Today, there are more surgical options for cancer than ever before. This is especially true of breast cancer where removal of the tumor(s) and reconstruction vary on what I call the “Three Ps”: the pathology, the patient, and the professional. Early on, breast cancer patients will face choices about their surgery and treatment. Depending on their type of cancer, they might also have to consider the type of reconstruction to opt for. If there is a silver lining to having breast cancer, it’s that there are many reconstruction options and the results can be jaw-droppingly beautiful. Trust me when I say that it softens the blow. No matter what type of cancer you have, the decisions you make regarding the type of surgery and treatment will be a huge factor in your recovery. But they aren’t the most important things you will have to decide on during this battle. Selecting your medical team is.

the key to it all: finding the best surgeon

Getting a cancer diagnosis makes you feel like you have been swept up in a tornado. And in a way, you have been. It knocks you off your feet and before you know it, you’re whipping around from one doctor’s office to another. For me, the most surprising part of this process was that the first doctor I was instructed to see was the surgical oncologist. “Why am I seeing a surgeon before seeing an oncologist?” I thought. It’s a common question because it is the reverse of what happens with most illnesses. Typically, a patient goes to their primary medical doctor first, then to a specialist or surgeon. It’s just the opposite when it comes to breast cancer. Surgery comes first because the size, location, and pathology of the tumor(s) often determine the subsequent treatment protocol that is necessary.

After finding out you have cancer, you are going to feel like you need to rush and get it removed STAT. This is very normal. In fact, I would be a little worried if you didn’t feel that way. But before you work yourself into a panic, consider this: The probability is that you’ve most likely had this cancer for months, if not years, without even knowing it. Just to give you some perspective, my surgical oncologist told me that my one-inch tumor was probably growing for a few years before I felt it. So… taking a week or two to find the best surgeon isn’t going to put you any further into the danger zone. In fact, the only thing that will put you there is getting any ol’ doc to do the job.

Who you select as your surgeon is by far the most important decision you will make because he/she paves the road for the rest of your cancer journey. Their experience and expertise will ensure that the cancer is removed from your body and that it is done in a way that takes your physical and emotional well-being into consideration. They will also make recommendations for the rest of your medical team, including your medical oncologist, radiology oncologist, and plastic surgeon. Your surgical oncologist spearheads and sets the tone for your treatment. How you feel and look after all is said and done is directly linked to them.

This is exactly how Hoda Kotb, cohost of NBC’s Today Show’s fourth hour (the best hour!!!) felt when she was diagnosed with breast cancer. Hoda opted to have a TRAM flap reconstruction, where the breast is re-created using the flap of skin, fat, and underlying abdominal muscle. Today, there are more than a dozen different types of flap reconstructions. But when Hoda was diagnosed in 2007, flaps were relatively new. This made her decision about her medical team even more critical. “It starts with the surgeon; at least for me it did,” says Hoda. “There were so many people that were describing what they were going to do [during the surgery]. But I wanted to know what was going to be left behind when they were finished—and that does matter. So choosing the right breast cancer surgeon is important because they work in tandem with the plastic surgeon who comes in right after. It is the plastic surgeon who does most of the repair and rebuilding and how they did it mattered to me. I wanted to feel confident and comfortable.”

I felt the exactly the same way. While I wasn’t a candidate for any of the flap procedures, I wanted to make sure I would get a good aesthetic result. What woman doesn’t want that? And by the way, we shouldn’t be made to feel vain or bad about that either.

We have the God-given right to look and feel normal—and, dare I say, even beautiful.

After my diagnosis, I immediately started emailing everybody I thought would point me in the right direction. Besides my family and friends, I reached out to colleagues who wrote for health magazines, people who were connected to cancer in one way or another, and I started researching the web. After two weeks, I had a list of only three names. I made consultation appointments with each surgical oncologist to—essentially—interview them. This is what you need to do if you want to find the best possible surgeon. You wouldn’t buy a car without researching its safety rating, consumer feedback, or the features it comes with. So why wouldn’t you do the exact same thing when selecting your medical team? Choosing a surgeon is a life-altering decision, so it’s critical to take the time to do it thoroughly.

By the last interview, I knew the questions to ask but what I was looking for was something deeper, more instinctive. “At the point where you have three doctors telling you you need a mastectomy, then you start looking for somebody who you feel like you have a connection with,” says Hoda. The minute I met Dr. Elisa Port, the chief of breast surgery at Mount Sinai and the codirector of the Dubin Breast Center—I felt that connection. Dr. Port is one of the leading breast surgeons in the United States. While her qualifications are beyond impressive, she was authentically concerned for my well-being: She was kind, supportive, and provided me with all the intel I needed to make the right decision for myself. But beyond that, she never judged me for any concerns or questions I had. This became more important than her résumé when halfway through my treatment I decided not to do radiation but to have a mastectomy instead. At this point, I was in full-on panic mode—so much so that it rendered me incapable of making a decision. During one of the many visits I made to her office to discuss my options, she turned to me and said, “Sweetie, you just have to make a decision. It’s going to be okay. Whatever you decide, it’s going to be the right decision.” She essentially gave me permission to feel good about what I wanted to do but was too scared to actually do. As I went into surgery a week later, she held my hand until I fell asleep. I will never forget her tender acts of kindness. It is those little things that make all the difference in the care you receive. For this book, I thought there would be no better authority than Dr. Port to give advice on how to find the best surgeon and what to expect from surgery. Below, she weighs in.

how to find the best surgeon and medical team

reputation is everything

“Number one: Look at the reputation of the medical center,” advises Dr. Elisa Port, author of The New Generation Breast Cancer Book: How to Navigate Your Diagnosis and Treatment Options—and Remain Optimistic—in an Age of Information Overload. “You’ll up your odds of getting the best possible outcome when you go to a top-tier academic center.”

