Surgery... The Tracks of my Tears

I have written, deleted and re-written this post at least three times.  I'm not sure why it is so difficult to write about my surgery on September 25th, 2014.  Nor can I figure out why it has been so difficult to write about everything that followed.

Of course, I have a few theories:

1) The event(s) including and surrounding my oncoplasty were traumatic. Living through it once was hard enough, let alone reliving it to share.  I know... like the rest of this hasn't been tough!?!  

Thanks Kirsten (-;

2)  I still struggle with how much to share.  FYI, I am going for it... I always end up going for it.  Herein, I will share the good, the bad, the ugly and grotesque.  Please, do NOT let your children view the images in this post without your consent and explanation.  In talking with other fighters in hospital and doctor waiting rooms, I found many women still shudder at the lack of modesty and privacy afforded breast cancer patients, while others, like myself, find the exact opposite.  I see my breasts as a body part, like any other appendage, joint, organ, bone, etc.  They broke and they needed fixing.  I took my turn with them, as did my husband and children.  Now they belong to science and posterity. I am neither ashamed nor proud.  They are just breasts. 

3) Memory loss.  Chemo brain is a real thing!  The Andriomycin, Cytoxin, and Taxol (ACT) portion of my treatment is designed to kill or disrupt rapidly dividing cells; disrupt them by making it difficult or impossible to attach to one another and replicate. ACT does not discriminate my rapidly dividing cancer cells and my brain or any other high metabolic organ cell.  In this way, chemo is a Utopian-like drug.  It is indiscriminate. 

4)  I can't remember... Ha!

On September 24th, my husband and I went to Hoag for the pre-op insertion of guide wires.  HELLO!!! Apparently, the doctors want to know exactly where to cut!  In my case, chemo (thankfully) worked really well, and the tumor disappeared on all scans. So, how were the doctors supposed find the tumor and lymph node areas without point of references and a map?

Coiled guide wires under tape & bandage

Have you ever de-boned a fish? Could you take an x-ray to find a few different 1mm tags or titanium markers inserted during biopsies, then slice the fish open, find the 1 mm markers, remove them and other "bad" tissue, then sew it all back together so that the fish was better than before?  This is what my amazing surgeons were able to do.  However, in order to do so, they needed to use ultra sound and MRI imagery with contrast to insert titanium guide wires into my breast and underarm at the exact location of my metastatic tumor and lymph node sites.

Writing on the wall. Dr. Silverstein marks several points of reference, the date and his initials

It hurt! Even with a great deal of local anesthetic, it hurt. Because I was the first surgery scheduled on the 25th (7:00 am), the guide wires had to be placed on the afternoon of September 24th.  Rather than going to the expense of keeping me in the hospital overnight, comfortable on pain meds, they sent me home.  While I did have pain and sleep meds to help, the discomfort and anxiety was too great to sleep. You gotta love medicine dictated by insurance! 

        

At 5:00 am on the 25th, Graham and I walked onto the surgical floor of Hoag hospital (2nd floor).  You could cut the fear and anxiety in the small lobby with a knife.  After an all too brief wait, I walked alone into a curtained staging area, undressed as ordered, and waited for the anesthesiologist to come and alleviate my worries with a tap of the vein.  

I don't know if I actually remember anything about the 48 - 72 hours post-surgery, or if I simply recall the stories, pictures, and videos shared with me in the days and months since surgery.  Either way, thanks to the shared stories of others, I know I was surrounded by people that truly love and support me.  
   
      

My cousin Melissa and fellow cancer sister.  Nothing like a little solidarity to get you through surgery.  PS She has survived four major cancer-related surgeries since her stage 4 thyroid cancer diagnosis at 23!  You are my hero Melissa!  I love you!

As the haze began to dissipate, I noticed something very strange.  Besides the Frankenstein-like patchwork of tissue that remained, my left breast and areola were left substantially larger than the right.  My oncology surgeon, Dr. Mel Silverstein once described my plastic surgeon, Dr. Nirav Savalia, as "a true artist".  High praise indeed from such a notable surgeon.  Yet, I was left lopsided?  

Who says size doesn't matter!?!

On or around day 4, (I don't remember, as I was on a lot of pain medication), I went in for the first of many post-op appointments.  Dr. Savalia, my plastic surgeon) stood silent, head cocked, with a friendly, patient and sympathetic gaze as I muttered unintelligible questions regarding size and pain. 

Apparently, he told me all about the size differentiation he would deliberately leave behind at our pre-op appointment.  I have no memory of the discussion, but my husband assures me it took place.  In any case, he is an artist and he was right... the left breast was larger than the right for good reason: radiation therapy shrinks tissue like ice water shrinks a man! 

  

Ahhhh... relief! I was prepared to get all new, smaller bras, but I was not prepared to get bras with two different cup sizes! 

