Wednesday, September 26, 2012

The Pee Indicator

What hurts the most is having to go pee.  That first night after surgery, the reason I think I felt like I was dealing with constant pregnancy contractions is because I had to pee so badly...and I couldn't.  The weight just pushed on my new injury and it hurt so badly to try to pee that I couldn't physically do it.

Now, it doesn't hurt that much, but it still hurts the most at this point.  I think when I no longer feel the pain of peeing that I will be pretty much recovered.

Today I had quite a scare.  For the most part I could tell my healing was coming along because my insides didn't hurt quite as much though I still felt tugging.  A real indicator was that I didn't have much blood...but today there was a lot!  A lot!  So, I called the doctor's office in a panic.  The nurse asked if I've been lifting and doing much house work.  She pinned me right away. 

Ever since our sweet baby boy has been home, I've been lifting him a bit (not a lot)...getting him out of his crib, carrying him to the deck, to the fridge for milk...  And I've been loading the dishwasher, bathing the kids, picking up constantly, folding laundry, sweeping and cleaning counters and appliances.  It seems that I've been doing less of that than normal so I sort of thought I was taking it easy?  But maybe the housework and the baby have pushed it too far.  My insides hurt a lot more today too. 

It's so crazy because I feel okay enough to do these things.  I feel like I have energy in the morning, but by afternoon I am tired.  It's only since Friday (3 to 4 days) that James has been home and I've gotten myself in a pickle. 

We were all so excited when Baby Boy came back home after a week and it's so hard to see him leave again, but I think I'm going to have to ask my in-laws to take him.  It's the only way I can really rest.  Maybe one more week away and then have him home to sleep and for his morning nap and find someone each day to take him.  I hate this part.  I and We already miss him.  We'll see if I can do it.  I worry about him when he's not with me.

But I worry about myself if I don't take it easy... the reason I'm doing this is to be around for my get better, do it right, do it faster by taking care of myself.

Saturday, September 22, 2012

Expanders vs One Step with Alloderm

Another question:  Would I be a good candidate for the direct to implant procedure?

Is it true that you are a one step candidate only if you want to go about the same size, slightly larger or smaller?

Is it true that you have to get expanders if you have "thin skin"?

Here is good insight from the FORCE message boards:

"Direct to implant vs expander question":

-just wondering if the information told to me by a PS was infact correct or not..... she said you cant do direct to implant (w/out expanders) unless you are going SMALLER than you already are. That direct to implant would not have as favorable results and again could only be done if you are going smaller (even with the use of alloderm) . To stay the same size or go larger you need to get expanders. All these options are WITHOUT nipple sparing. I had thought I heard of ppl staying the same size or even going larger and not doing expanders. Has anyone done this (and what did you think of the results?)
Thank you for the info!

-Originally I was going to do immediate implants but once it was determined that they were unable to spare the nipple in the cancerous side, they needed to do expanders. There just is not enough tissue there to put an implant in, particularly if you want to go larger. The skin needs to be stretched in order for the implant to fit. Hope that helps. If you were doing nipple sparing then I believe you can go somewhat larger. That is what my PS told me.

-I used the ny doctors for my one step (nipple sparing) and was able to go up about 1/cup size. I think ps who are not comfortable with the direct to implant procedure often say what your ps told you. I am 4 months out and my results are awesome.

-I did one-step, did not do NS. What they do during surgery is once the breast tissue is taken out they weight it and that gives them a place to start with implants. I know that my last appointment with the PS prior to surgery they try to measure your breasts to at least get a good idea of what size implants they need, but they do bring in more than one set to surgery. I was a C and had no desire to be any bigger after surgery and I would say I am still a C, although I don't wear a bra so not exactly sure. I have 450cc Mentor high profile implants. Don't forget there is always that chance that they might have to do expanders if your skin is too thin--I was warned about that, but the PS also knew that implants were my first choice and expanders a huge distant 2nd choice.

TOPIC "Do you like your implants?"

