is achieved through Glymatrix Technology, a manufacturing process that cross-links the collagen with a natural sugar, not synthetic chemicals or substances.

Another bright point of Evolence is that it may cause less post-injection bruising and swelling than Restylane and Juvederm, according to Dr. Kenneth Beer, a West Palm Beach dermatologist.

Only time will tell if Evolence will catch on as an alternative to Restylane and Juvederm.

Links

See Restylane, Juvederm before & after photos

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By Dr. Michael C. Pickart, M.D., F.A.C.S.

Breast Implants: Should I Wait Until I’ve Completed All My Pregnancies?

It’s up to you.

Many young women are interested both in breast augmentation and in having children. They frequently wonder…

• Are breast implants dangerous for the baby?
• Do breast implants create issues when breast feeding?
• Will the implants still look good after pregnancies?

My short answers:

• Among mothers with implants, breast feeding is safe for the babies.
• On the other hand, breast implants may decrease the chance (by about 5-10%) that a mother can successfully breast feed.
• Breast implants may improve chest appearance both before and after pregnancies and breast feeding.
• Ultimately, a patient must decide for herself after she has had a chance to consider the facts….

Here are my long answers, with all the facts:

A woman who is interested in breast implants and in motherhood should weigh the plusses and minuses of both options.

One school of thought is to do the surgery when you want it. If you want a breast augmentation now, then do it now! You might not have your children for another 5-10 years. Why should you go without the implants for that relatively long period of time?

Moreover, breast implants are safe for children. They do not contaminate the breast milk.

And implants may actually improve breast appearance after pregnancies and lactation. Often, women lose fullness in the upper halves of their breasts after children and breast feeding. In recent mothers, I frequently place implants to increase upper pole volume, and sometimes I add breast lifts to position the nipple properly. If a patient has already had a breast augmentation, then I usually need to perform the lifts (called mastopexies) only.

Implants are not, however, without some risks. Large implants can stretch nerves, especially the nerves that provide sensation to the nipples and areolas. If those nerves are excessively stretched, then the nipples and areolas can become numb. If the nipples and areolas are numb, the breasts might not produce enough milk. Nipple-areolar numbness is uncommon but not rare; about 5-10% of patients do notice some degree of numbness.

Another way that breast implants affect lactation is incision location. One of my favorite incisions for breast augmentations is from 3 o’clock to 9 o’clock around the lower half of the areola. However, I never use this incision if a woman intends to breast feed. I want to avoid severing any milk ducts that might be important for lactation. Instead, I recommend an inframammary incision (in the fold under the breast).

(By the way, I no longer do armpit or bellybutton incisions. These were both novelty incisions, through which I have never seen perfect results—either in my own patients or in anybody else’s. I am very fussy, and I am only satisfied when the breasts are perfect. With armpit and bellybutton incisions, the results are just too unpredictable.)

So, the bottom line: a patient must decide for herself….

• If you’d feel better about your chest appearance with implants now, then let’s proceed.
• You shouldn’t worry that you are putting your baby at risk.
• I’d recommend an implant on the smaller side (that will be less likely to cause nipple numbness).
• And we should agree that an incision in the fold underneath the breast will be safest.
• However, if you really want to maximize the chance that you will be able to successfully breast feed, then I must admit that we should wait until after your pregnancies; you’ll probably have a 5-10% greater chance of being able to breast feed your baby.

Visit Dr. Michael C. Pickart’s Plastic Surgery Message Board on Make Me Heal, where you can ask him questions about liposuction and get answers.

An accomplished plastic surgeon with expertise in both cosmetic surgery and reconstructive surgery, Dr. Michael C. Pickart (http://www.pickartplasticsurgery.com)specializes in all breast surgery procedures (breast implants, reduction, lift), body contouring procedures such as liposuction and tummy tuck, and has extensive experience in facial plastic surgery (i.e. facelift, eyelid surgery, rhinoplasty). Certified by the American Board of Plastic Surgery, Dr. Pickart previously served as a Clinical Assistant Professor of Plastic Surgery at Loma Linda University, where he has taught students and residents the principles of plastic surgery. Graduating from Stanford University with honors, Dr. Pickart trained with renowned plastic surgeons Drs. John Grossman and Philippe Capraro, in Denver, Colorado. Dr. Pickart graduated in the top of his class from the School of Medicine at the University of California, San Francisco, one of the most selective medical schools in the country.

