Walking on the water involves getting out of the boat and leaving the shore.

My appointment to meet the plastic surgeon at Queen Victoria Hospital finally came round and my husband took me over to East Grinstead. To say I was nervous would be a massive understatement but it was another step towards beating cancer so I was also glad to be there at last. I was advised to expect to be at the hospital for several hours so that they could do some assessments and other parts of the process for this type of surgery.

Firstly, the surgeon was absolutely lovely and has a very impressive CV! She graduated from Cambridge University with Distinction in 2008 and in 2015 she was awarded the Intercollegiate Fellowship in Plastic Surgery or FRCS(Plast). For her outstanding performance in these final examinations she was awarded the McGregor ‘Gold’ Medal. In 2017-18 she was awarded the Lady Estelle Wolfson Emerging Leaders Fellowship at the Royal College of Surgeons of England. I was going to be in good and very safe hands (literally!).

Before doing any physical examination she discussed the plan with us. Although the referral had mentioned that I would like to be considered for a double mastectomy she didn’t talk about that so I had to bring it up. She then asked me to get undressed so she could have a look at my breasts and also my stomach. She did some measurements of my breasts to get a gauge of size and then felt around my tummy to work out how much could be used for the DIEP flap reconstruction. She quite quickly said that she didn’t think it would be feasible to do a double reconstruction in this way as I didn’t have enough fat in my tummy to get a satisfying result for both breasts. Despite eating my body weight in chocolate over Easter I still hadn’t gained enough wait! I mean, I guess that’s kind of a positive! Every cloud and all that….!

Thou shalt not weigh more than thy refrigerator…

This is the explanation on the letter to my surgeon:

“On examination, (she) has a BMI of 29.2 and wears a 36-38C bra. She has very nicely shaped breasts, with a nipple to notch distance of 24 cm. Her breasts are quite projected, and although she has good abdominal tissue for a DIEP, I have explained that she would get a better cosmetic result if we were able to use the centre of her abdomen to reconstruct her left breast. If we were trying to do a bilateral reconstruction, she would probably not get the same shape and projection as she has now.”

Joking apart though, I did feel rather deflated initially but she did a lot to reassure me. We discussed my family history and the level of risk of the cancer returning in the right breast which was not high. Of course I still felt anxious about this but, on reflection, I thought about how my mum’s cancer hadn’t returned in either breast (she had not had a mastectomy) but it came back as secondary bone cancer. It was still classed as breast cancer as it was a direct result of the primary cancer and ‘breast cancer’ was recorded as the cause of death on her death certificate. That can be quite confusing. I also have the benefit of hindsight because my mum was badly let down by her GP and her secondary diagnosis took 12 months, significantly affecting her prognosis. I would have the opportunity to be extra vigilant having learned from my poor mum’s experience who might otherwise have had a better chance of survival if she had not been constantly dismissed by doctors telling her the aches and pains were simply a part of the ageing process.

I stated that I had one question about this decision and the plastic surgeon said she had an idea of what I was going to ask. My question was that if you can only have one DIEP procedure would that mean I would not be able to have a natural/organic reconstruction of the right breast if the cancer did return in the future. She had preempted this question and explained that there are other alternative autologous procedures. A transverse myocutaneous gracilis flap (TMG) or transverse upper gracilis flap (TUG flap) uses skin, fat, and usually muscle from the thigh. She subsequently examined my thighs and confirmed that they would be suitable. In other words, I might not have enough tummy fat to make two breasts but my Beyoncé thighs would be more than sufficient should I need them for the other one! I can’t help feeling that my ‘strong’ thighs are responsible for my BMI figure putting me in the ‘overweight’ bracket! Anyway, what’s a thigh gap? Asking for a friend….!

This information was also all well documented in her letter:

“We briefly discussed implants, which she is not keen on. She is content to proceed with unilateral mastectomy and reconstruction, and I think this is a very sensible decision given that it would give her a better cosmetic outcome, and also reduce the number of surgical sites which need to heal before her chemotherapy. I have also reassured her that should she have any problems in the right side in future, she has also got adequate tissue on her thigh for autologous reconstruction.

I have also discussed the basics of DIEP reconstruction surgery with her today (using tissue from the abdomen)…..

I have explained the risks of surgery as per our checklist including a <1% chance of losing the reconstruction. Other complications include bleeding, infection, delayed wound healing, seroma (collection of clear fluid), abdominal weakness or hernia, asymmetry of size/shape compared to the other breast and the need for further surgery….”

Just a few risks then! I wholly agree that you have to be given this information and be prepared for complications. Equally though I focused on the positives rather than stress myself out about things that might never happen.