-I had expanders and now have had my implants for almost 3 months. Most of the time, I do LOVE them. There's a small, mostly unnoticeable divot at the top of the left one that I might do fat grafting for - but all my friends and my husband tell me they don't even see it. I think it's just my overanalyzing them. They are definitely an upgrade for me! I went from an A (after nursing 3 kids) to a C. I don't have to wear a bra EVER and they look great, young, perky, natural. And they feel great! I don't even notice them most of the time. I do feel a different sensation when I do push ups or certain machines at the gym, but it's not painful at all - just odd. I also wanted to do one step, but my surgeon said my skin was too thin, or something like that. the expanders were not bad, and the exchange surgery was a breeze. The time before the surgery was definitely awful - I spent all my time browsing the internet looking at pictures of reconstruction and boobs - I can tell you that the other side is SOOOOO much better. You'll get there!!!

Nipples or No Nipples?

I am wondering I keep my nipples? I know it's BREAST TISSUE. Some physicians recommend that the risk is minimal in keeping the nipple since you are drastically reducing your risk with the double mastectomy. I know I would feel that I did everything I could do if I removed everything I could.  I know that keeping my nipples would be due to vanity...but...

Here is some insight:


-there is a 5-10% chance either way. there have been 2 recent studies, one from sloan kettering and one from georgetown, both of which found that NS did not increase chances of cancer. one or both were retrospective. i remember in one study, only one person had a recurrence, and her surgery had been for DCIS, not prophylactic. there should be citations for these studies on the boards somewhere.

-I'm in my mid-40s, BRCA2, and I had breast cancer. My bilateral mastectomy was performed one year ago, with my breast surgeon - chief surgeon at a major cancer/academic medical center -- recommending that I keep my nipples (even the one on the cancer side). I did so, and I'm so thankful for his recommendation on a daily basis! NSM is harder for surgeons to perform, so please make sure you ask how many of these he/she has done. According to one study, "NSM has been considered safe in women with small, peripherally located tumors, without multicentricity, or for prophylactic mastectomy." ... 921821.pdf. Good luck with your decision.


-Here is another supportive ten year study released recently by MSKCC!!!

Nipple-sparing mastectomy for breast cancer and risk-reducing surgery: the Memorial Sloan-Kettering Cancer Center experience.

Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.

BACKGROUND: Nipple-sparing mastectomy (NSM) has been gathering increased recognition as an alternative to more traditional mastectomy approaches. Initially, questions concerning its oncologic safety limited the use of NSM. Nevertheless, mounting evidence supporting the practice of NSM for both prophylactic and oncologic purposes is leading to its more widespread use and broadened indications.

METHODS: Using a prospectively maintained database, we reviewed our experience of 353 NSM procedures performed in 200 patients over the past 10 years.

RESULTS: The indications for surgery were: 196 prophylactic risk-reduction (55.5%), 74 ductal carcinoma in situ (DCIS) (20.8%), 82 invasive cancer (23.2%), and 1 phyllodes tumor (0.5%). The nipple areolar complex (NAC) was entirely preserved in 341 mastectomies (96.7%). There were 11 patients (3.1%) who were found to have cancer at the nipple margin, warranting further excision. A total of 69 breasts (19.5%) had some degree of skin desquamation or necrosis, but only 12 (3.3%) required operative debridement, of which 3 breasts (1%) necessitated removal of a breast implant. Also, 6 patients (2%) were treated for infection. Of the 196 prophylactic NSMs, 11 specimens (5.6%) were found to harbor occult cancer (8 DCIS and 3 invasive cancers). One patient who underwent NSM for invasive ductal carcinoma in 2006 developed metastatic disease to her brain. No other recurrences are attributable to the 353 NSMs.

CONCLUSIONS: The trends demonstrate the increasing acceptance of NSM as a prophylactic procedure as well as for therapeutic purposes. Although NSM is not standard, our experience supports the selective use of NSM in both prophylactic and malignant settings.

- ... lateID=295
Georgetown University Medical Center


CONTACT: Karen Mallet
(media only)
Georgetown Researchers Examine 21-Year Series of Nipple Sparing Mastectomy Cases and Find No Cancers

WASHINGTON, D.C. -- A new study suggests some women needing a lumpectomy or mastectomy to treat their breast cancer have another potential option that is safe and effective, say researchers at Georgetown. They say the procedure known as a nipple sparing mastectomy is also a viable surgical option for women who choose to have their breasts removed because of their increased risk of developing the disease. For both groups of women, the surgery offers a chance for a more natural looking and normal feeling reconstructed breast as compared to other forms of mastectomy.