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By Lillie Shockney, RN., BS., MAS
Director of Education and Outreach
The Johns Hopkins Breast Center

I was diagnosed with breast cancer in 1992 at age 38. Our daughter, Laura, was twelve. When I told her that I had breast cancer and needed to have a mastectomy, she was distressed. She was worried that her mommy might die. Even more troubling, Laura was upset that my giving birth to her may in some way caused the cancer. She was somewhat relieved, however, when I explained that I had multi-focal disease in Stage I. Giving birth to her at age 26 actually should have helped reduce my risk. I went on to explain that because of my other medical conditions I wouldn’t be permitted to have reconstruction surgery. Instead, I would wear a breast prosthesis and mastectomy bra. She bluntly replied, “That’s okay, Mommy. Your breast is so valuable, it can’t be replaced anyway.” I sat in silence staring at a face that was so much wiser than its years. She was just beginning to learn about the importance of breasts, having been fitted for her first training bra just days earlier. That was when I went bra shopping with her for the first time; actually, for the only time.

I underwent transformation surgery in July of 1992. That’s what my husband called it and is the term I have since adopted. I use that phrase when I am with patients whom I have the privilege to spend time with at Johns Hopkins while they are undergoing breast cancer surgery. Al, my husband, told me “the surgeon’s mission is to transform you from a victim into a breast cancer survivor. You are exchanging your breast for another chance at life and that is a fair trade.” He was right. It was initially hard, however, to look down and see my left foot and toes. It was a sight I hadn’t seen since I was 12 years old. I developed early and, by adulthood, was large busted like my grandmother: 44D. Certainly, part of my self image was tied to my chest. Laura wrote me a poem to remind me of who I am inside and the importance of focusing on my psychological well being. I took pride in realizing that we had reared her well. This is Laura’s poem. She had my husband bring it to the hospital and read it to me as soon as I had awakened from my breast cancer surgery:

Appearance

Nobody’s perfect
Just look at me
But if you really think about it
Who wants to be

Beauty and glamour
Are nice to get
But it’s what’s inside that counts
You must never forget

I hope you understand
What I’ve been trying to say
I hope you get well soon
And I love you more each day.
Love,
Laura

Six weeks after surgery I was fitted for my breast prosthesis. I was appreciative of how natural they had become. I remembered how unnatural and poor-fitting they were in the early 1970’s when I first saw them on patients as a student nurse. I decided to name her. After all, she would become my bosom buddy. I would take her everywhere I go, so she deserved a name. I selected the name “Betty Boob.” My silhouette was whole again and I stood tall once more, all 5’2” of me. I was growing more confident week by week and month by month about my appearance and sexual being. I sent out adoption notices to my best friends to let them know I had gotten Betty. One friend mailed her a gift—a ceramic Christmas ornament in the shape of a baby bottle. Inscribed on it was “Betty Boob’s 1st Christmas, 1992.” It is displayed in our living room year round.

A year later I had a lumpectomy of my remaining breast. Just 11 months after, at age 30, I had another bad mammogram. Betty Boob got a roommate, Bobbie Sue. I chose to have several sets of breast prostheses since I could now be whatever size I wanted to be - an advantage of a bilateral mastectomy patient. Losing the second breast was emotionally harder. I fretted about the impact this loss may have on our sex life and on my self image once again. Laura, now 14, said she was glad it had happened because she worried everyday that the cancer would return and we wouldn’t catch it in time. We had though - Stage 0 this time. A mastectomy, however, was still the surgical recommendation. Again, I mentioned reconstruction options but my history of life threatening complications from general anesthesia (a rare but deadly condition) hadn’t changed. I resolved to be a breastless woman, thankful to be a survivor, and who had a loving husband. That was my focus— surviving this disease was the priority. Nothing else was important. “It doesn’t matter. Just let me live. I have a child to raise. I must be here for her.” Any thing else would just be gravy. To validate my womanhood and my husband’s love for me, he took me away to the Pocono Mountains (where the honeymooners go) for a long weekend. He said, “I’ve read before when you lose one of your senses like your sense of sight or sense of smell. Your other senses become more intensified. Maybe the same thing happens to your erotic zones. I intend to prove this hypothesis in the next 48 hours.” And he did!

