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Home: The Toast

Nicole Nolan last wrote about scrubbing in on a penis implant.

Saline-filled_breast_implantsThe first plastic surgery operation I ever saw was breast implants. Our patient was young, pretty, twenty-six. She had recently lost about a hundred and fifty pounds, and consequently went from an E cup down to a C cup, and she wanted her old breast size back. She had paid up front for the operation—six thousand dollars, in cash. “This lady is already paid,” our attending physician announced to the OR staff, before she even arrived. That meant we didn’t open extra equipment, because we couldn’t charge her for it later. It meant the implants we picked out beforehand had to be just right, because we couldn’t throw them away and open another package later. I have never before or since seen surgeons so cost-conscious in the operating room as when their client has pre-paid in cash.

There are many ways to do a breast reconstruction (which is usually post-mastectomy) or breast augmentation (implants). Some of them involve using artificial implants—the ever-popular silicone implant, which is what our twenty-six year old client wanted, is just one option. For many women, especially post-mastectomy, we start out with what we call “tissue expanders”, which are plastic bags that we fill with saline. They have a rubber valve over one surface, and with a special needle you can go through the skin, through the rubber valve, and inject more saline into the plastic bags, so the implants gradually get bigger over weeks or months. This stretches out the skin incrementally, allowing it to accommodate without the stretch marks. With tissue expanders, breasts can also reach a larger volume than would be possible with a one-and-done implant job.

You come back and see your plastic surgeon once a week. You get to know them. My residents and attendings spoke very fondly of their patients, clients they worked with for months before surgery and sometimes years after. They consider themselves artists, and any artist dealing with the human body has to deal with the fact that your body is constantly changing.

“What are the two forces that keep plastic surgeons in business?” my attending asked me, during that surgery, as we sat our patient up on the operating table to check that both breasts fell evenly. “Gravity,” I guessed. “Gravity and entropy.”

“Entropy?” he asked. “How do you define entropy?”

“Things get worse as time goes on,” I said, and he laughed.

Later that week another patient came back with failed breast implants. She had tried silicone, post-mastectomy, after a series of tissue expanders. Her expanders had gotten infected before she got full implants, and so the first time she went to the OR they took out the expanders, sucked out a puddle of pus from her chest where the expanders had been, irrigated with antibiotic solution before putting the new, sterile implants in place. My attending warned her, then, that the possibility of re-infection was real and that the consequences could be serious. But she wanted her breasts back. If we stopped then, after the tissue expanders got infected, all that progress would be lost. It would mean that the breast implants failed, that she would have to go another six months or longer with bandages across her chest, until we could try another type of reconstruction. She just wanted her body to look like it did before—before she had cancer.

When I saw her she was back because again, her breasts were red, swollen, itching, painful. We took her back to the OR, cut open her old incision site, and immediately saw the implants—again covered with creamy, greenish pus. We took them out, sucked out as much fluid as we could, irrigated each pocket with antibiotic solution five times. This time we didn’t put anything back. We sewed her skin back together and it flopped loosely across her chest, too much skin with nothing underneath. “She can do a flap later,” my attending said, but she went home with long-term antibiotics and her flat chest wrapped in bandages.

Like any foreign object in the body, breast implants are very prone to becoming infected. Any bacteria on the implant have a new environment full of nutrients to grow. On any foreign object, from breast implants to a deep access IV line or a Foley urinary catheter, bacteria can form what are called biofilms—tiny cities of bacteria that form a gelatinous matrix growing on the foreign object. Once they form this biofilm they can keep growing indefinitely, because antibiotics can’t penetrate biofilms. The only way to get rid of a biofilm is to remove the infected foreign body, whether it be an elective breast implant or central venous line keeping a patient alive in the ICU. The infection in her chest could have easily gotten into her blood. In a hospital, where MRSA is on everything, the step from infection to sepsis is so small. She was lucky that the infection remained local, lucky that we could take out the implants and eradicate the bacteria with antibiotics, lucky that the infection didn’t seed her blood and give her sepsis.

