Quandary about recon after BMX: TE/implant, Lat Flap, or both

Paloverde:

Here are my two cents -- I have definitely seen the worst of flaps and TEs.

Reconstruction takes time away from work. No way to avoid that. You can take it all at once with the lat d flaps, or over time with the TEs. I preferred the TEs. Bottom line is any reconstruction will impact your work in a big way, and any complication can arise from either surgery, taking even more time! I say that as an executive who has had to put my job on the back burner for reconstruction.

Free flap is MAJOR surgery. I had two failed flaps which sent me into acute renal failure. You are healthy though/great BMI, but be glad you escaped this surgery and that your PS thought about how the risk/reward was not there for you. He/she is a keeper.

Lat D is very reliable with less recovery time than free flaps. I totally get why the PS would discuss implants. Gummy bears are out there now for us TE gals. They are awesome and provide a much better cosmetic result, even the smaller ones could be beneficial in providing symmetry and feel. In the end, symmetry and feel trumps weight lifting for me. Think about it.

About TEs--I have had TEs. I am almost at 1000 ccs on my TEs. You can take it. If you are a weight lifting lady you will not be bothered by the TE. You don't have far to go at all! If you are complication-free, you will be happy with the process. Infections for TEs--ask to take prophylactic antibiotics, do a decolonization protocol before surgery, perhaps colloidal silver pre op to avoid hospital acquired infections and be FANATICAL about keeping your drain tubes clean and get them out ASAP. I was told activity causes drain fluid and to absolutely reduce my activity to get them out. It worked. There are some weird things about TEs, like they are rock hard to make the breast implant pocket, but it is a transitional thing.

About the weights--I don't want to be a downer but believe me when I say nobody gets out of these surgeries with 100% upper body strength. Just commit to rehab your body, find other ways to develop and compensate upper body strength, and avoid any chest wall development in the future. You can develop your shoulders, biceps, triceps, but stay away from the chest wall. As for your lats, I'm not sure if I'll be able to do lat weight exercises in the future but I would ask your PS. With the implants/TEs, you will notice when your pecs flex that your breasts move--however, a good PS can use the lat flap, alloderm, and other fat to soften the look.

If it were me, with as little expansion as you'll need, I'd do the TEs, maybe with a lat d for a more natural ptosis. However, it really comes down to whether you can stand to avoid pec strength training--maybe lat training too--in the future. It will definitely be more cosmetically natural looking and symmetrical with the implants. Your PS might be able to do TEs/implants without the lat D--and this was my original plan too until I decided I wanted a more natural hang to my implants.

Good luck. You are super smart to think this through.

third option autologous fat grafting... do a search for fat grafting and brava threads. or check out fatgraftpatients.com

paloverde - since you are interested in going small have you pursued the option of direct to implant?  That allows you to skip the TE and hopefully just have one surgery.

I, too am BRCA2 positive.  I had  cancer in my left breast 13 years ago.  it was not an aggressive cancer and so I was treated w lumpectomy and radiation.  I already had implants, under my muscle.  I went through radiation w implant and over I had capsular contraction, so the implants were replaced.  Mastectomy was not suggested to me, I think that long ago, it was less common to go straight to mastectomy because of the gene. I was warned that my risk was cancer in other breast and was monitored closely.  I had a hysterectomy, removing my ovaries and so my estrogen levels dropped.  Doing great until this summer when DCIS showed up in other breast, so at this point mastectomy is what I chose to do.  (at this point, doctors still seemed to think I had choices, but I was DONE!)

Anyway, I see the general surgeon who does the mastectomy part, and she thinks it can be done with exchanging implants.  Back to life in 3 to 4 weeks.

THEN, I go see this PS who is so slick and shiny......."oh, no honey, you are at huge risk of infection, you r only option is lat flap.......has his nurse "cue the slide show" of the beautiful symmetrical boobs that can be mine. (note, mine were pretty asymmetrical at the time due to lumpectomy and rads.  My non rad side was going south faster than rad side!)  Asked him about missing the muscle, he told me it really didn't do much, it was "no big deal"  ....told him I had child w autism, he goes "well you are going to need lots of help"  he told me there were no other options for me. He was doing quite the hard sell.  Turns out it is his "pet" surgery. 