Since 1983, I have worked in a nursing position at Johns Hopkins. After several years of volunteering in the Johns Hopkins Breast Center, I formally joined the faculty as the Director of Education and Outreach in 1997. I had known for some time that I was meant to get this disease. It redirected my nursing career path in line with taking care of other women who ended up wearing the same type of bra I did. I take care of women from all walks of life and all stages of the disease. I counsel patients about their surgical options and discuss with them the pro’s and con’s to assist them with their decision-making. This is of course, if they are fortunate enough to be in a situation to make choices. Most women today can make such health decisions. This also means that I see the surgical outcomes of women post lumpectomy, mastectomy, and mastectomy with reconstruction.

In 1997, after much effort, a federal bill was finally passed to ensure insurance coverage of breast reconstruction as a consequence of breast cancer. I provided testimony to get this bill passed and felt really good about that. In 1998, I held a special fundraiser with proceeds from the event going to cover expenses for Dr. Maurice Nahabedian (fondly known by his patients as Dr. Mo). The purpose of his trip to Europe was to learn a new breast reconstruction method called DIEP flap - deep inferior epigastric perforator. This procedure involves taking tummy tissue and fat but leaving preserved all the muscles. This is accomplished by stripping out of the muscle tiny perforators and reconnecting those blood vessels up in the chest area. This procedure, therefore, is a true transplant. The tummy tissue and fat are molded into a breast and serves as an amazing Memorex version of a woman’s breast. This technique requires learning how to do microvascular surgery. I was thrilled that our patients had a new state-of-the-art option available for them. This new surgery lifted restrictions we previously needed to recommend to women having the traditional TRAM flap procedure (TRAM flap uses the abdominal muscles to reconstruct a breast). As years went by, the surgical outcomes of skin sparing mastectomy with DIEP flap reconstruction became even more impressive to me. Many women reported nerve regeneration. Although different than breast sensation, they did have some feeling restored to their new breasts. Fascinating.

Each year I saw my various oncology doctors. For the first few years I mentioned that I still wanted reconstruction one day. Then, at some point in time, I stopped asking, expecting the doctor(s) to bring it up to me. No one did. “How are you doing?” they’d ask. – “Fine,” I’d say. “Any problems?” they’d reply. “No, not really,” I’d tell them.

We brought on board a new medical director for the Breast Center in March 2002. He was a surgical oncologist who specialized in breast cancer. Having a reputation as a skillful surgeon, he was academically talented and was a wonderful leader and team player. Patients adored him and this was well known. His name was Ted Tsangaris. I saw newly diagnosed patients with him just as I had with our previous medical director. I quickly began learning his routine. For women needing mastectomy surgery, he encouraged consultations with our plastic surgery team to discuss reconstruction options. At first, I worried he was being too forceful about discussing reconstruction options. I soon realized he did have the patient’s best interest in mind. He told me when we discussed this privately that “when a woman is diagnosed with breast cancer, all she can focus on is survival. ‘Let me live. I don’t care if I have breasts or not.’ She probably does care, though. She is born with two breasts and has the right to have two breasts if medically it is safe for her to do so and doesn’t impact her treatment and outcome. Therefore, she should see the plastic surgeon and talk about reconstruction options.” At that moment, I realized that I had yearned to have breasts again but was doing as most of our patients do - I was waiting for my doctors to bring it up to me; not me mention it again to them. The last time I had brought it up to my doctor was in 1998 when I mentioned that Mo was traveling to Europe to learn how to do DIEP flap reconstruction. The response was, “That sounds interesting. Good for him.” What I wanted to hear was, “Is this something you want to possibly pursue for yourself?” I didn’t hear those words, though. And frankly, why should I? I am one of the most assertive women you’ll ever meet. I am down right aggressive when it comes to making sure that our patients needs and desires are addressed and heard. So, no doubt, my doctors expected me to take the initiative and speak up. But I didn’t because I was functioning as a patient and there was, ironically enough, no Lillie Shockney to be my patient advocate and have my desires heard and taken seriously. How ironic.