Nipple sparing mastectomy (NSM) involves the removal of the breast tissue while keeping intact the breast skin and nipple areola complex, which includes the nipple and darker pigmented circle of skin that surrounds it. The breast is usually reconstructed immediately.

A long standing concern with this type of surgery is that cancer cells might be left under the nipple, posing a threat over time. To examine the effectiveness of NSM, surgeons conducted a review of patient records for all women receiving the surgery at Georgetown University Hospital (GUH) between 1989 and 2010 including surgeries to either prevent or treat breast cancer. The results are published in the November issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons.

“Our findings were reassuring. Of the 162 surgeries performed, we found no cancer recurrences and no new cancers in those receiving NSM,” says Scott Spear, M.D., professor of plastic surgery at Georgetown University Medical Center and chairman of the department of plastic surgery at GUH. “The nipple-sparing technique is not appropriate for every patient depending upon their anatomy and type of breast pathology. Careful selection of the right patient for NSM is an important element of success.”

Some patients who received NSM at Georgetown had early-stage cancer or DCIS, which can become an invasive cancer if not treated properly. In fact, while the majority of women with early cancers typically have a lumpectomy, many women choose to have a mastectomy.

Georgetown breast cancer surgeon Shawna C. Willey, M.D., says the first priority always is to treat or prevent the cancer. “We need to be able to offer women options that they know will successfully treat or prevent their cancer while at the same time, preserve their quality of life whether it be in their appearance or psychologically. Nipple sparing mastectomy goes a long way toward reaching that goal.” Willey is chief of breast cancer surgery at GUH, and she and Spear are members of the Georgetown Lombardi Comprehensive Cancer Center.

One step credited for why cancers didn’t develop later is that biopsies were done on the tissue that remained under the nipple area after the NSM. If abnormal cells in this tissue were identified, as it was in four cases reviewed, either the nipple or entire nipple areola complex later were removed.

A second concern for this kind of surgery is that the nipple areola complex (NAC) might not receive enough blood after the tissue and blood vessels below it are removed causing necrosis or tissue death. Researchers say the records showed three NACs became necrotic and required removal. Four other NACs had partial necrosis requiring surgery though the nipple and majority of the areola was spared.

“What we’ve learned from this review is that our established procedures and patient-selection protocol lead to favorable results,” confirms Spear. “As more data become available, I think we’ll see nipple sparing mastectomy play a larger role, particularly in the prevention setting.”

This work was not supported by any external funding. In addition to Spear and Willey, authors include Elizabeth D. Feldman, M.D., Costanza Cocilovo, M.D., Mary Sidawy, M.D., Ali Al-Attar, M.D., Ph.D., Catherine Hannan, M.D., Laura Seiboth, M.D., and Maurice Y. Nahabedian, M.D. Spear and Nahabedian are paid consultants to Lifecell and Allergan Corporations. None of the remaining authors report having personal financial interests related to the study.

About Georgetown Lombardi Comprehensive Cancer Center Georgetown Lombardi Comprehensive Cancer Center, part of Georgetown University Medical Center and Georgetown University Hospital, seeks to improve the diagnosis, treatment, and prevention of cancer through innovative basic and clinical research, patient care, community education and outreach, and the training of cancer specialists of the future. Georgetown Lombardi is one of only 40 comprehensive cancer centers in the nation, as designated by the National Cancer Institute, and the only one in the Washington, DC, area. For more information, go to

About Georgetown University Medical Center Georgetown University Medical Center is an internationally recognized academic medical center with a three-part mission of research, teaching and patient care (through MedStar Health). GUMC’s mission is carried out with a strong emphasis on public service and a dedication to the Catholic, Jesuit principle of cura personalis -- or "care of the whole person." The Medical Center includes the School of Medicine and the School of Nursing & Health Studies, both nationally ranked; Georgetown Lombardi Comprehensive Cancer Center, designated as a comprehensive cancer center by the National Cancer Institute; and the Biomedical Graduate Research Organization (BGRO), which accounts for the majority of externally funded research at GUMC including a Clinical Translation and Science Award from the National Institutes of Health. In fiscal year 2010-11, GUMC accounted for 85 percent of the university’s sponsored research funding.

If I get my nipples removed and have nipple is some good insight:

 -My plastic surgeon has also advised me to wait 3 months or more after the swap for the nipple reconstruction. He thinks I will be happier with that timing because the implants will have a chance to settle in and the nipple will look more natural. He stressed he will reconstruct nipples when he swaps if I am feeling in need of them then, but he advises waiting. I am choosing to wait because I have already invested so much time and effort in the process that I figure what's a few more months to be happier with the end result.

