The Way I See It

When it comes to surgery for cancer, having a “positive margin” is a bad thing.  It means that when the surgeon said he “got it all,” even though he meant it with all of his heart, likely he didn’t.  For a woman undergoing a lumpectomy for breast cancer, that positive margin means a re-excision of the lumpectomy site or alternatively, a mastectomy.  For a woman who has just had a mastectomy, it means that she will likely be seeing me.

I saw a new breast cancer patient on Thursday, a very attractive woman in her early fifties.  She had undergone a mastectomy last March, and had a tissue expander placed at the time to facilitate a later reconstruction with a silicone implant.  The final pathology showed positive lymph nodes on her sentinel node biopsy, and a positive margin where the tumor was close to the chest wall.  She required chemotherapy because of her lymph node involvement, and radiation to her chest wall for the tumor cells that may have been left behind.  She finished her chemotherapy without any difficulty in June.  But instead of coming to me at that time, she elected to complete her reconstruction first.

The first time her expander was replaced with a permanent implant, in August, there were complications which resulted in a failed reconstruction. The plastic surgeon elected to take her back to surgery in November, and replace the implant, and transfer fat cells from her inner thighs to make the reconstructed breast rounder and more perfect.  When the patient saw me on Thursday, she was still not entirely happy with the result, and was looking forward to having additional fat transplanted in the upper inner quadrant.  She guided my hand to the area and said, “See?  The tissue is so THIN right there.”  I stared at her reconstruction in amazement.  It was one of the best I had ever seen.

But yes, there was a problem.  It was not a problem that she had concerned herself with.  The problem was that it was nine months after her mastectomy, and that no one had pointed out to her that a local recurrence of her breast cancer, for which she was certainly at high risk, is a harbinger of metastatic disease and death.  In other words, she had failed to grasp the fact that it was her cancer, and not her breast reconstruction, that she needed to pay attention to.  It took me the better part of an hour and a half to convince her that she should proceed with radiation BEFORE her plastic surgeon achieved the perfection that she sought, and BEFORE her cancer recurred, if it has not already.

I understand the importance of breast reconstruction, and of feeling whole, and feminine again.  But I also understand the evil nature of “the beast.”  I may be a curmudgeon, but I want my ladies to comprehend that it’s not about the boob and the plastic surgeon isn’t going to tell you that—that’s MY job.  First and foremost, pure and simple, it’s about getting rid of the cancer. That’s the only priority.  It’s just the way I see it.

My Father’s Hands

I never gave my hands much thought until a few years ago.  They were never pretty, but they were functional serviceable hands that did what they were asked—I could examine a patient, type fast and accurately enough, and everyone always told me that my handwriting was outstanding.  That has always been a point of pride for I knew that I was never going to kill a patient because a pharmacist could not read my prescription.  I sign my name with the broad sweeping rounded cursive of a 10 year old child.

Perhaps because my hands are no longer young, I realized with a start a couple of years back that they look exactly like my father’s hands.  I was not thrilled to realize this, but it certainly explained the reaction I would always get when trying on rings at a jewelry counter—the salesperson would always say, with great surprise, “Your ring size is SO SMALL!”  Why wouldn’t my ring size be small?  I am a short person—just never grew much.  What I realized was that I have broad palms, and short fingers, and the proportions are all wrong for a person with a size 5 ring finger—yes, I dare say it—because of the proportions my fingers look fat.  This was a huge disappointment to me, since I have always desired the long delicate fingers of a nail polish model.  It does not matter if your ring size is a 5, if your hands are broad and your fingers are short.  Of all the things I could inherit from my father, the green eyes were welcome; the short fingers were not.

My father is eighty seven years old.  Never a tall man, he has lost several inches in height as he has aged, and now barely reaches five feet.  He is a plastic surgeon, once world renowned for his work in maxillo-facial surgery, where surgeons must truly be artists  to repair the faces of children with hideous birth defects, and victims of terrible accidents.  Although he has been “retired” for many years, he never stopped working.  He travels the world with various charitable groups who send surgeons to the far reaches of the globe to repair birth defects and accident and burn victims, allowing them to lead the normal lives that others take for granted.  Yesterday, he returned from Zambia where Surgicorps volunteer plastic surgeons and teams of scrub nurses, anesthesiologists, physical and occupational therapists performed miracles at the Beit Cure Hospital in Lukasa for 60 children in desperate need of surgery to repair their birth defects and burn scar contractures.  This time, for the first time, he took my daughter, the 4th year medical student with him.

My daughter, like me, has chronicled her life in photographs.  This trip was no exception.  She took pictures of the parents and of the children who patiently waited for hours on the hospital lawn, just to be seen, to be evaluated, to have a chance at a better life.  Despite the cleft lips, the cleft palates, the fused fingers and toes and the burn scars, there is happiness and joy in her photographs, and there is patience and forbearance and acceptance.  One photograph, in particular struck me with a force that brought tears to my eyes.  It is a photograph of my father, seated across from a tiny girl.  In this picture, the little girl’s hand, tiny and plump, has closed its fingers around my father’s right index finger.  They are gazing into each others eyes and they are smiling.

Today, I was proud to have my father’s hands.