She was unlucky because her second attempt at breast reconstruction, after she already had bilateral mastectomies for breast cancer, had failed. She was unlucky because she had to have three separate surgeries for these implants. She was unlucky because she had to have radical mastectomies. She was unlucky because she had breast cancer.

Implants are not the only way to do breast reconstructive surgery. What the plastic surgeons prefer is taking another piece of muscle, covered with skin and with its own blood supply, and moving it around to cover the chest—usually the rectus abdominus (six pack muscles) or the latissimus dorsi (a large broad muscle covering your back and sides). Because it’s the body’s own native tissue, there is very little chance of rejection or infection, and there’s less sagging and tissue settling with time, unlike implants. Silicone implants, my intern informed me, often give you a problem called “Snoopy’s Nose Deformity” (a thing you can google image search if you are very curious). This occurs when the nipple, over time, slides down to the bottom of the implant, leaving the silicone bag as a bulge on the top of the breast. To fix this we can do another surgery, called a mastopexy, to raise the nipple. In the plastic surgery lounge this procedure was drawn on the whiteboard, a crude drawing of breasts with dotted lines marked ‘cut here.’  Skin around the nipples is cut out in concentric ovals and then the nipple is threaded, like a drawstring purse, and sewn into its new position. The ovals are longer on top than bottom, to pull the nipple higher up on the breast. You can get augmentation without mastopexy—that’s what our twenty six year old patient chose, and throughout the surgery my resident kept saying: “She’s not going to be pleased with her nipple in a year.” It’s even possible to get a mastopexy without breast augmentation surgery, if you feel like your nipples are too saggy, but like your breasts the size they are. But since you’re going to be under anesthesia anyway, why not go ahead and get everything done at once?

I learned, on my two weeks rotating through plastic surgery, that you can have surgery for almost every aspect of your breast. Do you want smaller breasts? Larger breasts? Smaller nipples? Nipples that are higher up? Is there too much tissue on the outsides? Do you want fat taken out of your abdomen and put in your breasts? (That one’s tricky, because you have to get fat stem cells–if you just transfer fat, it will die in the new location and grow back in the old one.) I had never before thought that my nipples might be in the wrong position, or too big, or too small. I had never thought about how many milliliters was in a standard cup size (it’s about 150). I had never thought about average nipple size (4 centimeters). I became more aware of my own breasts, the way they were asymmetrical, one larger and more off to the side. I measured my nipples to see if they were average. When, I thought, do women start to think that their nipples are too large? Who tells them that things about their breasts are wrong or abnormal? Having reconstruction after cancer, obviously a surgeon has to think about how to recreate a normal look of an entire breast. Even having breasts that you think are too large, or too small, or two different sizes—those things don’t seem too far a jump to corrective surgery. But when do you think that in addition to your breast implants, you may need your nipples moved? Is it something your partner says to you, or a friend comments on? Is it a suggestion your plastic surgeon makes when you ask about implants in the first place? Is it a problem created post-surgery, when your implants are in but nothing looks the way you wanted it to, and your plastic surgeon is just trying to help? Many plastic surgeons spend their career just doing breast surgery—mastectomies, reconstructions, implants, mastopexies. There’s a lot of business, and it’s often elective procedure with more than one surgery, which means money.

In the plastic surgery lounge, where they have three computers, a table with a candy bowl, a recliner couch, a TV and an Xbox, I and our one female intern spent an entire call day watching Gossip Girl. Between episodes of Serena & Blair wearing thousand dollar dresses in Manhattan we, dressed in scrubs from a vending machine, walked in our ugly expensive Danskos down to the ER to see consults. Kids who had fallen and needed stitches across their temporal bone. A 50 year old chain-smoking landscaper with a chainsaw injury to his left palm, a ragged, four inch gash right through his hand that we, two twenty-something, attractive young people, sewed up under procedure lights in the ED. Afterward we went back upstairs and made fun of Chuck’s scarf, critiqued the way he wears polos with popped collars under button downs with his white suits. We rounded on our patients: three different women with bilateral radical mastectomies, a 24 year old male who had had a total perineal reconstruction for Crohn’s disease, and a forty four year old woman with squamous cell carcinoma in her mouth who had had part of her mandible removed, leaving her with just a skin flap covering half of her face, now missing its underlying bones and muscles.