Wanting DIEP flap reconstruction didn’t mean that I had overcome my anesthesia problems that had prevented me from pursuing anything in 1992. My anesthesia problem had continued to be a problem that I had to work around. (Implants didn’t interest me either.) I wasn’t an ideal candidate for reconstruction anyway, having had multiple abdominal surgeries, as well, making the traditional TRAM flap a bit tricky. I had had five previous abdominal surgeries prior to my diagnosis of breast cancer. Three out of five times I had respiratory arrests immediately following the operation, either in the recovery room or out on the nursing units. No one liked putting me to sleep and no nurse wanted the responsibility to take care of me during this phase of recovery. My father has had similar problems, though not quite as severe. In April 2002, he needed a total knee replacement and I spent a great deal of time with anesthesiology to try to decipher what would be safe to give him so his surgery would go well. He had a six-hour procedure and sailed through it, spending the night in the ICU for precautionary reasons only. This opened the door to discussing with anesthesiology my personal history and what options they may be now able to offer me. A friend on the anesthesia team carefully reviewed my records and determined that sodium pentathol and phenergan given in combination may be the culprit to cause my respiratory system to crash. Propafol would be a good alternative with a 15 second half-life, and an overnight stay in the ICU for observation. Now suddenly, choice had been restored to me. I didn’t have the choice in 1992 or 1994 to do reconstruction with my mastectomy surgeries. I only had desire. I met with Mo Nahabedian and told him I wanted to be evaluated for DIEP flap reconstruction. After examining me and talking with me about my personal situation, he felt I was an excellent candidate.

My brain went into overdrive now. Was it okay for me to pursue this? Did I deserve this opportunity? Was it too late? (I always told my patients it was never too late and that they have the right to be anatomically whole; a woman has the right to choose what is best for her. It was necessary for her to not focus on anything but herself and what she really wanted.) But I was struggling with giving myself permission to pursue it. Who would take care of patients while I would be on medical leave? This haunted me. I rarely took off blocks of time because of this chronic problem - feeling guilty if I had let a patient down while I was away, no matter what the reason.

When I told my husband what I was considering, he became very concerned. “It sounds risky. I don’t want anything to happen to you. I’ve nearly lost you before. Aren’t we okay? I think we have a great sex life. Don’t you? Am I doing something wrong?” I assured him that we were fine. Now I was being offered options – to choose or not to choose reconstruction. I wanted to do it. When I pressed him about this he agreed that he, too, missed my breasts. I prayed about this for many days. What should I do? Is it okay to pursue this? Am I being selfish? I was leaving church one evening and asked God to please give me a sign that it was okay to proceed with the reconstruction surgery. As I arrived to my car and turned on the ignition, playing on the car radio was the song “Sexual Healing.” The first full verse I heard was, “You’re my medicine, come on and let me in. I can’t wait for you to operate.” It was the sign I needed, rational or not! I drove home and announced to my husband that I was going to get on the OR schedule for 6 months from then to do the reconstruction surgery over the Christmas holidays. This would give me 6 months to plan out my work schedule and hopefully recruit help from our survivor volunteer team to pinch-hit for me. Yes, I’m a planner. I wanted to decipher a plan that would have me away from patients the shortest period of time and help ensure those who were diagnosed and treated while I was out would have someone there with them filling my role. I kept my plans a secret from everyone but my husband. A month later I told our daughter, then 22. She worried about the surgery, telling me, “Mom, you look fine as you are.” I had a heart-to-heart with her explaining that just as she enjoys her cleavage now, I missed having my own. I waited until September to tell my parents, who were quite stunned by the news. Dad asked, “Are you doing one or two?” I told him, “Dad, I might do one big one right in the middle - Ms Uni-boob.” He was overwhelmed with everything and simply said supportively, “Okay.”