Incidence of Breast Cancer after a double Mastectomy

I thought I'd look to see if there are studies showing the recurrance rate of cancer after a mastectomy.  This is after someone has already had cancer.  I wonder if my chance of getting it is even lower than that... Here are some insights I found around the web.

Susan G Komen for the cure site:

Mastectomy and local recurrence

With mastectomy, the best predictor of local recurrence is how far the cancer has spread in the lymph nodes. The chance of local recurrence in five years is about six percent for women with negative lymph nodes (do not contain cancer) [89].
For those who have cancer in one to three nodes, the chance of local recurrence in five years is about 16 percent. Radiation therapy can reduce this risk to about two percent [89].
The chance of local recurrence increases to about 26 percent when cancer is in four or more lymph nodes [89]. Radiation therapy to the chest wall after mastectomy is given routinely when there are four or more positive nodes. This reduces the risk of local recurrence in five years to about six percent for those with positive lymph nodes [89].

Dr. SUsan Love Research Foundation:

Local Recurrence After Mastectomy Approximately 20–30 percent of women with local recurrences after mastectomy have already been diagnosed with metastatic disease and another 20–30 percent will develop it within a few months of diagnosis. Therefore, just as with local recurrences after breast conservation, tests should be done to look for distant disease. These tests may include a bone scan, chest X-ray, CT scan, MRI, or PET scan. They may also incorporate some blood tests, among which are tests for tumor markers. Local recurrence after mastectomy usually shows up as one or more nodules on or under the skin in or near the scar. With implants, the recurrences are in front of the implant. With a flap, the recurrences are not in the flap itself (tissue from the abdomen) but along the edge of the old breast skin.

Most commonly the lesion will be removed surgically and followed by radiation to the chest wall if the woman has not previously had radiation. Occasionally, even larger lesions will be surgically removed, including sections of rib and breastbone. Although this approach has not been shown to increase survival, it can improve the quality of life by preventing further local spread, which can be difficult to manage.

Despite aggressive local treatment, up to 80–85 percent of women with an isolated local recurrence following mastectomy will eventually develop distant metastases. For this reason, systemic therapy is sometimes used in this group as well. There are, however, no randomized controlled studies showing an advantage to restarting systemic therapy at this time rather than waiting and using it if and when metastatic disease appears. The biggest predictor of overall survival is the length of time between the original therapy and the recurrence or the length of the disease-free interval. The later the recurrence, the better

Wednesday, September 19, 2012


I want to remember and so I journal...

Days before the surgery, Aunt Theresa was on my mind.  Weeks earlier, she had passed after a 4 year battle with ovarian cancer.  What cancer took from our family is still so vivid as I think about all of my mother's family gathering to be together at Aunt Theresa's funeral.

Theresa is the definition of "hard-worker" and "service".  She was always the first one up to clean the table and help with dishes when they came to visit...even when she was in the middle of chemo treatments.  She worked honestly at her humble employment.  She saved her money and on her modest income, was able to pay off a lovely home and take care of her disabled husband.  She had such a soft heart and was the first to tears when it was time to say goodbye.  Theresa is an amazing lady!  We miss her.

As I sat outside of the surgery OR room in my little bed with my blue cap on, I talked to Theresa...asking for her strength and support.  I know she was right in there beside me making sure everything was running smoothly.

That first very rough night, I prayed to my Heavenly Father for comfort.   I also took comfort from Theresa again.  I needed to feel her support and her immense strength.  A very strong woman... I felt her comfort and love that night.

I know that Theresa's experience helped me to make this very difficult decision.  I am grateful for her life and example.  We love you Theresa!

Monday, September 17, 2012

Every Day is Better...

We are being showered with love...meals, flowers, goodies, babysitting...  Wow!  We love our friends and family!  It's hard to take so much love and feel "deserving", but we are grateful for the help and love!