get recommendations

Word of mouth is very telling about the level of skill, experience, and bedside manner that you need to know when selecting your medical team. A surgeon could have extensive expertise but if they are gruff and always rushed, they may not be the best pick. When facing complicated surgeries and treatments, you will want, no, need, a doctor who is not only experienced but also emotionally supportive and patient with you. Cancer doesn’t just take a physical toll on the body—it takes an emotional toll as well. The best way to arm yourself for the battle is to come to the field with the sharpest weapon of defense: a great surgeon.

look for a surgeon who specializes in your type of cancer

This rule applies for every type of cancer. If you have breast cancer, then you should look for a surgeon whose practice focuses on breast cancer surgery. If you needed brain surgery, you wouldn’t go to a podiatrist, would you? No, you wouldn’t. Same philosophy applies here. Dr. Port also advises looking for surgeons who have completed a fellowship within their focused cancer category. Surgeons who have completed a fellowship have dedicated an additional year beyond general surgery residency learning the latest information and the most advanced surgical techniques. “There is so much new information and things are constantly changing, developing, and progressing so rapidly,” says Dr. Port. “So, you really want doctors who are very specialized and up-to-date.”

inquire about the numbers

A surgeon may do breast cancer surgery but that doesn’t mean they are a breast cancer surgeon. There is a huge difference. “The most recent statistics show that approximately 75 percent of breast cancer surgeries are performed by surgeons who do fewer than sixteen breast operations a year,” reveals Dr. Port. “That’s one a month. I’m doing ten to fifteen a week.” This is a staggering fact that can come with serious ramifications to the patient. She adds, “There is clear-cut data demonstrating that surgeons and centers that do a high volume of specific types of surgery have better outcomes. Practice makes perfect.” Don’t be afraid to ask potential surgeons how many lumpectomies and mastectomies they have done every week or month. Those that hesitate to discuss their numbers are generally those who don’t have an impressive number to share.

be willing to travel

Most of us are thrilled when we can hop on a plane and fly to a vacation spot. And many of us are willing to log long hours in a train or car for business. So why is it that so many people refuse to travel for health care? I understand that financial constraints and work-life obligations can make it difficult. I also know that all of us would feel more comfortable and content if our doctors were in close proximity to our homes. But that isn’t always going to be the case. Traveling to a specialist who can get you healthy again is worth being out of your comfort zones—financially and physically. When my stepmother’s cancer returned for the third time, my parents boarded a plane from Florida and lived temporarily in New York so she could have surgery at Memorial Sloan Kettering. After her surgeries were done, she was understandably anxious to get back home. Her New York surgeon was willing to work with a medical oncologist in Florida to oversee her chemotherapy treatments so she could recoup at home. If you can travel for the best care, do it! Most doctors want you to be content and comfortable during treatment and will work on your behalf to get you home as quickly as possible.

The caveat here is that traveling to see a doctor can be expensive. Lodging, even more so, especially if longer treatment is required. Here are some organizations that can offer help:

traveling assistance

Air Care Alliance offers a central listing of free transportation services provided by volunteer pilots and charitable aviation groups. Call 888-260-9707 or visit www.aircareall.org.

Air Charity Network coordinates free air transportation for people in need through various organizations around the United States. Call 877-621-7177 or visit www.aircharitynetwork.org.

Angel Airline Samaritans facilitates no-cost or reduced-rate commercial airline tickets to and from distant specialized medical evaluations or treatments for people with cancer in need and their families. Call 800-296-1217 or visit www.angelairlinesamaritans.org.

The Corporate Angel Network arranges free air transportation for people with cancer traveling to treatment using empty seats on corporate jets. Call 866-328-1313 or visit www.corpangelnetwork.org.

LifeLine Pilots are volunteer pilots who donate their time and all flight expenses to people in need of free transportation for ongoing treatment, diagnosis, and follow-up care. Call 800-822-7972 or visit www.lifelinepilots.org.

Mercy Medical Angels offers free or low-cost transportation for medical evaluation, diagnosis, or treatment. Call 888-675-1405 or visit www.mercymedical.org.

National Patient Travel Center provides information about long-distance travel for people with cancer and their families in need of travel. Call 800-296-1217 or visit www.patienttravel.org.

PALS (Patient AirLift Services) has a network of volunteer pilots who provide people with chronic illnesses air transport services at no cost. Call 888-818-1231 or visit www.palservices.org.

housing assistance

Healthcare Hospitality Network is an association of more than two hundred nonprofit organizations that provide lodging and support services to families and their loved ones who are receiving medical treatment away from home. Call 800-542-9730 or visit www.hhnetwork.org.

The American Cancer Society’s Hope Lodge gives cancer patients and their caregivers a free place to stay while receiving treatment in another city. Currently, there are thirty-one Hope Lodge locations throughout the United States. Call 800-227-2345 or visit www.cancer.org.

Joe’s House is a nonprofit organization providing a nationwide online service that helps cancer patients and their families find lodging near treatment centers. Call 877-563-7468 or visit www.joeshouse.org.

Ronald McDonald House Charities offer free or reduced-cost lodging for families of seriously ill children who are receiving treatment at nearby hospitals. Call 630-623-7078 or visit rmhc.org.

always get a second opinion

Don’t you like having options? I do! And for that reason alone I am a big advocate of getting a second opinion. It is important to know that there are some doctors—not all—who will advise a patient to do a certain type of surgery or reconstruction based on what they feel comfortable doing, and not what’s in the best interest of the patient. There have been instances where patients were talked out of the type of surgery or reconstruction they wanted because it wasn’t what the surgeon wanted to do. This happens more when it comes to some of the trickier or newer reconstruction surgeries, like flap reconstructions, that require time and a certain skill set that not all doctors are equipped with. If one doctor tells you not to consider a particular course of action but can’t give you a reason why, that should raise some red flags. But if you talk to a few doctors and they all agree, it makes the intel more believable.