As the weeks approached to my surgery date, December 5th, 2002, I felt like I was preparing for the birth of a baby. So I began to refer to my future new breasts as ‘the girls.’ “The girls are being delivered December 5th. We will bring them home from the hospital on December 9th.” I started looking at bra ads in the newspaper again. I hadn’t done that for years - ten years to be exact.

I went public with my decision to do delayed reconstruction at the beginning of November, announcing it at our Survivor Retreat and received applause and support for my decision. And just as Mo predicted, breast cancer survivors who had had mastectomies without reconstruction in the past began calling, requesting evaluations for “the same surgery Lillie is having.” I was clearly clueless until then of the impact my own previous breast cancer surgery had had on other women and their decision to have or not have reconstruction.

As I showered the morning of my surgery, I rubbed the bar of soap across my chest for the last time. I had always said that when I looked down in the shower, I didn’t see that my breasts were gone - I saw that the cancer was gone. I realized that soon I would be seeing two healthy surgically created breasts that would be cancer free and remain that way for life, hopefully. Wow. I also realized that every person taking care of me, from checking me in at the registration desk to putting me to sleep, operating on me, and caring for me post op all knew me, worked with me, and several were my closest friends. What an extraordinary journey I was taking with them. I had asked Ted Tsangaris to be with me while I was put to sleep, feeling this would be my most nervous period. He agreed to do so, but exceeded my expectations as a dear friend by serving as Mo’s first assistant in the OR, helping throughout my surgery from beginning to end. The surgery lasted more than 12 hours. Laurel Moore, also a dear friend, was my anesthesiologist who, ironically enough, was with me for my first mastectomy. I requested to listen to the song Sexual Healing as I went under anesthesia.

Once asleep, I knew that my hospital gown would be lifted up to my neck exposing nearly every inch of my body. I prepared typed signs to wear, which were taped to my chest and abdomen - some comic relief for the OR staff. Over my right mastectomy incision it said, “Mo, please super size me.” Over my left mastectomy incision it said, “I’m here for a front end realignment.” And over my navel it said, “Dear Santa, thanks for bringing me cleavage for Christmas.” Undoubtedly the signage brought a laugh to the OR team. I hoped it would reduce their stress a bit as they began working on one of their own Hopkins’ family members. I also realized that this would be for me yet another form of transformation surgery.

With the exception of initial laryngeal edema that was quickly under control in the ICU and sciatica that had flared up from being on the OR table longer than anticipated, I did well and awakened in the ICU with family at my side. Mo and Ted spent the night at the hospital to be doubly sure I did fine and that the circulation to my new breasts continued. (Wouldn’t you know it - a woman’s fantasy is to have two men to sleep with whose focus is on her breasts and I looked like crap and felt like hell. Oh well.)

A Doppler was used hourly to listen to the blood supply in each of my new breasts. It reminded me of listening to a baby’s heartbeat in utero. Wawoosh. Wawoosh. My mother heard a different sound though—wow, wow, wow. She said, “That’s the sound I hear them saying because they are so happy to be here!” I went home on day four with six drains that would stay in for a week. My tummy was flay and tight and initially, if I tried to stand up too suddenly, I felt like my vagina was bungee jumping off my chin. This feeling subsided as a few more days passed.

The day my drains came out and I was able to get in the shower without tubes and devices in my way, I took a bar of soap and slowly washed my new breasts with tears streaming down my face. It was a profound moment. The girls and I were home and doing fine (and they were each capable of holding a bar of soap under their mammary fold.)

Anxious to be back with patients, I returned to work early - at four weeks post-op. Al and I resumed sex at five weeks. (Yes, a little ahead of doctor’s recommendation of six weeks.) We quickly turned into a pair of honeymooners, test-driving my new body often. He told his brother, “I feel like I’m sleeping with another woman and have my wife’s permission.”