Last night I wasn't sure if I was feeling hot flashes, or I was just getting a bit hot.  It will be interesting to see how things go as far as side effects these upcoming weeks.
I'm not showing this picture because it's pretty.... just want to document what the after surgery looked like.  I had orange-scrub-antisceptic stuff on my tummy and it scrubbed off my tummy hairs and left razor rash (doesn't hurt).  So, I think they made these three holes and then put tunnel ports in each of them.  Through the middle tunnel, I believe they pushed a scope and the hose of CO2 gas (you can see my tummy is still bloated in this photo.  I actually woke up with swollen eyes from the air and red sprinkles around my eyes where blood vessles burst and a nice red spot on the bottom of my eye...I'm guessing all from the CO2 gas being shoved into my body...just cosmetic, doesn't hurt and the swelling in my face has gone down after 3 days).  Then in the other tunnel ports, I believe they used the tools to perform the surgery.

Every day is getting easier.  Sleep is still difficult, but better.  I was on Toredol in the hospital (drip), but since I've been home, I've been on 600mg Ibuprofen, 2 Tylenol (1000mg), and a Gas X every 6 hours.  I've also been sipping a glass of Miralax water each day.  I'd say that definitely has all been helping.  They sent me home with a purcocet script, but I am weary to take it since I am caring for the girls a bit and want to be "present".  I feel a little pain, but am pretty well controlled.

Dan has been sick too, poor boy, and been sleeping and feeling out of it, but I think he's feeling better today.  Last night in bed, he asked, "Are you glad you did it?"  After an affirmative, he said "Me too".  Despite the difficult choice to stop having children, we are both so grateful that I was cancer free and we can enjoy our lovely life together with our wonderful children.  So grateful.

Saturday, September 15, 2012

Game Day

Keep in mind this post is just after surgery and on my phone keyboard:

Mom and dad came over early Thursday morning to help get the girls off to school.  Thank goodness!  We needed the extra time to get ready and leave for the hopital. We were to check in at nine but we ended up waiting an hour and a half after the 10:25 projected surgery start time since Dr. Soisson was finishing up at another hospital.  A young man wheeled my bed down the hall with Dan walking beside me. Then dan kissed me goodbye and I was parked outside the OR room. The nurse, anesthesiologisy doc and physician resident spoke with me while we waited for Soisson. I was attired in long compression hose, socks, net panties and the gown....and a blue cap to keep in my hair.  When Dr soisson arrived, he was full of energy and asked again to make sure I was ready...I thought back to the check in stage where I had to sign a consent to sterilization form, so stark and cold and set me on the edge of tears. even as I write this post from my phone keypad in my hospital bed, I feel a peace from having this procedure behind me. Before surgery the resident reminded me that I am still at risk for cancers in the peritoneal cavity but I am greatly reducing my risk of other cancers.  So the anesthesiologist dripped some loopy meds into my iv and i remember saying "I thank you in advance and you look great in green"...okay...

I remember waking up groggy in recovery and slipping back into slep often. Then I rememeber being in my room with Dan at my bedside while I am trying to answer the nurse's questions and Dan was answering for me. I remember talking to Dan for a sec and then sleeping and waking up to tell Dan to go on ahead home since i couldn't stay awake anyway.
Last night was the worst night of sleep of my life.  I felt the gas pain in my ribs and shoulders from the nonflammable CO2 they pumped in me to be able to see during the procedure.  I had urine sitting sooo heavily on my bladder and I tried several times to get up and go without succcess. Each time I got up it was easier, but still so difficult and I felt dizzy and nausiated.  They thought they were going to have to put in a catheter. Finally after a bag of fluids and the third attempt I was able to urinate and it made a huge difference in my pain level in my tummy  .  I went potty about two hours later again and it helped relieve the tummy pain. All night it seemed like I was trying to sleep while being on the verge of transition labor contractions, plus the gas pain in my ribs and shoulders and the back pain from lying uncomfortably. After the second potty trip and some meds i was able to rest better around 2 am I guess.

Interestingly a girl from labs came to draw blood at 3 am. She also has the BRCA2 and last year she was tested for the gene and had a hyst ooph. Her cousin had just died at age thirty two of ovarian cancer so that's why she was tested.  When they opened her up, they found ovarian cancer in its early stages. She has been doing chemo this past year.  I am so blessed that they said I looked clean.  The lab tech told me about a support site called so I'll go check it out.  She said they share about the side effects and treatments they are undergoing.  This morning another lab tech came in and she was from the Czech Republic so we had a nice visit and chat in Czech.  She escaped communist Czech in the early eighties while on vacation to Yugoslavia.  She is from Olomouc, a city where I served. It was fun to speak with her. Heavenly Father sent me some lovely people to encourage and lift me.

