Merry Christmas

I have thought so much about the tremendous treasure you are as a person, and as a physician. Your efforts have given me a starting over point in life that has been magical; in many ways you have authored hope. Thank you for every battle you fought to achieve all you have accomplished; many lives are different because of you.
As you embrace this holiday time with your family, know that there are those of us who count you among our greatest blessings. You will always be on the list of prayers in my life that were answered in ways beyond my greatest expectations.
Merry Christmas to you and your family,

Better than Before

There is a book written by a BRCA patient who had a PM titled “When Pretty Changes”…. We need one titled “ Better Than Before!!” ☺

A Beautiful Outcome

Dr. Kauff,

I remember that you normally don’t email, but I want to make sure you are in the loop! To remind you, we met last year and discussed my options for breast surveillance as a BRCA1 patient. I thought I would choose surveillance over a PM, at that time. I went forward with the PM with Dr. Pat Maxwell. I had a nipple sparing procedure and am in expanders. Even now, I am amazed at how good I look, and I have feeling in my breasts. I did have a very aggressive mastectomy, and the final result will be amazing.

As far as my own story, I visited many plastic surgeons, due to the risky nature of my case ( I had had prior breast surgery, with incisions around the nipples) and I was not given much hope for tissue survival which would affect the aesthetic outcome. Dr. Maxwell used many techniques to ensure an optimal mastectomy, while preserving blood flow, and the results are amazing. Alloderm is used in the 1st and 2nd stage, and the final implant will be the gummy bear 410. All of my tissue survived, and I have feeling in my breasts….and I LOVE the way I look----I could not ask for more. Having been through this, I know it is so important that women understand that they can have a PM, avoid breast cancer, and have a beautiful outcome.


Day of Surgery

When I left my house for surgery, I woke up my kids, Zach 14, and Sophie 13, and as I held them, breathing the smell of my babies, I knew I would do anything I had to do to protect them from losing their mother…. What was hard was knowing that could mean losing my sense of womanhood in the process… I had total faith in Dr. Maxwell; I truly believe I was to have this surgery…. I was a risky case…..and all of my tissue survived. Pink, healthy, tissue is what I see in the mirror…. And I was squirming the other day, 1 ½ weeks out of surgery, because the needle hurt going in to fill up the expanders!---- I have as much feeling as I did prior to surgery ☺

Reaching for More

I completely understand the challenge with oncologists regarding preventative surgery. I believe that the more we can reflect a satisfied patient base, moving on with life, the more acceptable this choice becomes. When Christina Applegate chose a bi-lateral mastectomy after early diagnosis for breast cancer, she said “ I don’t really like my breasts now, but I don’t know any woman who has had this surgery that does” I have seen quite a number of the post ops in Dr. Maxwell’s file and I can’t imagine that this statement is true…when he first opened the photos, I said “ is this the augmentation file?” we have to have the voice of women who can say “ I love my breasts now, as much as I did before”

A Soul's Evolving Lines

Dr. Maxwell,

I have been reminded of the attached throughout this period of my life, diagnosis forward….. I wrote it many years ago, and it has been true throughout my life……the last 2 verses were about watching Christ shape my soul, and I have thought of them as I have watched you shape my body; as you are doing so, my faith is also shaped and strengthened…. I have always believed that the only visual representation of God that we get to see here on earth is reflected in the eyes, and heart, of another person….I have felt his touch through your hands….. you have done that for me….thank you……

A Soul’s Evolving Lines

Storms collide within the soul,
Waters crash against the dam;
Surges of power rise in turmoil,
Challenging everything I am.

Strong foundations have been shaken,
Winds have rocked a solid core,
Fogged vision shades the distant,
Blurred boundaries of the shore.

Dim light cast by fading beacons,
No clear pathway within grasp,
Hopeful future wagered boldly,
With tokens gathered from the past.

Am I taught or taunted,
Breaking through or breaking down?
Bards will either fall or fly,
When they reach past solid ground.

Irony leads without restraint,
Its cunning wit, unsurpassed.

Life, you never let a soul get lost,
Until it’s sure of where it’s at.

Watchful of your every step,
Strength bracing reigning blows,
But, I never win; you always break me,
…And, somehow, again, I grow.

These moments tinged by yesterday,
Remembered fire that burns,
Steadfast will that overcomes the pain,
Endured by those who learn.

So often now I touch my age,
Outlined scars upon soft skin,
Too old to believe I can teach the Master;
Too young to ever give in.

Seeking God for holy wisdom,
Poetic sketches at my hand,
I pray for answers; he gives questions
Only my pen can understand.
Dulled brush strokes on time’s canvas,
Where muted ancient shades remain,
Angels guard a fiery spirit,
…And keep a wild heart tame.