My residents talked a lot about what they’d do after they got out of residency. Most of them wanted to go into private practice, where the hours were shorter, the caseload was lighter, and the money was better. They spent a lot of time doing breast cases, reading up on reconstructive surgeries, talking about former colleagues who just ran botox clinics. They used the word “money” as a synonym for “awesome” or “good job”. “That’s money,” they’d say to me, as praise, when my stitches looked good. I started carrying my credit card tucked into my bra, next to my breast, because my scrub pockets were too big and I was afraid the card would fall out. I lived off clif bars at 10am and cafeteria soup at 3pm, at 6am eating leftover Panera bagels from the plastic surgeons’ morning conference. Only one of my residents was a mother. On rounds she always seemed harried and annoyed, but in the OR she taught the entire time, quizzing me on anatomy, explaining surgical procedures. I asked her how she managed being a resident, working 80 hour weeks, with having a two year old. “There’s no extra time in my life,” she said. After I left the hospital at 7pm, after a 13 hour day, I was lucky if could somehow both heat up a can of soup and take a shower.

My residents were always tired. The call room gossip was always about life after residency—all the breast jobs they’d do, the short facelifts, not having to deal with insurance premiums. “Cosmetics is where you make 80% of your money,” they told me. “It pays for the reconstructive work.” One night we stayed until midnight because a man came in with his hand chopped off. We spent an hour cleaning up the amputated hand, cutting out dead tissue, dissecting nerves & tagging muscles so that we could reattach them. When our patient came in, what was left of his arm, from his elbow to his shoulder, was completely shredded. They had to amputate at the shoulder. “When I get in private practice, I’ll never have to do hands again,” my resident said.

Plastic surgeons take call, at my institution, every other day for hand and face. We switch off with orthopedics for hand injuries, and otolaryngology (ENT—ear, nose & throat) for face. We’re always on call for burns. We do skin grafts, free flaps, bone grafts, tendon reattachments, laser therapy—sewing up kids’ faces, injecting wrinkled faces, filling holes when tumors get cut out, taking out breast tissue, filling in breast tissue, removing adipose, injecting adipose, getting rid of spider veins, cutting out burned skin, recovering the exposed tissue underneath. Plastic, as an adjective, means malleable, “capable of being shaped or formed”. For every skin incision we sewed up, they told me again and again that the scar matters more, that patients will never see what you did inside their body, but they will have to look at this scar for the rest of their lives.

Our twenty six year old patient did well. She went home after one day in the hospital, pleased with her new breasts. I saw her once, after her operation—she had hair the same color as me, and a new tattoo on her left arm, and she smiled at me when I asked her how she was doing. I don’t know if she had any complications, if she got infected, if she decided to come back to get her nipples raised later. I never saw her again. I made friends with my intern, the one who introduced me to Gossip Girl—when I see her in the hallways now she smiles and waves at me. I kept watching Gossip Girl. When one of my friends made a comment about how hot Blair was, I said: “but her breasts are so small.” I scrubbed into a lot of breast surgeries, on patients aged 13 to 85. I spent my last night on call, slept for two hours in the plastic surgery lounge on the couch in front of that TV, then got up at midnight to work on a presentation I had to give the next day on burns. The other student on service with me presented two different approaches to breast reconstruction. In my last case, my resident let me do the stitches, telling me how to hold my needle, how to pull skin together to leave the smallest possible scar. “That’s money,” he said, when I had tied the knot in my suture. Later I found myself judging other surgeons by how well they closed skin, how big were the scars they left behind.

Nicole Nolan is in medical school. Someday she will be a gynecologist, and then her entire job will be NSFW.

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