New beginnings at the end of the road

Recently, I was moved by the successful start of a very special persons nursing career. In the short time working with her, I hope Laken was able to learn as much from me as I did from her. I always tell students that I enjoy them shadowing me because I remember the mental conflicts I often had as a nursing student, not just in applying the psychomotor skills we learn in lab, but also in the behind the scenes practical logic that they dont teach you in a class room, learning answers to questions you never thought of, and the confidence to know the right kind of short cuts, and when you should take them. I’ve been a personal cheerleader for Laken this summer, encouraging her self esteem and confidence with the best guidance, constructive criticism and positive support I knew how to offer. Now my baby bird has passed her boards, and about to start her first job as an RN, a real nurse. And it would not be beyond reason for her to have her own reservations and anxieties, being nervous about moving into this phase of her life and career. But she knows well that, as her mentor, I will always be a source of encouragement and support in her times of doubt. I have heard myself say many times “dont be scared, you are going to be great.” Strangely, this is encouragement that I have not only been giving, but receiving more and more myself recently. As my own impending graduation date grows frightfully close, I have found my own fears and reservations becoming more apparent in my plans leading up to, and after December 15 2012. The question crosses my path far too often; “where are you going to go after you graduate?” My generic response  is “I just want to graduate.” But as we move at high speed to that sanctioned date, I’m starting to find myself feeling it becoming less of an exciting milestone, and more of a sobering obligation. In undergrad, I used to say “for high school graduation you say ‘congratulations’; For college graduations, you say ‘my condolences'”. Without a doubt college is the best 4 years of our lives, you are a college kid, not a “real grown up.” Who would want that to end? For some, we continue on to grad school, telling ourselves that we are determined and ambitious, advancing our degrees and our education to improve our careers and professional opportunities. I dont doubt that this is the primary intention for everyone that goes straight into grad school. But recently, I have noticed additional characteristics that make me feel sadness over graduating. Its not so much a fear of the unknown, about not passing my boards or not getting a job (well yes, these are some fears), but it is also a fear of losing a part of my identity. I have always been a student, and the last 6 and a half years especially, I have been consistent, eager, and hardworking towards my degrees. I have learned ways to use my brain to learn in ways I never imagined. In grad school, studying often became a hobby (as evidenced by this blog). Its not that I believe that graduating is going to stop me from learning. I learn something new everyday, through academics or otherwise. But being a student was like having a security blanket from reality. A sort of limbo excusing you from the realities of life. Getting married, having kids, settling down, finding a permanent job, etc. (not that these things are something people dont do as students). But being a student, particularly going directly into grad school gives sort of an excuse to delay some of pressures of real life. There is always a goal, an objective, a reason to wait until after graduation to think of these things. After spending so much time and effort investing in this goal, how do you proceed once you have achieved it? Sure, getting my masters is by no means the end of the road for nursing. We had a great assignment for class where we describe where we see ourselves in 1, 5, 10, 20 years; the typical pregraduation assignment. I started with typical ambitious responses, but then it started beginning alot more sobering than I anticipated. There are so many paths to choose: DNP? PhD? Practice? Research? Legislation? With so many possibles, it is overwhelming to think of starting over with a new set of lifetime goals. Until now, my immediate goals of graduating allowed me to put these ideas off while I focused on the first step. But the pressure is on. Whats next? And my answer is not just to avoid further overwhelming discussion about my future, but Im also tring to convince my self that “I just want to graduate.”

Real or fake? The boob job dilemma

Whether breast augmentation may be seen by some as tacky taboo, others may marvel at the prospect, while still others just simply enjoy all the talk about boobs. While breast augmentation is by no means unheard of, understanding breast implants in relation to breast cancer and breast feeding is not the hottest topic. Regardless, of whether you are in favor of silicone, saline, or the good old fashioned all-natural, its  likely that either you or someone you know has breast implants. Please share the info.

About Breastfeeding…

ImageAs mentioned in one of my previous posts, “Breast is Best”. The American Academy of Pediatrics recommends that babies should be exclusively breast fed for the first year of life. This is not only beneficial to the nutritional intake of the infant, but breast feeding is also exceedingly beneficial to the mother as well (see my blog post for more info: https://g8rk8.wordpress.com/2011/03/26/breastfeeding-to-keep-kosher/). A common concern among women who have, or are considering breast implants, is the ability to breastfeed. ImageThe literature is varied, however, the review by Cruz and Korchin (2010) summarizes key investigations related to breast feeding success following augmentation. While there are a multitude of potential factors that could impede breastfeeding (in both augmented and non-augmented breasts), incision site remains to be a common denominator in nearly all studies. Though the differences between the periareolar and submammary approaches were minimal, these incision sites generally had the least success with breastfeeding when compared to transaxillary approaches. This is possibly due to a couple factors. First, the tissue surrounding the underside of the nipple is composed of many glands, ducts, and nerves that are involved in lactation. Damage to any of these structures can therefore interrupt the process of milk production, leading to absent or insufficient milk supply. Additionally, the periareolar incision involves severing many superficial nerves in the nipple, and is thus most often linked to decreased nipple sensation. Nipple sensation plays a crucial role in milk production; the suckling sensation produces a reflexive stimulation of the pituitary gland, with subsequent release of prolactin, an essential hormone needed for lactation (Cruz & Korchin, 2010). While it was thought that the transaxillary approach may have better breastfeeding outcomes due to reduced manipulation of breast tissue, this approach does, however, involve extensive trauma to the nerves and lymph nodes that are essential to proper mammary gland function. Another theory that has recently been suggestion for future investigation is the association of small “hypoplastic breasts,” and inadequate milk supply (Cruz & Korchin, 2010). ImageThis theory suggests that women who have difficulty breast feeding following breast augmentation are more likely to have had small, inadequately developed breast tissue prior to augmentation (thus inciting desire for surgical enhancement). Finally, placement of the breast implant is significantly related to breastfeeding ability. Typically, the implant is placed under the muscle (submuscular) or under the glands (subglandular). When the implants are placed under the glands, there is a greater chance of complications related to pressure from the implant against the glands, more discomfort during breastfeeding, and the possibility of capsular contraction (a long term complication of implants) that could potentially interfere with the breast anatomy and function of the glands.

