Guest blog – Terri Coutee “A patients view – plastic surgery”

Below is a blog from Terri Coutee a patient who’s had reconstuctive breast surgery. We would like to thank Terri and Drs Chrysopoulo, Oliver Brandford Patrick Malluci for sharing this blog with us. – Gareth Presch

Best Plastic Surgery International Paper of the Year

Congratulations Drs. Branford and Mallucci!

Congratulations to Drs. Olivier Branford and Patrick Mallucci of the UK for being awarded best plastic surgery International Paper of the year from the American Society of Plastic SurgeonsPlastic Surgery Journal. They will be recognized by their peers in Boston October 16-20, 2015, atPlastic Surgery the Meeting, a gathering of over 3,000 plastic surgeons and surgical medical professionals from all over the World.

The paper, Population Analysis of the Perfect Breast: A Morphometric Analysis, was a study done to determine current trends in what is considered the aesthetically pleasing breast shape using a measurement of form (morphometric). It was a comprehensive survey study with cross-cultural opinions from men, women and plastic surgeons regarding ideal breast proportions. The consensus was a 45:55 ratio meaning; 45 percent of breast fullness lies above the nipple line and 55 percent below the nipple line. Simply stated, this measurement tool was determined by the study to be the guide in achieving the “perfect” breast shape for use by plastic surgeons.  History has shown that this perception of the perfect breast shape dates back to the sculpture of Venus de Milo discovered on the island of Melos in 1820.


A Complex & Meticulous Procedure

I was far from having the “perfect breast” when this study was done. I am a breast reconstruction patient. I had my breasts rebuilt after a nipple sparring, double mastectomy due to a second breast cancer diagnosis. I had a complex and meticulous procedure called DIEP flap surgery which stands for deep inferior epigastric perforators. This is also known as autologous free flap breast reconstruction. This method preserves the rectus abdominis (sit-up) muscle and thereby greatly reduces abdominal wall hernia, weakness and bulge after surgery not to mention less post-operative pain. My own tummy tissue, fat and blood vessels were disconnected from my abdomen and transplanted to the breast area to create two soft, warm, breast mounds.

I chose this type of breast reconstruction because I wanted to be my own tissue donor. I was uncomfortable being an amputee, although no one knew that looking at me. They could not see under my clothing that I had no feminine form, no breasts, and wore a heavy and uncomfortable prosthesis. I lived with that prosthesis for seven months. I tried daily to conceal the fact that I had no breast shape. It left me feeling less beautiful, unbalanced, challenged in finding clothing that covered the deep divots and gashes on my chest that were left there from the cancer that was carved out. Wrinkles of skin from what was my breast tissue lay awkwardly on my chest. Divots were visible near the top of and on either side of my sternum. The outline of my sternum was faintly visible and it was awkward for me to feel the boniness of my chest that was once soft, warm, breast tissue.

Agile Hands, Artistry & a Keen Eye

I had no expectations going in to my initial consult with my plastic surgeon in early October of 2014 other than the desire to have a body part back. I knew that this surgery was not routine. I knew that this surgery had to be done by a plastic surgeon of micro-surgical skill, expertise and experience. This is not a surgery that you dabble in. A successful breast reconstruction surgeon is dedicated to long hours standing at the surgical table creating perfection with agile hands, artistry and a keen eye to attain the best possible patient outcomes. The physical demands of this surgery can top the charts in length, execution, alertness, focus, and grit.

What did I notice about my plastic surgeon after his initial and very compassionate greeting at that first consult? I noticed his hands. They were the hands of an artist, agile and well-defined. He used measurement tools to carefully determine what shape and size my new breasts would look like. He called out numbers to his nurse as she recorded the findings of those measurements. He carefully studied the area where my breasts used to be as if examining the canvas of a piece of art yet to be completed.

The Tools of a Plastic Surgeon

In many ways I have worked backwards in understanding what was done to my body during DIEP flap breast reconstruction surgery. The paper from Dr. Branford and his partner, Dr. Mallucci were a personal focal point in understanding the mind of and tools used by a plastic surgeon. My social media engagement began with Dr. Branford early in 2014. I had just started my outreach and education to breast reconstruction patients and noticed that I got a “follow” January 1, 2014, shortly after phase one of my own breast reconstruction. I latched on to his tweets since they focused on evidence based research.

I read the article mentioned in the first paragraph of this blog. We direct messaged each other on Twitter and even shared personal emails so that we could begin our dialogue about “the perfect breast”. My opinion of the title after first viewing it was border-line odious and I think Dr. Branford sensed that. He wanted to know how I felt as a cancer patient who was reconstructed and not someone seeking to reform a “normal”, non-diseased breast into a “perfect” breast.