Well. logically I KNOW the latissimus muscle is important for posture and it seemed to ME to be an irreversible thing to do to my body.  I am 53, but very active.  I love pilates, and what muscle do we work a lot there?  oh yea, that USELESS muscle on my back.  yea, the one that has my posture so improved after doing pilates.

So, I started coming on boards like this one.  One WHIFF of hearing about the iron bra.......um, no thank you.

So I went to another plastic surgeon.  She offered tissue expanders, esp since I didn't have any problem w radiation and it was 13 years ago.  I told her I was fine being smaller. So she said she may be able to go straight to implants.

Two weeks ago, I had my surgery, straight to implants, off pain killers in a day and a half, and right now I am a little more tired than usual and cannot lift anything heavy.  I know I am out of the woods yet, but I feel awesome. 

 AND I for one, am very grateful that people like Rozem who stay on these boards and are honest about the negative consequences.  If all I heard was sunshine and roses about lat flap surgery, I may have done it not knowing how hard it can be to recover from.  I have almost full range of motion and love my new smaller boobs.  It has inspired me to lose some weight to match them, and eating healthier smaller portions  is part of why I am feeling so good.

I know other people have other priorities, so I don't judge what choices someone makes.  But is important to hear all the options and opinions as it is a big surgery any way you choose to do it.  I wish you the best of luck, whatever choice you make!

Paloverde,  I am not sure how much smaller than my "natural" breast I am because I have had implants since I was 29.  I was extremely flat chested, can't even guess how I got breast cancer! (just kidding!)

My PS exchanged my implants for smaller ones, so I think I am still a tiny bit bigger than I would be naturally, but smaller than before.  I really think it is up to you what makes you feel good.  Have your PS show you some implant sizes, I am visual so all the cc# mean nothing without the visual difference.  I had left it up to the PS when I went into surgery, if my radiated muscle and skin could handle a smaller implant that is what we would do.  If not, I was going to have tissue expanders.  Happy with the result.  I already had a "pocket" under the muscle by already having implants so I think that is why it was ok for me. But I know I still have to be careful as it can fail with rad skin.  She seemed to think I was fine all these years, so I would be ok.  funny I have lots of allergic reactions to lotions, Tylenol, have to use hypoallergenic makeup, allergic to surgical tape, yet I have never had issues with my implants.  The first time I got implants, the doctor brought out a bunch and let me look at them, feel them etc so I had an idea of what I wanted.

Just a little side note, I live in southern CA, used to live in Newport Beach, land of the giant artificial boobies (mine never looked fake as they were not that big)  I have a friend who works in the ladies dept at Neiman Marcus there.  She said the new trend is smaller boobs, so a lot of her clients are "downsizing" their boobs.  Guess I am trendy, LOL!  Don't know if that will change your outlook at all, but it is food for thought.  I think my first PS wanted to do the lat flap to give me the giant SO CAL boobs.  I just keep thinking how happy I am to have sought more options.

Follow your gut feeling, my experience and other's experiences are information, but ultimately it is your body and you know what is most important to you and your lifestyle.

Another option is to have the mastectomy first and return later to have reconstruction, especially if you are not sure. I understand the stress and need to get the surgery behind you! Scheduling a surgery with one doctor is easier.

There are so many choices in reconstruction, and it is a big decision and you want to be comfortable with. If all goes well, you won't regret moving forward, but if you have complications, you might regret your decision.

I chose not to reconstruct as my understanding is that the pectoral muscle is shaped to create a ledge to hold the implant. I talked with women who never got their strength back. My BS said my pecs will return to normal without implants. It is a crap shoot. Some people have problems and others don't. But good that you are doing your homework.

Good luck moving forward! Hope whatever you decide goes smoothly.

hugs,

georgie

Anyone have knowledge regarding if implants are a necessity for reconstruction, which method is preferable, DIEP or latissimus dorsi flap? And with lat flap do they take the entire muscle or just a part? If you only want small breasts after recon, can smaller amount of muscle be used or is the entire muscle always used with lat flap regardless of desired outcome regarding size.