Breast Cancer Screening…

While breast feeding with breast implants is an important topic that is left untouched by many women’s health providers, the primary intention of this blog was to discuss and bring awareness to the myths, risks, and screening tools for breast cancer in someone with breast implants. It is no secret in the health care field that breast implants pose substantial challenges to current breast cancer screening measures such as self-breast exams, clinical breast exams, and mammography. However, the greater majority of clinical investigations exploring the incidence of breast cancer following augmentation have shown little to no difference in statistics between augmented and non-augmented breast cancer patients3. In fact, some studies actually saw better cancer prognoses for patients with implants. There are several theories that have been elicited from this conclusion. This will be addressed after a review of the obstacles (booby traps?) imposed by implants on breast cancer screening. Chiefly, reduced imaging quality of mammograms is a primary concern with breast implants. Mammography provides detection of different densities in breast tissue, identifying possible tumors, which appear as radiopaque white masses  (pardon my lack of radiology expertise from that definition). This screening technique is a widely used and recommended method for the early detection of breast masses. Unfortunately, breast implants possess similar opacity to tumor masses, and can often lead to inconclusive and inaccurate results if a significant portion of breast tissue is obscured from the image.

Therefore, the more breast tissue that can be isolated from the implant, the better the likelihood of a more accurate mammogram. As mentioned previously, submuscular placement refers to implants that are placed under the muscles of the chest wall. This allows for more breast tissue to be dispersed away from the implant, and thus less opportunity for masses to be concealed. The same concept is true for self and clinical breast exams. The submuscular implant is well separated from the glandular breast tissue, and thus provides a firm “backdrop” with which to compress the breast tissue, providing greater ability to distinguish the different textures of tissue3. It is essential, however, to have an adequate knowledge of self-exam techniques, and the ability to distinguish between normal breast tissue, implant structures, and possible pathology.

Health care provider skepticism to breast implants may be related to challenges in reliable early detection of abnormal breast masses4.  However, as mentioned, several studies have had surprising results of breast cancer detection in augmented versus non-augmented breasts. Some studies found that women with breast implants often detected masses and were diagnosed at early stages of the disease, and frequently had smaller sized tumors than women without implants4.  Theories behind this concept are as follows:

  • Increased body awareness. Women who have undergone breast augmentation generally display a greater awareness of body image, identification of changes, and comfort with self assessment and examination3.
  • Increased implementation of self breast exams through the use of massage to prevent capsular contraction4.
  • Better educated about proper assessment, screening measures, and consistent follow-up.
    • Women with breast implants tend to have increased interaction and communication with surgeons and other health care providers about expectations, recommendations, and what to look out for3.
    • Women with breast implants are more likely than women without implants to have regular mammograms3.
    • Possible anatomical advantages: enhanced local immune response and surveillance due to the presence of a foreign body; compression of surrounding breast tissue leading to conservative blood distribution and reduced blood supply to growing tumors4.

In general, most of the research has shown very little other significant differences in either rate of detection, extent of metastasis, or disease prognosis amongst women with or without breast implants3. While these theories are simply just that, they do offer a firm foundation for consideration in a risk versus benefit analysis. I hope this blog has shed some light on a very unspoken issue in women’s health, and please pass on the information. I don’t feel breast implants are in any way better or worse than not having implants, but I respect and support the choice to do so if desired. As always, please take all information in this blog with a grain of salt. This is not professional medical advice, simply a casual discussion. Do not use this info as a substitute for professional medical attention.

 

References:

1Cruz, N., & Korchin, L., (2010). Breastfeeding After Augmentation Mammaplasty with Saline Implants. Annals of Plastic Surgery, 64(5): 530-533.

2Strom, S., Balwin, B., Sigurdson, A., Schusterman, M., (1997). Cosmetic saline breast implants: A survey of satisfaction, breast-feeding experience, cancer, and health. Plastic and Reconstructive Surgery, 100(6):1553-1557

3Smalley, S., (2003). Breast implants and breast cancer screening. Journal of Midwifery & Women’s Health, 48(5): 329-337.

4Deapen, D., (2007). Breast Implants and Breast Cancer: A Review of Incidence, Detection, Mortality, and Survival. Plastic and Reconstructive Surgery, 120(7):70S-80S