Master Sculptor, here, a presence,
Chiseled marks roughed out in stone,
Touches feathering hand wrought edges,
Detailing places I have grown.

I trace his face, those knowing eyes,
Speaking wounds of yesteryears,
He smoothes the cheeks of his creation,
…his scarred hands catch my doubtful tears…


What kind of outcome is acceptable?

I am a woman who was very concerned about the cosmetic outcome… I am 5’1, 105, fit, very comfortable with my body, with very high standards and I had previous aug, so I have a high expectation of outcome…that probably gives me some credibility, from a woman’s perspective, in speaking about the issue… I can tell you, as women, we tend to evaluate a woman communicating on such a sensitive topic, by our comfort with her overall physical appearance. In other words, if she looks like a woman who cares about how she looks, dressed and undressed, we are more likely to believe her when she tells us this surgery will leave us visually comfortable with the outcome. As more women consider this option prophylactically, this becomes an important issue. We need to have women we can relate to, and admire physically, tell us this is a good choice.

Referral to Dr. Maxwell


The fact that you've had prior peri-areolar incisions does not always preclude the ability to do nipple sparing mastectomy (NSM) surgery, but it can present some technical issues. One strategy might be to perform the procedure thru a separate incision under your breast or extend your prior incision laterally for access. The biggest challenge for me personally with NSM is keeping the nipple centered on the reconstructed breast mound as you can get an excellent shape with an offset nipple that detracts from the aesthetics.

AS you are from Tennessee, I would encourage you to go visit Dr. Pat Maxwell in Nashville (office: (615) 932-7700) as he is (for my money) the world authority on this. Pat frequently will perform both the mastectomy and reconstruction in prophylactic surgery such as your case. He also works a lot with Dr. Pat Whitworth , one of the countries leading breast cancer surgeons there in town. Dr. Maxwell should be able to assess what your options are for getting the best result with your prior procedures.

Dr. Rob Oliver Jr.
visit me at Plastic Surgery Specialists of Birmingham

Blogging on the web at Plastic Surgery 101

Rejected as Patient

i am very sorry to tell you that at this point, i cannot in good conscience accept you as a patient.....i think that somehow through all of this, you have lost the first and most important concept that you are at high risk for developing a life threatening disease and so the first and i think only important issue is that you have all the breast tissue at risk for the next step o f reconstruction, nothing is guaranteed...your e-mails to my plastic surgeon seem to be most concerned about visual physical outcome....i know that we are actually quite excellent with our reconstructive results but if feel comfortable with a non university based team on your side, then please continue your future care with been very nice to meet you and see you....i think you will do well with another group and i do wish you well....

it is reasonable but i feel at this point it outweighs the true goal and mission i have for my patients.....cosmetic outcome is important but never guaranteed....our issue here is to cure you to the utmost possibility for you never having to face breast cancer.....discussing pictures and other such expectations takes away from our mission at cornell.........i am so sorry that we are not in a position to help you in your goals, but i know you have communicated with others and i sense that they may be better able to help you...

dr. s.

In Search of a Common Goal

One thing that was said that confused me was that this is not a subjective exercise, that the amount taken out is weighed and the same volume replaced….what I am looking for is the artistic component that will take whatever my situation is and adjust the strategy to give me back a beautiful breast…. Whatever volume or shape of implant that means…. That is what I am trying to find in all this…..a common goal with a strategy to reach it….

Surgeon's Limitations

Hello Tamarin

I am starting to become a bit concerned that your expectations of the outcome are a bit unrealistic. At baseline we are dealing with a mastectomy deformity, and for that reason the results of this procedure are not predictable like they are with cosmetic surgery. While it is our lofty goal to have the breasts look better, this may be the case in someone who has never had cosmetic surgery in order to make the breasts nearly perfect. I want you to be very clear and comfortable with the fact that the breasts will likely not look better. If I can get them to look close to what they look like now, I will be overjoyed. I am dealing with a significant challenge to your blood supply and im still at the level of worrying that the nipple and skin flaps will not necrose, while you are focusing on sub centimeter differences between nipple height.

I am very concerned also in the attempt to extrapolate from other patients post-operative photos what you will look like post-operatively. Truly it is a futile endeavor, unrealistic and uninformative. Each mastectomy defect is different, and this is sometimes true on either side of the same person. The one photo i sent you was to exemplify the shape of the implants, not to suggest that you will have a similar outcome to that patient.

On a final note, one of the most difficult challenges is to minimize tension on the mastectomy flap to improve blood supply. To this end, we are limited in how much we can upsize the implants at the time of the mastectomy, and I doubt we will be able to make the implants tight in the pocket.

I encourage you to really think these issues through prior to your surgery. I will be happy to continue the discussion with you on Monday.

Dr. T