Our daughter took me bra shopping - an event that should have been videotaped. Three hours of laughter and twice a few tears. She went through the department store bra sections like Grant went through Richmond, and proceeded to show me what a bra can do for a woman’s breasts today: lift them up, push them together, pull them apart, add a cup size, deepen cleavage - you name it and there is a bra that could do it. And the color choices were amazing. My last experience with bras before mastectomy bras was wearing a Cross Your Heart minimizer bra I had ordered from a catalog. Now I’d be wearing bras that had names, color, and designer configurations that really should come with an operator’s manual. Not to mention the role reversal of my daughter, now 23, fitting her mother for a bra. (I also privately ordered a few items from Frederick’s of Hollywood, too.)

In April, I had my nipple reconstruction done. It was a 22-minute operation with a local anesthetic. I actually had it done between morning and afternoon clinic. For this procedure, my husband had gotten me pink sequenced pasties to wear to mark where I wanted my nipples to go. To prevent prematurely flattening the nipple, it is recommended to not wear a bra for a while. This resulted in me looking like the ‘erotic oncology nurse.’ So I bought callus cushions at the drug store that look like small flat donuts, perfect for sticking over the nipple to protect them. By stacking them and sticking them on, 2 deep, they were level with the tip of the new nipple and fit fine inside a soft cup bra. Great! (Of course without my bra on, my breasts looked like they were going scuba diving, having their goggles already on.)

This summer I’ll have the areola tattooed. I can hardly wait. It’s been four months and I still surprise myself when I look in the mirror. I still smile with joy in the shower every morning when the girls and I get wet and soapy. And perhaps I am even more pleased than most women would be because I have mourned the loss of my breasts, was resolved I would never have them again and was given the gift of choice at long last - to choose or not to choose reconstruction. Was it worth the wait? You betcha. In my case, waiting gave me the opportunity to experience a newer method of reconstruction superior to the traditional flap reconstruction still done throughout most of the country. This newer method along with free flaps has become the standard for Hopkins’ patients and it is a wonderful improvement that has been made over the last decade.

What did I do with Betty Boob and Bobbie Sue, my breast prostheses? I wanted to select someone very special to receive them. I took my time in selecting a patient who would be having bilateral mastectomies without reconstruction. The patient I selected didn’t undergo reconstruction since she had no time for recovery, having 5 young children she was raising, none of which were even her own. (They were born with a variety of medical complications since their mothers were heroin addicts.) She had outpatient mastectomies so that she could get back to the children as soon as possible. She was large busted like myself. She came to the clinic post-op, hunched over wearing a large sweatshirt with her cotton batting breast forms underneath. She was clearly lacking self-confidence in her appearance. I presented her with my breast prostheses and mastectomy bras and properly fit her to ensure they would work for her. She literally wore them out of the Breast Center like a child wearing new shoes from the shoe store. She stood tall and confident again and said, “I think I might be able to catch a man with these.” She hugged me tight for giving her this special gift of an important piece of me - from an important time in my life - my bosom buddies. I realized at that moment as we were embracing that my new breasts were actually hugging my old prosthetic breasts. It was as if my old girls were perhaps saying, “Welcome to Lillie’s. We know you will enjoy your stay. We did. She is full of life and love and energy like no one else we know. You will meet many newly diagnosed women with breast cancer just as we have over the last decade. She will utilize you as she did us - giving women hope and reminding them that this is a disease that is emotionally charged and tests our psyches. We’ll come by to visit periodically with our new owner. Again, welcome.”

Remember that women have the right to choose. It is a personal choice whether to do breast reconstruction or not. It can be done usually at the time of (skin sparing) mastectomy surgery, but also can be done later if necessary or desired. Sometimes we simply have to be reminded that choice is a woman’s right.

Relevant Links

Visit the Mastectomy, Lumpectomy & Breast Reconstruction Shop and find breast cancer surgery bras, camisoles, and swimsuits, and a wide variety of natural breast forms (breast prosthesis) in all shapes, styles, and sizes, and related accessories.

Chat with women and survivors on the Mastectomy Message Board.

This article was reprinted by permission from www.thebreastcaresite.com, which is devoted to addressing the general needs of all who have been touched by breast cancer, including newly diagnosed patients and long time survivors, as well as their friends, family members and coworkers. Breastcaresite.com’s specific mission focuses on providing breast cancer survivors with accurate information about everything from post-surgery options and products to information about insurance and intimacy issues.