Dr. Savalia and I at our first post-op appointment    

The fact that the size differentiation was intentional provided fleeting relief.  Soon enough, I could trace the tracks of my tears over the suture lines, which were covered, for the time being at least, with surgical tape.

The steri-tape makes the suture lines look innocuous enough until... removal of the tape reveals a thick, dark, keloid surgical map and a post surgical infection in the right Breast suture line. 

Once I reconciled that the size differentiation would not be lasting, I began to focus on the pain and healing process. As you can see from the photos above, the Oncoplasty cuts make an anchor-like track with a large anchor bottom stretching from armpit to declotage where the underwire of a bra digs into the fold at the bottom of the breast. That's right, no more underwire bras for me, not EVER!  From the bottom of the anchor, the doctors cut straight up to the areola and use a tool affectionately called the "cookie cutter" to stamp out my areola, leaving the overall diameter and circumference substantially smaller than my post breast feeding areolas (bonus!).  

On the left side there is a break in symmetry at the bottom of the anchor (as you can see above),  The surgeons deviated from the bra wire cut and jogged up into my arm pit in order to remove the tissue around my former tumor, sentinel and secondary lymph nodes.  Eight lymph nodes were removed in all. 

The result: breasts that are roughly 70% smaller, areolas that are 40-50% smaller and a patchwork of tissue marked by thick, purple, keloid suture lines. 

The fallout from surgery was extensive. Besides being much more painful than expected, I could not lift my arms for quite some time. It was six weeks before I could lift my arms over my head or hold my babies.  I got stir crazy and overly ambitious around week 3.5 and decided to tidy up the house.  While bending over to pick up a toy, I popped an internal stitch on the suture line under my left arm.  There is no comparison to the acute pain radiating from deep within. The only relief, time.   

Knowing that radiation therapy would flatten and minimize the scaring on the left side, my plastic surgeon suggested some silicone tape called Rejuvenation for the scars on the right side.  The tape is similar to steri-tape or surgical tape in the sense that it adheres to the skin for 2-3 weeks and is not meant to get wet oily from lotions or oils.  Unfortunately, the tape began to fold on the cleavage end of the scar on the right breast.  The fold allowed air to get under the tape and rubbed the two sides of the suture line together.  This perfect little storm created an infection.  The infection dug a worm-like "tunnel" into the layers of flesh beneath, which needed to be drained.  I will never forget that smell.

Like much of my journey through cancer, the biggest challenge is managing the effects of treatment. For instance, you have surgery, the anti-scarring tape causes an infection, you take antibiotics, then you find yourself falling further down the rabbit hole of consequences.  Three weeks post antibiotics, I lay in the fetal position with severe chills, body aches, fever, vomiting, and diarrhea.  The nausea could not be controlled with any of my pharmaceutical or herbal remedies, so I knew I was in trouble.  

Five days in the hospital and $33,000 later, it was determined that the antibiotics caused gastroenteritis, colitis, and created a weakened immune system ripe for C.diff (short for C.difficile). C.diff is a so-called super bug that is resistant to antibiotics.  It is found in hospitals and other highly sanitized environments.  I figure I picked it up going in and out of the Radiology wing of the hospital everyday, but who knows!?!

Either way, I was allowed one day off of radiation, and even though I was kept in isolation, they wheeled me down to radiation in my bubble every day for treatment.  You can look at this phenomenon in two ways: the hurt, tired, sick, and pessimistic side of me looks at this as torture; a commitment to killing me or getting as close to it as possible without actually killing me.  The retrospective, supposedly cancer-free, and post-treatment side of me appreciates the doctors' and nurses commitment to my treatment and steadfast determination to kill the cancer no matter how sick and tired my mind, body, and spirit were.  Honestly, I still go back and forth.

As always, my family got me through it.  Melissa got my doctors on the phone in under 15 minutes and determined a plan of action to get me safely to isolation at the hospital. She repeatedly warmed blankets up in the dryer to try and get some heat into me.  She is my rock.  My husband, Mom and Dad managed my work, home and children.  My Godfather was there; he's always there... to pray for me, to pray with me, to take me to appointments, to feed me, to watch me sleep. My breast cancer sister Kirsten was there to visit, cheer me up, and sneak some champagne into isolation! Neither Melissa nor Kirsten let the fact that their immune systems are weakened from their own cancer treatments (not to mention the rest of their bodies and souls), deter them from braving the potentially infectious hospital environment to comfort me.  This is what my angels do.

It's been four months since surgery. As I look to finally finish this post, I hope to put this chapter of my life in the past where it belongs.  While some physical effects remain: scarring, numbness, stiffness in my arm and shoulder, I am confident these will fade over time.  Some effects are lasting.  Losing lymph nodes means I will never again have my blood pressure or blood drawn from the left arm, and I will always need to use a compressive arm band and gauntlet on my left arm and hand when I travel or lift heavy things.  I will always worry about lymphedema and endeavour to prevent it.  

However, I will live on and I will do so without hearing the wail of the Banshee!