take notes

Dr. Port says it best: “This is a time of information overload.” Nowhere will you feel this more strongly than the first visit, post-diagnosis, with the oncologist. Trust me when I say, it’s like a crash course in Math 55 with stats, studies, and test results whizzing past your ears. If you’re like me, you’ll probably only absorb a third of it. And I’m not alone in that. “In the beginning, I started taking notes because there was just so much information flying at me,” says Joan Lunden, who created the Internet channel ALIVE with Joan after she was diagnosed with breast cancer. “I wrote down all the questions, then I started writing down all my emotions and fears. Eventually, that’s what became Had I Known [her New York Times–best-selling memoir].” Notes will help you review all the information when your mind is swimming and emotions are swirling. If writing all the information down is too emotionally draining for you, bring someone who will take notes on your behalf.

follow your gut

You may have scored a coveted appointment with one of the leading surgeons in the world but if the two of you don’t click and it doesn’t feel right, then follow your gut and find another surgeon. We can agree that skill and expertise rank high on the list of important qualifications, but so does getting information, time, and support. You are going to be in a long-term relationship with whatever doctor you choose, so choose one who makes you feel safe and supported.

Once you line up your medical team, then you can start thinking about surgery and treatment. For some of you, the type of cancer you have will determine what surgery and treatment you require. For others, there will be more options. Many factors come into play when making a decision, from the size of the tumor to the type of cancer, to your lifestyle, et cetera. Just know—there is not one right road to travel.

In this book, I am not going to get into the different surgeries and treatment options. I think that is better left for you to discuss with your medical team. This book is strictly a beauty guide to help you manage and care for your body as it is changing because of cancer. That said, I have had both a lumpectomy and a mastectomy, so I want to share some of the pros and cons of each, since I have lived through both experiences and know the aesthetic results you can expect.

lumpectomy

PROs:

Minimally invasive, outpatient surgery. “I had one patient who wanted to put her kids on the school bus in the morning, have her surgery and be home in time to get them off the bus that afternoon and we made that happen,” says Dr. Port.

The incision leaves a small scar that surgeons have done wonders to minimize, often hiding along the rim of the areola.

Quick recovery—a few days of pain and swelling (often controlled by ibuprofen) and no exercise.

Same survival rate as mastectomy.

CONs:

Chance of not getting clean margins. “In about 10 to 20 percent of cases we have a situation where we don’t get clear margins around the tumor and we have to go in a second or third time,” says Dr. Port. “That’s something that a lot of people don’t know about lumpectomy surgery. When you go in a second and third time and you’re chiseling out more tissue, that’s when you can start getting into more disfigurement.”

Unclear margins require repeat trips to the OR and, ultimately, lead to a mastectomy. “That initial incision for the lumpectomy can have huge ramifications for the patient in terms of aesthetic results if you end up needing to have mastectomy soon after,” says Dr. Port. (This is just another reason why it’s important to have an experienced surgeon who is always thinking ten steps ahead and is prepared for all possible scenarios that can play out.)

Slightly higher chance of local recurrence after a lumpectomy versus a mastectomy.

Radiation treatment generally consists of six weeks of daily treatments. The initial visit, where the radiation oncologist tattoos the breast, can be up to two hours. After that, daily appointments last a mere five to ten minutes. Even still, the energy of getting to the hospital or facility, waiting, undressing, having treatment, then heading home or to work—for thirty days in a row—is emotionally and physically exhausting. Some of my cancer buddies who had radiation felt that it was more grueling on their body than chemo. Something to consider.

A breast previously radiated cannot safely tolerate additional radiation if there is a recurrence.

The side effects of radiation are no joke. Temporary side effects include exhaustion, lymphedema, and skin burning, peeling, and discoloration—just to name a few. But it’s the long-term effects that concerned me most. Radiation can cause the breast tissue to lose its elasticity and harden. “During the six weeks of radiation, there is an accumulation of injury,” says my talented plastic surgeon, Dr. Leo Keegan, the medical director of Fifth Avenue Millennium Aesthetic Surgery and the assistant clinical professor of surgery, Division of Plastic Surgery, at the Icahn School of Medicine at Mount Sinai. “That injury leads to a fibrosis of all the tissue that has been radiated. You can think about it like scarring on a more cellular level. The skin, breast, and muscle will experience permanent changes where the breast tissue feels more indurated and firm leaving them not as pliable than nonradiated tissue. In implant-based reconstructions, it also creates the increased risk of capsular contracture, infection, and increased wound healing risks.” This can change the appearance of the breast to the point where it appears higher, firmer, and indented at the surgical site. That hardened tissue can make it more challenging—and in some rare cases, impossible—to operate on or reconstruct. A woman I know experienced this firsthand. She had gotten breast cancer and opted to have a lumpectomy and radiation. About six years later, and a year after she finished her course of Tamoxifen, she got cancer in her other breast. When they couldn’t get clear margins, she opted to have a bilateral mastectomy. In her breast that had been previously radiated, the reconstruction didn’t take. Her skin lacked the elasticity it required to keep the incision closed so her expander could stretch the skin and make room for the implant. The incision kept opening, leaving her expander exposed. Her plastic surgeon had to reoperate to remove the expander. She was forced to wait several months to allow the wound to heal. Two tries later, they were finally able to finish her reconstruction. You can only imagine how devastating this was emotionally, physically—and, let’s face it—aesthetically.

mastectomy

PROs:

If you decide from the get-go that you want to have a mastectomy, surgeons can place the incisions in such a way that scars are almost undetectable later on.

In the right scenarios, surgeons can also perform nipple-sparing mastectomies, where a woman’s nipples can be preserved. Angelina Jolie opted to have this done. While this is a technically challenging surgery, it preserves the look of a “normal,” healthy breast.

Limited follow-up screenings.

CONs:

Permanent removal of the natural breast tissue.