Take risks. If you win you will be happy; if you lose you will be wise.

I signed the consent forms there and then which meant that as soon as they could give me a date for surgery I would be ready to proceed.

The consultant also shared some photographs with me of similar results to what I could expect which I found reassuring.

The other thing we discussed at that appointment was whether I would be happy to be added to the UK National Flap Registry (UKNFR). Participation in this type of clinical audit helps to gather information about individual surgeries by following up on a large number of patients after treatment. Before any research is conducted on your data all personal information is made anonymous or coded so that researchers cannot identify you and patient data will never be given or sold to any other person or organisation (Data Protection Act 1998). I am all for helping with research and could only see this as a good thing to do. As a leading specialist centre for reconstructive surgery and rehabilitation Queen Victoria Hospital has a proud heritage and is known throughout the world for pioneering new and innovative techniques and treatments. They are able to offer excellent educational opportunities in clinical areas and in the classroom. The way I see it, without this research, I might not have had the choices I had been given to make my situation less intolerable.

The next part of the process was to take some blood. This has always been problematic for me and has been made more so by the fact that this could no longer be done using my left arm due to the sentinel node biopsy I’d had a few weeks earlier. After attempts by three medical practitioners, including one of the doctors, and a lot of apologies, it was decided to take the blood from my hand and insert a cannula at the same time.

I had been booked in to have a CT scan that afternoon but there was a bit of time to wait so I was given a form to take to the photographic department. Clinical photographs are taken at the consultant’s request and the purpose of them is to help doctors and other health professionals monitor various clinical conditions. They are also used as part of the planning process or for educational purposes and publication if the right consent is received. The images are kept securely within your medical records.

The photographer was very sensitive and respectful. I had to undress just my top half and roll down my bottoms slightly to show my tummy. She took a handful of shots from different angles and it was all finished in just a few minutes. All very painless and my dignity remained intact.

The next and final procedure of the day was a CT scan. “A CT angiogram (CTA) is a special type of CT scan that evaluates the blood flow in the abdomen to determine if the required blood vessels are intact and able to be used for DIEP flap reconstruction. It can also provide a “road map” for the surgeon and help locate the larger blood vessels (perforators). Surgeon preferences are mixed when it comes to CT angiograms. Some surgeons obtain a CTA on their patients routinely before DIEP flap surgery as they feel it can significantly help with planning the procedure.”

A lot of care is taken to follow safety procedures as the test exposes patients to radiation. I had to complete more forms and answer a lot of questions. One of the main questions is whether a patient thinks they could be pregnant. I categorically said no but at the last minute a nurse came in to double-check as she was concerned that my last period had been four months earlier. I explained that I was 54 and peri-menopausal! She didn’t seem overly reassured by that but didn’t challenge me any further.

As I mentioned earlier, I had been pre-prepared with the cannula in the back of my hand. I was positioned on the table in the scanning room and an IV line was inserted, into which a contrast agent was injected. Contrast agents are commonly used to improve the visibility of blood vessels. I was advised that I may experience brief flushing or a metallic taste in my mouth. You may wonder what ‘brief flushing’ feels like. Well basically it’s the feeling that you’re wetting yourself but you’re not! It’s a very strange sensation! The IV line is kept in place until the end of the scan which I think lasted around 30-45 minutes. I’ll be honest, I can’t remember exactly.

That was it in terms of procedures and assessments for that appointment. We had already discussed dates with the consultant. My brother was due to get married on 26th June and it was yet another thing I feared I would miss out on. In the absence of my mum it was really important to me to be there for him and it would have impacted on everyone’s enjoyment of the day if we could not all be together as a family. Having said that, I had mixed feelings about being the one to delay my surgery. However, in the end it made no difference because first my breast consultant tested positive for Covid and was off work for a couple of weeks then subsequently she had to cover a colleague’s clinics due to long term sickness. It meant that technically the delay had not actually been wholly driven by me and the ultimate date for my operation was only a few days later than the first date they could offer me anyway. I reassured myself that the consultant would not knowingly put me at risk and would advise me if she felt we shouldn’t postpone.

I decided to do my best to enjoy the few weeks of respite ahead of me. Despite the pandemic rules being relaxed for a few months, I had not felt the benefit of the freedom being enjoyed by others due to either the fear of contracting Covid ahead of appointments/operations or having to convalesce afterwards. I wanted to make the most of this time to catch up on a bit of socialising and overdue fun in the hope that I could take my mind off my situation and get my life back for a short while. And that’s exactly what I did…..

“The human capacity for burden is like bamboo- far more flexible than you’d ever believe at first glance.” – Jodi Picoult (‘My Sister’s Keeper’).