E-Memoirs

Empathy: can't you just stock up on Amazon if you need some more?

I had surgery last week. Easy procedure…feeling stronger every day. But it was surgery nevertheless which is called ‘reality’ when you have had breast cancer and reconstruction or really any other surgery for that matter. The most prevalent word in my recent life when telling others about pending surgeries for myself has been ‘empathy’. As in ‘this will give you more empathy for your patients’. Let’s break that down…

I feel I have been naturally blessed with tremendous empathy for my patients. As a female Plastic Surgeon, I can relate to my patients more personally and professionally than some other surgeons. Not because I’m extraordinary or special but because I have literally had most of the procedures I offer and can speak to the process from a patient’s standpoint. I have always been very open about my surgical history because I don’t know why I wouldn’t. My opinion of hypocrisy is to have tested the waters but be coy about the experience. Just my opinion.

I’ve had 2 rhinoplasties, the first at 16 years old because my nose was just genetically awful and I’m certain my parents had many late-night secret conversations about no one ever wanting to date or marry me because of my ugly nose. (That’s made up crap. My parents were awesome and generous and the fact that the allowed me to have cosmetic surgery over 30 years ago when this just was not the norm for teenagers is so beyond extraordinary I cannot even describe my gratitude.) My heritage is Italian and Scotch-Irish. That makes me a stubborn hot head…and gifted me with a most unattractive nose. That was baseline before 3 breaks. My nose was broken so many times before my first rhinoplasty that unfortunate nose I was born with was further disfigured by life. How does a teenage girl break her nose so many times if she is not in the Mob or a linebacker or a prize fighter? Life. Playing with friends, pulling a suit case off a closet shelf that hit me in the face…who knows. It’s a miracle to me that everyone on the planet has not broken their nose because it sticks out from the middle of your face just begging to be crushed.

I had my first rhinoplasty when I was 16 and was marveled at the difference. My nose healed well and for 6 beautiful months, I had a 1980s cute little nose unlike I could have ever imagined. I was so confident and proud. To wrap this story up, I was at a high school Super Bowl party with friends 6 months after my procedure, a pillow fight turned into a left hook to the face and my beloved nose broken again. I tried to hide it from my mother for a couple of days but she was WAY smarter than that. They allowed me to return to the operating room to fix the mess and it was much better after that but never like it was. Since that time, I have carried the words my surgeon said: ‘another break and your nose will slide right off your face…’. Dramatic? Yes. Poignant? Indeed. My first experience with ‘empathy’, whether I realized it at the time or not.

That experience is how the world of Plastic Surgery became known to me and the rest is history. Back to the relevance of my personal history and empathy and this blog post. I have had a tremendous amount of elective surgery. When I started my breast cancer journey and was filling out the paperwork, the ‘Surgeries’ line on all the intake forms was too short. I laughed. At least I practice what I preach. I’ve had the two rhinoplasties, liposuction (multiple rounds), a mastopexy. I’ve had fillers, Botox and Dysport, lasers, peels, skin tightening. There is not too much that I offer as a surgeon that I have not experienced myself. Is that not empathy if you know what you’re communicating with others about…you can speak to the experience, the decisions, the recovery…elective or essential?

When my breast cancer diagnosis was delivered, my reaction was instinctively surgeon mode. Here’s what we’re going to do, I said. Met with Anita Chow and Danielle LeBlanc: here’s what I want, what do you think? Let’s do it, they said. Decisions were made and the process was underway. Plan executed to great success. I am cured. I was stage 0, noninvasive cancer. I avoided chemotherapy and radiation. I do not have any indications for adjunctive therapy. One and done, as we say in surgery.

Or not so much.