Intense surgery that requires a two- or three-day hospital stay.

Recovery takes two to three weeks and includes dealing with surgical drains, pain meds, no exercise—among other things. For some of the flap-based reconstructions, this can extend up to six weeks.

Depending on the type of reconstruction you decide to have, it can mean multiple surgeries. Flap reconstructions are more intense and have a longer recovery period, but all the surgery is done in one shot. With implant-based surgeries, there will be at least three surgeries including: 1) Putting in the tissue expanders—typically done at the same time as the mastectomy—but not always. In some cases, patients can go directly to implants, avoiding the tissue expander step; 2) swapping out the expanders and replacing them with the implants; and 3) nipple reconstruction.

Implant-based mastectomies will require at least one future “swap” surgery to replace the implants once they start to show signs of age and/or wear and tear.

Implants can become encapsulated or rippled and they can rotate or drop—all requiring follow-up surgery to fix the issue.

Since the breast tissue has been removed, the implant is placed under the pectoral muscle to help protect the implant. Because of this, any time the muscle is activated—like opening a jar of pickles, doing a pull-up, even if you get cold and start to shiver—it can cause the implant to move or get squeezed into a weird position temporarily. I won’t lie—this looks as awkward as it sounds.

note: I understand there are some of you who will opt out of reconstruction. For those of you who do, turn to Chapter 8 (here) for all the intel and tips you will need about shopping for and wearing breast and nipple prostheses.

implant options

If you are considering an implant-based reconstruction, which is what I have, then you are going to have to consider the type of implant you prefer. There are three main types and each provides a different look. Below is a quick breakdown of each:

saline implants

Saline implants are much like tissue expanders because they are filled with salt water. Many patients prefer saline because they believe them to be safer; however, you should be aware that this type of implant tends to fatigue faster than silicone implants. While all implants wrinkle over time, saline implants are more likely to show visible signs of rippling and don’t feel as natural as silicone. After all breast tissue is removed during a mastectomy, the only thing left cushioning the implant is the thin pectoral muscle; the round shape and ripples can be very obvious. In terms of how they feel: The salt water provides a bouncy water balloon–like touch.

silicone implants

The reason a lot of women gravitate to implants filled with liquid silicone gel is they look and feel the most natural. When you are standing, the gel rests at the bottom of the implant and assumes a teardrop shape, mimicking what the natural breast tissue does. When lying down, the fluid spreads out and tends to rest near the armpit and outer breast, again, just like normal breasts. They also feel pillowy soft. In 2010, the study “Measuring and Managing Patient Expectations for Breast Reconstruction: Impact on Quality of Life and Patient Satisfaction” revealed “patients that receive silicone breast implants reported significantly higher satisfaction with the results of reconstruction than those who had received saline implants.”

cohesive silicone gel implants

In 2012, two years after the study mentioned above, teardrop-shaped cohesive silicone gel breast implants became available in the United States. These implants, which have been available in Europe for many years, are filled with a form-stable cohesive silicone. If you were to cut the implant in half, the interior gel would resemble the texture of the inside of a gummy bear. The silicone doesn’t move and won’t spill out. Hence its nickname “gummy bear” implants. With a thicker composition, these implants tend to ripple less than any of the other options. They also have a textured coating, which gives the implant a suedelike feel and helps prevent capsular contracture and implant rotation. Implant rotation can happen with round implants but most women don’t even know it has occurred because it doesn’t change the look of the breast. However, when a shaped implant rotates, it can make the breast look asymmetrical. The only fix for this is corrective surgery. So, while there are many benefits to cohesive gel implants, there are still things to keep in mind when or if you choose them.

safety concerns

There are many women who fear getting silicone breast implants. It is a fair concern. Any time you put something foreign into your body, your body can react to it. In the 1990s, many women believed their implants were causing a host of medical issues including rheumatoid arthritis, lupus, and cancer. Because of this, the FDA imposed a ban on all silicone implants until investigations could determine—one way or another—the status of their safety. In 2006, after fourteen years, the FDA lifted the ban, stating that the evidence did not link implants to subsequent health issues.

I think cancer is already a scary, emotional journey. I would caution all of you to avoid falling into the trap of letting rumor and innuendo affect your medical decisions. This goes for anything soapbox preachers will throw at you: from telling you to use all organic skin care products to what reconstruction option to choose. My advice: Quiet the background noise and focus on the facts. If you are concerned about the safety of implants, then you should read the literature, look at the FDA’s findings, and discuss it with your doctors. This way, you will make an informed choice and will prevent any fear and paranoia from creeping into your thoughts later on.

I will end this discussion by sharing that my silicone implants did more than make me look and feel “normal” again. They restored my ability to feel sexy and be comfortable while intimate with my partner. Trust me when I say this isn’t a given after cancer—it is a gift.

post-surgery care—such a drain!

Surgical drains are the worst. Right after waking up from a mastectomy—when you feel sore, groggy, and emotionally beaten to hell—you have to contend with surgical drains that look like hand grenades attached to tubes hanging from your body. Beside the obvious gross part—the excess blood and bodily fluids dripping from your body into the tubes—the drains are cumbersome and bulky. They make it difficult to sleep, walk about, and get dressed. “Everyone hates the drains but they are important for the healing process,” says Dr. Keegan. “The scars, fortunately, are small but they can vary in how they heal.”

The drains are a necessary evil. They are attached to clear tubes that rest under your skin near the surgical site, and help flush out the excess blood and lymphatic fluids that pool near the wound. The tubes may be held in place with a suture so they don’t accidently slip out or leak. The weight from the drains is made heavier by the fluids and can tug on the skin, causing the incision site to become irritated, red, and swollen. It’s important to make sure to empty the drains on schedule and keep them clean to prevent any disruption to the healing of the surgery. Make sure to:

1 Keep the incision clean and dry. Because you won’t be able to shower or bathe while you have the drains, you can use a mixture of peroxide and water to keep the area clean. Apply with a Q-tip and gently dab away any residue. Make sure to dry the area by dabbing with a tissue to soak up any extra moisture.

