I Feel a Great Weight Has Been Lifted

I don't know where to start this post. If it seems all over the map, that's because I'm so happy, I don't know where to begin, so I'm just spewing everything out...hope it all makes sense!

I had my appointment this morning with Dr. Murial Brackstone. I spent just over an hour with a nurse practitioner, Margo L. Bettger-Hahn, RN, BScN, MScN, before I saw Dr. Brackstone. Margo is a Clinical Nurse Specialist, Breast Care and Plastic Surgery Programs. Margo is awesome! First she gave me a very thorough breast exam, then we talked and talked and talked. She answered all of my questions without me having to even ask. Right from the start, I told her I wasn't interested in surveillance, that I wanted a mastectomy. She just smiled and said good decision, that's what Dr. Brackstone would recommend anyway.

Margo L. Bettger-Hahn, RN, BScN, MScN
Clinical Nurse Specialist, Breast Care and Plastic Surgery Programs

When we were discussing reconstruction techniques, she asked me what type I was interested in. I told her I had been wanting FREE TRAM Flap because I didn't want the loss of abdominal muscle associated with a TRAM Flap. When I said this she asked me if I'd ever heard of a DIEP (Deep Inferior Epigastric Perforation) Flap...I nearly fell off my chair. That's the reconstruction I really wanted, but thought it wasn't being done much in Canada yet. She said that the plastic surgery team of Dr. Claire Temple and Dr. Douglas Ross (no, NOT George Clooney, although he's pretty damn good looking!) have been doing DIEP for just over a year now. You have no idea how happy this made me! I was hoping to get Dr. Temple; and getting Dr. Temple to do a DIEP is just so amazing to me! :)

The DIEP flap uses skin and fat from the lower abdomen. No muscle is taken with this procedure. An incision (surgical cut) is made in the lower abdomen and you receive a “tummy tuck” in addition to the breast reconstruction.

These pictures aren't accurate, as I will be having circumareolar (skin sparing) mastectomy.

After talking with Margo for over an hour, I then met Dr. Brackstone. She's fabulous too! She also gave me a breast exam. Then we discussed my BRCA2 status, surgery and my previous MRI results from April. The small "indeterminant" spot on my MRI was nothing; she said not to worry about it as it is a normal occurrance in an aging woman's breast (AAGH! aging!!!). We then discussed my BRCA2 status. She told me with my BRCA2 status (a major deletion mutation), my likelihood of developing breast cancer at some point is more like 99% (not the previous 80 - 90% I'd been told), so it may as well be 100%. She said mastectomy is really the only decision to make or else the stress and constant worry, will drive me nuts. I agree, it already is! I don't like the idea of having MRIs every 6 months for the rest of my life and constantly waiting for results. After my surgery and reconstruction, I will have a less than 2% chance of developing breast cancer (that's less than the general population) and will no longer need to have mammograms, ultrasounds or MRIs. There's no point because I will have no breast tissue left. She told me I will need to have the hysterectomy done first, because of the abdominal surgery involved with the DIEP. The only downside to the DEIP is that it will likely be a 10 to 12 hour surgery. DH isn't too thrilled with this idea (nor am I), but it is a complicated surgery because it's microsurgery and it'll be worth it in the end.

Dr. Muriel Brackstone, MD, FRCPC

Margo was going to send in my referral to the plastic surgeons today. Margo is also the nurse practitioner working with them with breast cancer and reconstruction patients. She told me when I have my referral with Drs. Temple and Ross, she will more than likely be there. She said if she's not, to have them page her and she'll be right there. How wonderful! I have a feeling Margo is going to be a big part of this for me and will be a great support.


Dr. Claire Temple, MD FRCSC


Dr. Douglas Ross, MD MEd FRCSC

Now it's not 100% a given that I can have this type of reconstruction, but she figured I was a good candidate for it. Once I receive my referrals to the plastic surgeons, they will discuss it with me, and will schedule me for a CT Scan to map out the arteries in my abdomen.

When I have the surgery, Dr. Brackstone will first remove the breast tissue. This is done by circumareolar (skin sparing) circular incision around the areola and nipple, leaving all the breast skin intact. She then removes all the breast tissue. She said her part's the easy part! Pathology will be done on all my breast tissue to make sure there is no cancer cells. Once she's done her part, then Drs. Temple and Ross will work their magic. I have included a description below of what DIEP is. After the DIEP surgery, there will 2 smaller surgeries later on. One to reconstruct nipples and one to tattoo the areola area. I did ask Margo about nipple sparing and she emphatically said "no way" since you would be leaving breast tissue behind. She said "don't worry, we'll make you some nice new ones!" :)

I feel so much better after today's appointment. Things are starting to move forward and I feel a huge weight has been lifted.

What is a DIEP flap?
DIEP stands for Deep Inferior Epigastric Perforator. This is the named vessel for which the tissue to be transferred is based. “Flap” is a plastic surgery term referring to the tissue which is to be transferred. The deep inferior epigastric vessels arise from the external iliac vessels (the external iliac vessels become the femoral vessels in the leg). The deep inferior epigastric vessels course beneath the rectus abdominus (the major abdominal “six pack” muscle) on each side. These vessels send off branches to the muscle as well as through the muscle into the overlying fat. These perforating branches are those which are identified, preserved and transferred with the overlying tummy fat to reconstruct the breast.

Definition DIEP Flap:

Perforator flaps represent the state of the art in breast reconstruction. Replacing the skin and soft tissue removed at mastectomy with soft, warm, living tissue is accomplished by borrowing skin and fatty tissue from the abdomen.

A slim incision along the bikini line is made much like that used for a tummy tuck. The necessary skin, soft tissue, and tiny feeding blood vessels are removed. These tiny blood vessels are matched to supplying vessels at the mastectomy site and reattached under a microscope.

Unlike conventional TRAM flap reconstructions, use of refined perforator flap techniques allow for collection of this tissue without sacrifice of underlying abdominal muscles. This tissue is then surgically transformed into a new breast mound. The abdomen is the most common donor site, since excess fat and skin are usually found in this area. In addition to reconstructing the breast the contour of the abdomen is often improved much like a tummy tuck.

Restoration of the nipple and areola follow. Scars fade substantially with time. For many women the reconstructed breast may be firmer and have a more youthful appearance than their natural breasts."