There has never been a patient in my practice that I consulted with about surgery where I told them they would never need another operation. In fact, it would be extraordinary if a patient had a procedure and in their lifetime never needed some sort of adjustment or revision. Our preference as surgeons is that if any return to the operating room was indicated, it would be years later. For patients with implants, this reality is most relevant. You cannot implant what is simply a foreign body into someone and tell them, ‘this should be it…good luck for your lifetime.’ With breast implants, cosmetic or reconstructive, there are a myriad of concerns we discuss with our patients. The most important things that could evolve are animation deformity and capsular contracture. Let’s discuss…

The decision for an implant to be placed under the muscle in both cosmetic augmentation and reconstruction is a function of the amount of tissue coverage in the upper part of the breast. ‘The muscle’ is the pectorals major muscle, a relatively thin muscle that lies on the chest wall and serves to cover the top part of the implant if a patient happens to have tissues sufficiently thin that the implant would be more visible in this area. In cosmetic augmentation, if a patient naturally has very thin tissues, subpectoral placement is a very good decision. In reconstruction, with the breast tissue surgically removed, very little tissue remains so the implant has historically been placed beneath the muscle for the same reasons.

Animation deformity is a phenomenon related only to patients with implants under the muscle. Because the muscle is still functional and contracts, it can move the implant. This isn’t a functional concern and it’s harmless but it is not what one would consider ‘normal’. Before my mastectomies, I do not think I knew how to flex my pecs on command. Once your pec has been elevated and draped over an implant, you quickly discover that pretty much everything you do activates your pecs. Pushing down on arms to lift out of a chair, getting out of the bathtub, doing pushups…most anything…activates this muscle and can distort the shape of your implant. Again, doesn’t hurt anything and when you relax the muscle the effect is gone but nevertheless…very unexpected and unnatural. Natural breasts or implants placed over the muscle do not have this effect for obvious reasons.

Progressive modern surgical thinking and planning has made this ‘there is really no other choice for your implant placement’ less stringent. If a patient does not have sufficient tissue coverage, cosmetic or reconstructive, and desires correction of animation, fat grafting to enhance the tissue coverage in top part of the breast makes conversion to subglandular implant placement a reality. No more dancing boobies. I had animation after my mastectomies; my reconstruction was subpectoral because that was indicated and that’s what I would have done if I were the operating surgeon as well. The animation was sufficiently bothersome to me that Dr. LeBlanc and I agreed on a plan to address it. I went back to the operating room for fat grafting 3 months after my initial procedure. 5 months after that we went back to the operating room and converted to the prepectoral plane. I am completely thrilled with the improvement. Much more natural, no motion when you muscle flexes, way better for me…awesome!

As a surgeon, I empathized with my patients that have had this and we got through it. As a patient, I have now experienced animation deformity and the beauty of eradicating it.

A capsule is a necessary and expected consequence of an implant; it is natural scar tissue that anchors the implant internally in the pocket. Capsular contracture is an incompletely misunderstood phenomenon where your body creates more scar tissue than necessary. It can be no big deal and your implant just a little hard or a big deal and your implant very hard and uncomfortable, even asymmetric with the other side. Strangely, contracture is usually a one-sided phenomenon, which is another level of ‘what in the world’. I have had many patients through the years, both cosmetic and reconstructive, with capsular contracture…low grade and high grade. I’ve treated it conservatively and I’ve operated on it.

It is known that implants under the muscle have a slightly lower rate of capsular contracture, attributed to the constant massaging action of the muscle throughout daily life. Implants over the muscle do not have this constant effect and although the rates of capsular contracture are not significantly higher than the alternative, there is a known slight increase in risk. I was moving through the world just fine, thrilled with my decision to convert to over the muscle…until I started to notice a capsular contracture on one side. It was subtle at first, then more dramatic. A little uncomfortable, a little asymmetric in my clothing, nothing serious…just changing.

