The XX Factor: What women really think.

Adventures in Plastic Surgery

(Disclaimer: As I explained to the judge who wanted to seat me on a med-mal jury, I am the sort of person who took one look at the plaintiff and barely managed not to yell, "You go, girl!'' Some practitioners may think they are God, but the distinction is not lost on me. I'll skip the tick-tock on how this became so clear, other than to reiterate that you should always, always—no matter how dismissive your doctor is—always biopsy a palpable lump. And if they later go to the opposite extreme and tell you you're dying? You might not be.)

My problem with the whole plastic surgery industry, in any case, is that it's focused on cosmetic enhancements to the detriment of patients in need of upgrades that are not quite so elective. I learned this a little over a year after my initial cancer diagnosis, when I again had to insist on having some new breast changes biopsied. Just before they wheeled me into surgery, my doctor half-jokingly complained to my husband that I was an awfully interactive patient: "Your wife has been reading again,'' he told him. They found only pre-cancer that time, but the safest course was still a mastectomy, and the reconstruction was going to be more complicated because I'd already had radiation. So now, I had to navigate a whole new corner of the medical world, where health concerns often seemed beside the point.

The first plastic surgeon my doctor referred me to was a highly regarded guy whose waiting room was filled with black marble and nurses who greeted me by name, in a whisper. I knew going in that he did mostly elective work, because even before my visit, I'd been sent literature describing the full array of available services. (A little eye job, perhaps, with my mastectomy?) Still, I was floored by how little he seemed to understand about my options, because implants under radiated skin are iffy. When I asked about the possibility of transplanting abdominal tissue, he said I wasn't a candidate for that procedure because I didn't have enough padding to spare. (And no, sadly, bulking up like Renee Zellweger for her role in Bridget Jones would not have worked; those fat cells are smart little buggers.) To underscore his point, he reached over and pinched my belly. "Do you want a breast that looks like this?'' Uh, not really, I said. But could what I wanted have been any more irrelevant? While mentally strangling him with the jaunty little golf tie he was wearing, I asked if he had ever operated on anyone in my situation. Surely he had, he said, but he couldn't really remember.

Next, I sought the advice of two top surgeons at a teaching hospital, who do the procedure I "wanted,''  a procedure known as the free flap. They said I could expect to lose maybe a third of my abdominal strength after they cut into my rectus muscle. "But you don't look like a rock climber to me,'' one of them added cheerfully, so I'd hardly notice. I wasn't so sure. Doesn't abdominal muscle support the back? And come in handy for exotic pursuits like hoisting groceries and children, or throwing a suitcase into the overhead bin? How about that new muscle-sparing version of the procedure I'd been reading about? Not an option, they said.

In frustration, I hauled out my well-worn copy of Dr. Susan Love's Breast Book, and found her reference to a doctor at UCLA who had done some pioneering work with the free flap. Though he had since retired, I located a young doctor who had trained with him and regularly performs a muscle-sparing version of the free flap, the deep interior epigastric perforator (DIEP) flap. And he had the answers I'd been looking for: "There's never any reason to take the abdominal muscle,'' he told me, "except to add volume to the breast.'' (How much is enough? Shouldn't that, if nothing else, be left up to us?) Finally, I asked him why the DIEP flap was not more widely available. "To be honest? Because it's hard to do and it takes all day. You could do two facelifts and be on the golf course'' in half the time, with twice the profit.

But vanity, too, can survive cancer. As I left his office after my first post-op follow-up, he dashed through the waiting room after me, and right there in front of Jesus and half of Santa Monica said he had some Botox left over at the end of the day, and would I like to try some at no extra cost? I love this guy, so not all doctors deserve the booby prize, so to speak. And you gotta, gotta, gotta love L.A.