Compassion & Interest

That’s where he had me, at his sense of compassion and interest. I think about the pictures both of the Venus de Milo sculpture as well as the photos of women seen in a three-quarter profile pose in the study to give the reader a visual of the 45:55 upper pole to lower pole ratio of the “perfect breast”. His consideration and attention to my thoughts were that of a true gentleman and scholar. I responded with a blog post after understanding the purpose of the paper and carefully examining the depth, validity and intention of the paper.

Perfection is attained by slow degrees; it requires the hand of time.    ~ Voltaire

Artists must use tools. This paper was carefully planned, researched and presented to develop a tool for plastic surgeons to use in their practice. I asked my own plastic surgeon to weigh in on his thoughts about this paper. I want you to notice some words from his statement: “patient satisfaction”, “brilliant as they are simple”, “provides a common language”, and last but not least, “shared decision making”. Here is what he shared with me.

Plastic surgeons and patients generally have pre-existing visions in their minds as to what constitutes a great result. Many surgeons use before and after pictures or 3D planning software to demonstrate the likely results to the patient. Without these, ensuring appropriate patient expectations can be very difficult. Appropriate expectations are as important in ensuring great results and patient satisfaction as the surgeon’s expertise. Until recently, “what makes breasts beautiful or perfect” has very much been in the eye of the beholder. The observations and subsequent guidelines put forward by Drs Malluci and Branford in their article “Population Analysis of the Perfect Breast: A Morphometric Analysis” are as brilliant as they are simple. The guidelines are spot on. The study provides a common language for further discussion, not only among plastic surgeons, but more importantly pre-operatively between patients and their surgeons. The 45:55 ratio and associated metrics not only arms plastic surgeons with invaluable guides in optimizing breast aesthetics, but equally, can be used to facilitate the shared decision making process between patient and surgeon which has been shown repeatedly to improve patient outcomes.

~ Dr. Minas Chrysopoulo

Phases 1 2 3 4 Proof 3 45 55 3 blogSuccessful Result of Combined Passion

These two plastic surgeons were on different continents and yet, I not only sensed but truly felt that I was the successful result of their combined passion for their profession. My breast now are far more beautiful, more “perfect” than the breast I had before the mastectomy, the breasts that were part of my body before cancer. The result of the study from Drs Branford and Malluci’s paper is a tool used to achieve my now “perfect breasts”. As you can see in the artist’s sketches the scars have faded and the breasts have taken shape after the transfer and symmetry phases of my DIEP flap surgery.

I asked my artist, Meagan, who also did the backdrop for my website to sketch the progression of my rebuilt breasts from post mastectomy (panel 1), tissue transfer with drains after phase one (panel 2), pre-surgical symmetry and scar revision phase two (panel 3) and the final results of my DIEP flap surgery (panel 4). I wanted to use the same four panel model that Dr. Branford did to parallel the message of his study, perception of and the metrics used to build the perfect breast. It was important to me that women have a visual of how the scars have faded over time.  It was important to me for women to see the results and value of time invested in finding a successful, highly skilled and compassionate plastic surgeon, a plastic surgeon interested in patient outcomes and shared decision making.  I also want them to know the hours of research and dedication from the gentlemen mentioned in this paper so that they understand the vision and purpose that is plastic surgery.

I sent my artist photos that were taken of me before, during, and after my reconstruction. We sat and discussed the purpose of my paper. I told her how anxious and uneasy I was to have sketches of my new breasts visible to anyone who read the paper. She gently laid her hand on my shoulder and reassured me that women needed to see this. They needed to see what skill and artistry gave back to me, the beauty and femininity that I lost through cancer.

Reading Drs. Branford and Malluci’s paper gave me clarity. This paper gave me information to share with other women who are considering breast reconstruction. So what constitutes a “perfect breast” to a cancer patient? Perhaps another study with a targeted group of reconstruction patients may be in the works. The concerns and thoughts of the patient will be paramount should that paper be written, in my humble opinion. That shared decision making and concerns of the patient is what I experienced from my plastic surgeon.

I want to finish with a quote from my oldest son. We were taking a cool, autumn walk recently. I spoke to him about the science and purpose of the study. We chatted about the relationship I had developed with both Dr. Branford who I have never met in person and Dr. Chrysopoulo who rearranged my body in ways I never knew were possible until I was told I had cancer for the second time. It was a slow, methodical, but powerful walk and chat with my son. With a pause and thoughtful glance over at me he said,

There is more to the physical world than what we can perceive.    ~ Richard Coutee

Thank you Dr. Branford and Dr. Chrysopoulo for sharing your valuable time and input and for being a part of this blog.

*The opinions expressed are the bloggers own and do not necessarily reflect the views of the World Health Innovation Summit.
Twitter @HIC2016 @garethpresch
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