2 Dressings can keep the site germ-free. While you have the drains, “There are a variety of dressings that can be applied with antibiotic ointments,” says Dr. Keegan. “There’s something called a biopatch, which has an antibiotic impregnation to help reduce the risk of infection.” Your doctor or nurses should be applying these at the hospital. Also ask for some extra ones that you can bring home.

3 Keep the drains hoisted up. From the minute I woke up, my drains were secured to my hospital gown with safety pins. Safety pins!?! When I returned home and didn’t have nurses to help me pin my drains to my clothes, I can’t tell you how many time I pricked myself. And yes, even on painkillers, it hurt like hell. I suggest you borrow or buy a surgical bra that has built-in pockets for the drains or a drainage bulb holder, which is like a holster with Velcro straps that keeps the drains securely in place. The good thing about the drainage bulb holder is that it can be positioned around the chest, waist, hips, or thigh—so it works for whatever type of surgery or reconstruction that you’ve had. For advice and tips on shopping for drain holders and surgical bras, turn to Chapter 8 (here).

4 Stay on top of your drain schedule. If you miss emptying out your drains they will get heavy and pull on your skin. If you fidget with them too much, you will cause unnecessary irritation. You should have them for two weeks tops—so be diligent with them during this time. It will soon be over.

5 Prevent scarring. Once the drains are out and the incisions have fully healed, you can start treatment to prevent scarring. The how-to is listed below.

scar-tactics

how to minimize your scars

Scars are an unavoidable result of surgery. Some of you will wear them like a badge of honor. Others will want to wipe them from view and memory. I get it. Every time I look at my scars I am reminded that I am a survivor—something I’m damn proud of (and you should be, too!). But as a young, unmarried woman, I would prefer if I didn’t have two red ropy trails running across my boobs. Hoda, who was newly divorced, felt the same way. “I remember the first time after surgery that I saw my scars,” says Hoda. “After they cleaned me up, the nurse said, ‘Just turn toward the mirror’ and I looked up and was like ‘Oh my God.’ I was horrified. I had a hip-to-hip incision and then all the stuff they did on top. Don’t get me wrong, I was grateful to be alive. But there was a part of me that thought nobody would ever see my body again.”

The early days after surgery are no joke. Your body might look like a road map and you will probably feel like you were hit by a truck. As trite as this sounds, don’t let this get you down. Recovery takes time. Scars—both emotional and physical—take time to heal. “After a while, there comes a point in your life where you accept the scars as the new normal,” says Hoda. “You accept that this is your journey and this is a part of who you are. It shapes you, but it doesn’t define you.”

For those of you who want to erase all traces of your scars from existence, there are more options than ever before. So, let’s start with the basics.

What is a scar? Whenever you get hurt, collagen—the most abundant, structural protein in the human body—springs into action to help you start healing. With deep injuries, like surgical wounds, your body produces collagen to help fill in the cut and heal the skin back together again. In some cases, when the body senses major trauma, like a surgical incision, it can overproduce collagen, causing the wound to get red and rise above the site. In other cases, the scar can become indented or weblike. There are many variables that will determine what your scars look like. This includes: how experienced your surgeon is; how your body heals; if there is any tension on the scar; if the scar gets irritated or infected; and how well you take care of your incisions during the healing process.

“A scar starts the moment of surgery, so the number one most important thing is to find a surgeon with a lot of experience,” says leading scar specialist Dr. Jill Waibel, chief of dermatology at Baptist Hospital of Miami and founder of Miami Dermatology & Laser Institute. “Then, the postoperative care starts the minute surgery is done because that first week is really critical for healing.”

In the early days, right after surgery, do exactly what your surgeon tells you. If they tell you not to exercise, not to lift heavy things, not to clean—just listen. Most damage and infections are caused when a patient pushes it and does something they shouldn’t. Ladies—take a chill pill and just relax for these two weeks. Your healing is more important than doing the dishes or getting in a light workout. If you need help around the house, recruit some friends to pitch in. The most important thing is to care for your incisions. “You don’t walk out of the OR with a bad scar,” says Dr. Waibel. “That happens later in the ball game.”

proper wound care

Below is all the info you will need to care for your incisions so you can heal beautifully.

1 Keep the incision clean: Soak a face cloth in warm soapy water, and then gently clean the area. Pat dry with a towel, then dab on a little petroleum jelly. Be careful of antibacterial topicals creams and ointments with neomycin or bacitracin as they can cause allergic reactions.

2 Keep it covered: Use breathable gauze and paper tape or large Band-Aids to protect the wound. This helps shield the incision from anything rubbing up against the sutures creating friction that results in an irritation or, worse, an infection. It also shields it from airborne impurities, dirt, and germs.

3 Hands off: As the skin heals, your wound will get itchy—don’t scratch it! Other than cleaning or applying fresh dressing, you should not touch the incision at all.

4 Be patient: Scars take time to heal. That’s just the nature of the beast. Facial skin takes a least one week to heal. The chest and torso about two to four weeks. Legs take up to six months.