Every hour I am supposed to take ten breathes into a breathing tube to prevent pneumonia. My calvees have been constantly hooked up to leg squeezers to prevent blood clots.   I had a nice breakfast omlet, oatmeal and fruit.  I have been up walking a bit and taking it easy in bed. I am to consult with Dr. Soisson in four to six weeks and not be on any HRT or drugs for menopausal symptoms.  I'll have to see how it goes and then we'll talk hormone ish therapy.

I am in more pain than I had anticipated, but am grateful for a clean outcome.  Truly blessed.

Wednesday, September 12, 2012

Feel My Guts

I was just unloading the dishwasher and trying to "feel" my girlie parts inside of me.  Will I notice that they aren't there after Thursday?  I guess all of my other organs just fill in the empty space.  Interesting...

On Monday, I went into Salt Lake for a dental visit to fill a cavity.  I think the experience left me with a stuffy nose and sore throat and I hope that I'll be able to have the procedure on Thursday.  I called the office and they said to gargle with salt water and that if I do get a fever, then I can't have the procedure done. 

After the dentist, I was in  a dress so I could slip into the temple and share my heart with Heavenly Father.  I pulled into the empty parking lot...this could be why I haven't attended the temple on a Monday.  The temple was closed.  I pulled into a parking stall and knelt in the back of my van, resting my elbows up on the bench.  I felt like I needed to do everything that I could to make the effort to know that this was the right time to close the opportunity to have children.

This morning in the shower, I wept again...frightened, thinking about another little James that we aren't going to have.  "It's's's okay..." I tell myself outloud to comfort the hurt. 

It's such a tug-of-war with time.  Dan said that he doesn't want to be the one to influence my decision either way because the results of both decisions are so great.  Either I have the surgery now and we close the door on having more children, or we wait to do the surgery and things could be fine...or I could get cancer.  It seems like I've been so lucky so far.

My body has worked perfectly for me all through my life.  What a huge blessing.  I've been healthy and athletic, been strong with little sickness.  I've been able to bear four wonderful children.  It seems almost CRAZY that I would interrupt this great blessing of health.  Early menopause, night sweats, hot flashes, mood swings, inability to sleep at night...These are the trade offs I take for peace of mind.  Seems like a lot.  But, I am obviously trying to avoid cancer, the worse of all of these inconveniences.

I appreciate the love that my friends and family are showing in calls, running errands or taking on tasks for me, bringing meals and caring for my children.  I can't believe that I won't be able to lift James for almost 6 weeks.  This seems impossible!  It's difficult to let James live with NanaPapa for this next week.  Thank goodness they are willing; it would be impossible for me to care for him.  It seems the timing is premature with such a little one still at home, but when is the time right?  Racing the clock.  I'm so grateful for these little people.

I pray  that I'll be normal-ish and not on constant mood swings.  I want so much to enjoy the time I have with our children and with Daniel. 

I spoke with a woman on the phone while I sat in the temple parking lot.  She had so many girlie problems that after two children at age 28, she had all of her girlie parts removed.  She also talked about "what if" she were able to have more, but is so grateful for her two children.  It hurt my heart, but helped me see that I'm not the only one who grieves this loss.

She did encourage me to stay positive and remember that no matter what side effects, I'm doing this to be with my family.  I have to remember to actively CHOOSE to enjoy the time I have with my family.  I can CHOOSE to be pleasant, loving and kind at all times.  I CHOOSE to be grateful for this BRCA2 knowledge.  I CHOOSE to stay positive and get beyond the side effects and LIVE MY LIFE!  OUR LIFE!

Tuesday, September 11, 2012

Pre-Surgery Instructions

I registered with the hospital on the phone today...and was later called with pre-surgery instructions:

-They will call tomorrow with the actual time that I need to be at the hospital on Thursday
-Stop taking my fish oil
-Do not eat or drink after midnight (no gum, candy, mints, ice chips...)  I can brush my teeth in the morning, but only swish and spit
-They told me where to arrive at the hospital with my photo ID and insurance card
-I can't wear any jewler
-Wear loose clothing you can take off easily and put on when you leave to go home
-Wash the night before or that morning with an anti-bacterial soap
-only 2 adults with you and no small children