For all the patients that I have managed through capsular contracture over the years, I listened and made recommendations but until I developed it, I could not relate to what they were really experiencing. Externally, as the surgeon, you note a difference that may or may not be significant. Internally, as a patient, it becomes a foreign body that does not feel like part of your person. My experience has been that prior to capsular contracture, there were times when I literally forgot about the implants…they are just part of me now and there was really nothing to think about daily. Once the contracture evolved, it became unreal, separate from me. I made the analogy that it was like a pebble in the tread of your shoe: you just need to release it, get rid of it, because it feels so unnatural.

The decision was made to return to the operating room to address it. The fix is to take the implant out, release the scar tissue to allow the pocket to expand so it’s no longer tight around the implant and compressing it, and replace the implant. The operation was a tremendous success with immediate improvement in the look and feel of the breast and I was thrilled.

As a surgeon, I empathized with my patients that have had this and we got through it. As a patient, I have now experienced capsular contracture and the beauty of eradicating it.

Recovery uneventful, drain out in 5 days…. I was cleared to return to the operating room less than two weeks after my surgery. That first day back in the OR I did 4 breast augmentations, all did great. More than ever before in my practice, the potential for future sequelae was on my mind. All patients did just great, day was great, I felt great. Yeah, me! A little tight after the day, I went to my office and enjoyed a good shoulder stretch. That’s when the hematoma started…

There are about a hundred potential complications or sequelae of breast implants beyond capsular contracture and flexion deformity. Common surgical complications are failure of incisions to heal, hematoma, seroma. It goes on for pages. That night I noticed my right breast was swelling. Bigger and bigger…it quickly became obvious that my innocuous little stretch pissed something off inside the pocket that bled. And bled. Double the size of the left in a couple of days. Awesome.

Last Friday we went back to the operating room to drain the hematoma on my right side. We had a little wager going: how big was the hematoma? Danielle and I both guessed 250cc. Made me smile that she and I separately picked the exact same number: great minds think alike. Turns out there was 325cc in there. The most common breast implant size I use in my practice happens to be 325cc. I like that size…not too big, not too small for most patients. (For the nonclinical, a shot glass is about 30cc…so imagine 10 shots and change in that breast. Side note: my implant is 450cc so I almost doubled down on that side. 325cc alone would have been just fine with me…325+450=675cc: not so much. Everything is bigger in Texas but there are limits…)

As a surgeon, I empathized with my patients that have had this unexpected postop sequela and we got through it. As a patient, I have now experienced postoperative hematoma and the beauty of eradicating it.

So that’s that. I stand by the need to understand what your patients experience and feel. I embrace Plastic Surgery in every form and have experience as both a patient and a practitioner, cosmetically and from a reconstructive perspective. It is so often the case that people just don’t know what to say when you’ve had cancer or it’s because it’s breast cancer and maybe that’s awkward and uncomfortable to consider. I have experienced all of this. I live out loud with my experience because that’s how I have processed it all. What I have been most effected by over the last 3 weeks with two relatively unanticipated but not entirely unexpected procedures are how many have said to me, ‘this will give you more empathy for your patients.’

Well, I already had a lot of that. Maybe I needed more and I’m OK with getting that if necessary. I don’t think you could have too much empathy. I don’t think those of us in the world of Plastic Surgery must experience everything the field has to offer to relate to our patients. I do think it is helpful to my patients when I can speak to the experience personally and I am happy to do so.

If there is an Empathy Meter on Amazon I haven’t yet discovered it. They sell everything else in the world so it’s just a matter of time. I will purchase a subscription for monthly Empathy delivery if it makes me a better person and a better surgeon. What I will really be OK with is no more life experiences for quite some time in the operating room as a patient. I welcome the life experiences of travel to Italy and seeing Steven Tyler in concert and Zoo Ball and Hot Box Biscuit Club brunch with great friends, I am full to the gills with gathering more empathy otherwise.

Today I celebrate a successful surgery last week at the hands of my amazing surgeon…who is as frustrated with my body’s need to gain more empathy and life experiences as I am…and am enjoying life on the other side. Healing and happy I leave you with this…

Here’s up to it!

E