Once your sutures are removed or dissolve—seven to ten days after surgery—you should begin compression using silicone sheets like ScarAway or Steri-Strips. Compression is key because of how it affects fibroblasts, the important cells that make collagen. Essentially, the pressure of the sheets or strips alerts the fibroblast to turn off, relaying the message that the skin is finished healing. This prevents the buildup of collagen that leads to red, raised scars. “The studies haven’t borne out that there’s a huge improvement, but I’ll tell you, having seen thousands and thousands of scar patients for the last fifteen years, you can really tell a difference when patients have done a good job with compression,” says Dr. Waibel. That little extra step of applying a silicone sheet for the first three months makes a huge difference in the overall visual result you will end up with. And that lasts a lifetime. By the seventh month after surgery, if your scar is looking good, then you’re probably in the clear. “It’s kind of counterintuitive because most people are like, ‘I want to heal. I want to give my body time to heal before I start wearing the sheets or lasering’—but it’s quite the opposite,” she says. “The sooner you start applying pressure, the sooner you start thinking of your scar, the better the scar will be.”

types of scars

Here is a quick breakdown on the most common types of post-surgical scars, tips for how to conceal them or get rid of them altogether:

hypertrophic

Look and feel: These scars are usually red, raised, and contained to the actual size of the wound. These are the scars you will have after a lumpectomy, mastectomy, and/or reconstruction. They tend to fade over time.

Cover it: A creamy concealer can help smooth over the bumpy texture. One with a greenish tone will help neutralize red tones.

Remove it: Depending on the scar’s thickness, you’ll need two to seven injections of a corticosteroid like Kenalog ($100 to $300 each, sometimes covered by insurance). You’ll also want to wear silicone gel sheets like ScarAway (around $20 at drugstores) that will apply light pressure to help prevent collagen from building back up. For new scars, you’ll need to wear the gel sheets for eight to twelve weeks. For old scars, you’ll need to wear them for three to six months. The scars will still be visible, but much less noticeable.

atrophic

Look and feel: These scars are recessed, like little skin-colored potholes. Think chicken pox or cystic acne. They can also be caused when a surgical scar pulls apart. “When the wound is under tension or if you’ve had an infection, that’s when a white, thin, or pulled-apart scar results,” says Dr. Waibel.

Cover it: Hiding recess scars used to be almost impossible. However, there are now skin-toned silicone putties that fill in divots and hide them beautifully. Dermaflage ($60, www.dermaflage.com) is an almost miracle worker in this regard. It comes with a primer that adheres the putty to the skin and a texture pad that helps mimic the surface of the skin. It dries in a minute and lasts up to thirty-six hours.

Remove it: Fractional ablative lasers (about $1,000 per session) help vaporize the scar tissue. Afterward, an injection of Sculptra, a polylactic acid filler (about $400), pops those divots up. While the effects of Sculptra are temporary—two years tops—it helps stimulate the growth of collagen. Generally, two to five combo treatments are needed and are not covered by insurance.

contractured

Look and feel: Any time there is a loss of skin or tension on a wound, it can result in scars that are weblike in texture and marbleized in color. These scars are often a result from burns or reconstructions when there is a loss or lack of skin at the incision site.

Cover it: Microskin is a waterproof liquid that can be customized to precisely match your skin tone. It acts as a second skin, filling in and covering the scar. It stays on skin for several days, even through sweat and showers. The starter kit ($165, www.microskincenter.com) lasts about a month depending on the size of your scar.

Remove it: If range of motion is an issue, physical therapy will help, while steroid injections ($100 to 300) and fractional ablative lasers ($250 to $1,500) help break up excessive collagen. These are often used in combination with Z-plasty, during which a Z-shaped incision at the site helps remove the scarred skin and muscle tension. (All four treatments are sometimes covered by insurance.) While these scars can be minimized, unfortunately, they rarely disappear.

keloid

Look and feel: These scars tend to be reddish or purple-ish in color. They feel ropy and grow over the wound site. They can range in size from a pimple to an orange.

Cover it: An opaque concealer specifically designed for scars contains concentrated pigments that mean you don’t have to layer on a ton of it. Choose one that matches your skin tone, then dab it on with a small synthetic concealer brush. Synthetic bristles won’t absorb the product and can get into the hard-to-reach crevices of the skin.

Remove it: Steroid injections used to be the popular treatment for keloids; however, they often cause hyperpigmentation on dark skin. “I cut off most of the scar, then use a fractional ablative laser,” says Dr. Waibel. This creates a small wound that the body then repairs like normal skin while removing overgrowth. This ten-minute procedure costs under $1,000 and is often covered by insurance.

under construction: building nipples from nothing

One of the reasons I decided to have a mastectomy was because I didn’t want one single cancer cell remaining behind. I thought it was best to wipe the slate clean—so to speak—and get rid of everything, nipples included. After my implant swap surgery, all that remained were what I call “Barbie Boobs”—nipless mounds that look like those on the iconic blond doll.

There’s really nothing weirder than a pair of breasts with no nipples. I know, because I lived without them for five months. While I was in treatment, one of my dearest friends, Carly, got engaged and asked me to be a bridesmaid. Right after my reconstruction, our group of eight bridesmaids flew to Austin, Texas, for Carly’s bachelorette weekend. The day we arrived, we didn’t waste any time—we pulled on our bathing suits and headed straight to the rooftop pool party. We weren’t the only ones with that brilliant idea—all thirteen bachelor and bachelorette groups staying at the W Hotel were up there. While we lounged around, an assortment of single men kept checking out my boobs and offering to buy me drinks. I just kept thinking, “If they only knew I had no nipples!” Of course, I accepted the free drinks! I figured I might as well enjoy the upside of having a mastectomy: Boys liked my boobs and were willing to buy me booze. Silver linings!

Traveling with a group of girls inevitably puts you in close proximity that can lead to awkward moments. This is especially true when you are losing your hair and have no nipples. One day, the group of us went shopping and ended up huddled into one of those open-area fitting rooms. The salesperson interpreted my hesitation of taking off a top as me having literal trouble taking off the top, and without asking, came over and lifted it over my head. Until that moment, most of the women hadn’t seen my Barbie Boobs. Some didn’t even know the extent of my illness. But the second that top was off—all eyes were on my nipless chest. I acted fast—yelling—“Holy shit! My nipple just fell under the couch!” Carly, always quick on her feet, quickly yelled back while pointing under the couch, “It’s under there, it’s under there!” Nobody knew what to think or do. In shock and disbelief, each girl bent down and looked. This made Carly and me crack up until we were crying from laughter. From that moment on, whenever there was a potentially awkward situation, Carly and I would yell, “Oh my God, your nipple fell under the table!” It made some hard moments nothing short of hilarious. It became a running joke until I got nipples tattooed on.

The point being—having no nipples, which will be the case for some of you, is, to put it mildly, an incredibly surreal experience. When I would catch a glimpse of myself in the mirror and see the scarred mounds on my chest, it would leave me feeling completely unfeminine and detached from my body. By the time many of us get to the end of reconstruction, we are completely zapped, emotionally and physically. For this reason, I understand why many women opt to forgo nipple reconstruction. It’s one more surgery, plus tattoos, that can extend this already lengthy journey another six months. What you choose to do is up to you. Personally, I am a big advocate for finishing all the phases of reconstruction. Not only do they complete the look of the breasts, but once they are done you can close the door on this difficult chapter in your life.

So let’s chat about nipple reconstruction and nipple tattoos.

nipple reconstruction

This is surgery done to create or mimic the projection of a natural breast. It is conducted three or four months after the implant phase of reconstruction has had time to heal. It is an outpatient surgery done under twilight aesthetic. Working on the chest, where the nipple would be, the surgeon makes a few incisions creating a loose flap of skin from the scar. The sides of the flap are then folded together to create a mound that is then stitched in place. There are a number of different types of nipple flaps including the Alamo, star flap, skate flap, and the C-V flap—just to name a few. Each surgeon has a preference of the flap they prefer—but each generates similar results. Since reconstructed nipples lose up to 50 percent of the projection they had right after surgery, some surgeons will fill the core of the nipple to prevent it from flattening out over time. Typically, this is done with either a dermal matrix filler, like AlloDerm, or fat or scar tissues harvested from the patient’s body.

After the reconstruction is complete, your doctor will place a nipple shield—a protective covering shaped like a pointed hat and brim—filled with antibacterial ointment over the site. The shield should be left on for three days—during which you cannot get it wet. I wanted to make sure my nipples didn’t flatten out so I kept mine covered for over a week. When you remove the shield, your nipple(s) will be swollen and puffy. As the swelling subsides, roughly about two weeks, the nipple will shrink back down to an average size.

Over time, nipples can flatten out entirely. A small shot of injectable filler like Restylane will provide instant projection. I highly recommended if you are going to get fillers to help your headlights that you go to your plastic surgeon, or a plastic surgeon who specializes in reconstruction, to do the injection. The last thing you need to deal with is a punctured implant. Personally, I like having projection. I think it gives reconstructed breasts a realness that can’t be achieved with tattoos alone. It provides one more detail that helps restore the look and feel of being “normal” again.

nipple tattoos

These are done on breast cancer patients who were not candidates for, or who have opted against, having a nipple-sparing mastectomy. The tattoos are typically done three to five months after the nipple reconstruction has healed. Traditionally, nipple tattoos have been performed by a patient’s plastic surgeon, or someone on his staff. Today, as surgical techniques advance and aesthetic results get better, more and more patients are expecting the same level of quality and realism in every area and phase of their reconstruction. This especially applies to the nipple tattoos—which can make or break the look of a reconstruction.

I was no stranger to tattoo parlors, having gotten inked my first year in college. As I got older, the ink began to fade and spread. It looked really tacky. Rather than have it covered with another design, I opted have to have it lasered off. It was a small black tattoo, so I figured it would come off quickly. Wrong. What I learned, the hard way, is tattoo removal is a lengthy, painful, expensive process. My little tat took eight appointments and cost me more than $3,000. It also removed the natural pigment of my skin, leaving behind a white halo, outlining where the tattoo had been.

That little lesson ended up serving me well. When it was time for the final phase of my reconstruction—the nipple tattoos—I approached it like I was writing an investigative news story. I spent hours researching online and questioning some of my cancer buddies. What I saw frightened me. Most of the nipple tattoos out there were really bad. Like, really bad. The best way I can describe the tattoos I saw: pepperoni slices. They were perfectly round, overly red, and had no dimension.

Here’s the crux of the problem: Most nipple tattoos are performed by the plastic surgeon in charge of the reconstruction. In some (most) cases, the procedure isn’t even done by the doctor but by someone on his staff. With only a few hours of tattoo training, most of these professionals don’t have the skill to create a realistic nipple. They don’t know how to mix pigments to create nuanced shades. They don’t know how to draw shadows and highlights to create dimension. They can’t freehand the slightly imperfect shape of an areola. The end result is usually a passing resemblance to the real thing—a one-dimensional, reddish, pink, or brown overly perfect circle inked on the breast. It’s no wonder there are so many bad nipple tattoos out there.

Let me be clear: I have the highest regard for surgeons and their staff, but I wouldn’t go to a tattoo artist to perform a mastectomy, so why would I go to a plastic surgeon to give me a tattoo? It makes no sense. Getting the best result all comes back to finding the most skilled person trained to do the job. This is true of your surgeon, your oncologist—even down to your tattoo artist.

I decided I wouldn’t get my nipples done until I found a trained tattoo artist who could create the look I wanted. A few days later, I came across a survivor’s blog with a small post about her new 3-D nipple tattoos. If I hadn’t read the post, I would have believed her nipples were the real deal. But when I read that a tattoo artist named Vinnie Myers had inked her realistic nipples, my jaw dropped. I Googled his name and found his website. Once there, I spent hours looking through one tattoo after the next—and all of them looked totally believable. I called right then and booked an appointment at Little Vinnie’s Tattoos in Finksburg, Maryland. The earliest slot was five months away.

Vinnie Myers is a former army medic, who learned to tattoo by inking his military buddies while on duty. For years, he perfected his craft creating intricate and colorful sleeves and back pieces. Then, one fateful night at a party, he struck up a conversation with a woman who worked for a plastic surgeon. She explained that they were having a difficult time tattooing their breast cancer patients and asked if he would mind coming in to help correct some of the tattoos they had done. After a few jobs, Vinnie quickly recognized the need for trained tattoo artists to be involved in breast reconstruction. Just as quickly, word got out in the breast cancer community about the realistic tattoos he was creating. Pretty soon, women from as far away as Dubai were flying to the United States to get their “Vinnies.” His 3-D nipple tattoos have earned him the nickname, “the Michelangelo of Nipple Tattoos.”

“I get to see tattoos done by different doctors from all over the world and it never ceases to amaze me how bad most of them are,” says Vinnie. “I’ve seen tattoos that don’t match a woman’s skin tone or her existing areola, nipples that are so large and out of proportion they take up half the breast, or nipples that are positioned so far on the sides they are almost in the armpits.”

Vinnie’s work is quite the opposite. He creates symmetrical nipples in hues that match the unique coloring of each woman that stands before him. But the devil is in the details. Vinnie’s 3-D details go so far to include the Montgomery glands—the little glands that secrete oil that help with breastfeeding. “All I’m doing is creating the image of these little bumps with a highlight and a shadow,” says Vinnie. “It’s art 101—highlights and shadows give you the illusion of dimension. But it’s something that most doctors don’t know how to do.”

When I first walked into Little Vinnie’s, I had Barbie Boobs. When I left I had beautiful breasts. But the best part was that when I walked out of his tattoo parlor, I walked into the next phase of my life with some perky porn-star boobies leading the way…

how to find a nipple tattoo artist

Because I had such a difficult time trying to find someone who could create realistic nipple tattoos, I figured this must be the case for most breast cancer survivors. I decided to chronicle this last phase of my reconstruction by writing about it for the New York Times, in a piece titled “A Tattoo That Completes a New Breast.” A video, created by the New York Times’s talented video editor, Kassie Bracken, accompanied the piece. When the story was published, it went viral with more than ten million views.

To me, this signifies the overwhelming need and desire for talented tattoo artists like Vinnie Myers to be involved in reconstructions and provide this life-changing service. It is my hope that in the near future plastic surgeons will take part in this dialogue and begin working with trained tattoo artists to achieve the best reconstruction results possible. Healthcare—in any aspect—should always be about the benefit to the patient over the potential for profit.

So what should you do if you want a tattoo but can’t see Vinnie? I posed this question to the man himself and here are his tips for finding a skilled tattoo artist:

Experience matters. “It is extremely important to go to a tattoo artist who has experience working on reconstructed breasts,” says Vinnie. “Postoperative anatomy is very different than working on a normal breast. The skin is thinner, the breast tissue is gone, the pectoral muscle is stretched paper-thin, and then you have the implant. But a regular tattoo artist isn’t going to know that. If they tattoo at a normal tattoo depth, they will tattoo the muscle or puncture the implant—and that will cause damage to the reconstruction and the woman’s health. An experienced artist will be able to tell the integrity of the skin and tissue and keep you and your reconstruction safe.”

Pictures please! You’ve heard the expression, “A picture is worth a thousand words.” Well, in this case, it is worth so much more. Pictures are a direct indicator of what your tattoo will look like. “Once you find an artist that has done nipple tattoos, ask to see the photographs of the tattoos they’ve done and see what the quality of those tattoos looks like,” says Vinnie. “If you were going to have a regular tattoo done, you’d look at an artist’s portfolio before getting a tat from them. It’s the same deal. If they don’t have any pictures or the pictures don’t look good, don’t get the tattoo from them.”

Ask the important questions. “Tattoo artists aren’t known to be the friendliest people,” warns Vinnie. Conversations, especially those centered around nipples, might prove a little uncomfortable. That said, persevere. “It’s crucial to ask as many questions as possible,” he says. “Ask, ‘How many nipple tattoos have you done?’ ‘Are you familiar with tattooing over an implant?’ ‘Do you know what a TRAM flap is?’ ‘Do you know what a DIEP flap is?’” The answers to your questions will be telling in how much they know and how experienced they are.

Talk to other survivors. Pictures don’t lie but, sadly, people do. There have been cases where tattoo artists have stolen images of other artists’ work and passed it off as their own. It is important to protect yourself against such deception. Cancer patients tend to be more vulnerable, because they can allow hope to override common sense. Ask the tattoo artist if you can speak to some of his clients who have gotten nipple tattoos. If they aren’t willing to make the connection, you have to ask yourself why. Word-of-mouth recommendations will help point you in the right direction every time.

Do your research. “There are trained professionals all over that do nipple tattoos,” says Vinnie. “There is a website called the pinkink project.com with an unvetted list of tattooers. It will be your job to sort through the list and determine the quality of work each artist is doing. But at least it’s a place to start.” If you are having a hard time finding a tattoo artist online, you can also try searching the following titles: cosmetic tattoo artist, permanent makeup artists, paramedical tattoo specialists, and micropigmentation specialists. Once you find one of these professionals, make sure to look at their portfolio and speak to some of their clients. Fancy titles don’t always translate into fancy artwork.

Know the cost. Nipple tattoos range in cost depending on the professional you are getting them from. Doctors typically charge around $2,000, which is reimbursed by insurance. Some paramedical or cosmetic tattooers charge upward of $5,000, and some insurances will cover part of the cost. Tattoo artists, like Vinnie, charge around $400 to $800, with coverage varying from state to state. My insurance would not reimburse the cost, even though I got a patient advocate and tried to arbitrate. Ultimately, I ended up covering the cost out of pocket.

Be willing to wait. I hate to state the obvious, but a tattoo is permanent. Once it’s done—it’s hard to undo. This is especially true when working on compromised, delicate skin. Vinnie says, “It is better to wait two years to get the good tattoo, then to get a horrible tattoo quickly that takes two years to correct—and that ruins your reconstruction in the process.”