Update on DIEP vs TRAM flap procedure decisions

Balentine
Balentine Member Posts: 393
edited March 2014 in Breast Cancer #1
I went to the plastic surgeon today to discuss my reconstruction options. He has done over 300 breast reconstructions and is trained also in doing the DIEP. After examining me and from his experience, he advised me my best option was something called 'muscle sparing free TRAM flap' surgery. He said it gives the best results in good blood flow to the tissue from the transplanted blood vessels that they move from the stomach area to the breast area. They do not transplant any of the abdominal muscle...only tissue and fat to create a new breast and the blood vessels of course. You get a tummy tuck and a new belly button. They open the existing mastectomy incision but the other incision will be below the new breast so it is hidden. So the only new scar will be on the abdomen right around the panty line. Recovery is 4-6 weeks, hospital stay is 3-4 days and 3 drains...2 in abdomen and one is breast. I also have 2 years to get it done. My tricare insurance covers the reconstruction for that long so I can recover from the mastectomy and chemo for awhile before I have to do the reconstruction. Anyway, you go back in later to have the other breast lifted and at that time when they do the lift, they take some tissue to make the nipple and add that to the new breast at the same time. He seemed very confident in his work and put to rest alot of my fears. Especially the fact that I have time to wait and heal and won't be rushed to get it done. He also told me not to lose any weight which was also nice...now I have a reason to be fat for another year. He said I right now have enough tummy fat to do one breast but if I lose weight, I may not have enough. I am 5'7" and 180 pounds. Let me know if anyone has had this type of reconstruction and what your experience has been like. Thanks and God Bless.
Lorrie Balentine

Comments

  • waffle8
    waffle8 Member Posts: 234
    Hey Balentine I have been
    Hey Balentine I have been wondering how you are? You were just starting your treatments when i first started reading on here and I haven't seen how you are making out..? Your picture could be a twin to my sister nlaw....Your smile is great..Sorry I do not know about your procedure but I think when you have confidence in the doctor thats half the battle..I know God will lead you to what you need.Blessings Babette
  • Balentine
    Balentine Member Posts: 393
    waffle8 said:

    Hey Balentine I have been
    Hey Balentine I have been wondering how you are? You were just starting your treatments when i first started reading on here and I haven't seen how you are making out..? Your picture could be a twin to my sister nlaw....Your smile is great..Sorry I do not know about your procedure but I think when you have confidence in the doctor thats half the battle..I know God will lead you to what you need.Blessings Babette

    Hey
    Hello Babette,
    I am doing fine. I will have my 4th and final chemo on 5/17...Yippee! The 3rd one knocked me down and I was totally fatigued and depressed for about 2 weeks but God as always has brought me through it and out of it and soon this journey will be over in just a few more weeks. How are you doing and where are you with your treatments and prognosis?
    Lorrie Balentine
  • waffle8
    waffle8 Member Posts: 234
    Balentine said:

    Hey
    Hello Babette,
    I am doing fine. I will have my 4th and final chemo on 5/17...Yippee! The 3rd one knocked me down and I was totally fatigued and depressed for about 2 weeks but God as always has brought me through it and out of it and soon this journey will be over in just a few more weeks. How are you doing and where are you with your treatments and prognosis?
    Lorrie Balentine

    Hello! Thats sounds like my
    Hello! Thats sounds like my standard answer some days.."I am doing fine".....Just did my first chemo. April 29..My lips and nose are so dry feels like a bad sunburn.. Still itching like crazy but the nausea has finally let up....But everyday is better so I am just trusting the Lord to get to the end..I have same t/c 3 more to go. Will be glad to see July 4 get here since that will be end of chemo....Thanks for letting me know...Babette
  • jk1952
    jk1952 Member Posts: 613
    Balentine said:

    Hey
    Hello Babette,
    I am doing fine. I will have my 4th and final chemo on 5/17...Yippee! The 3rd one knocked me down and I was totally fatigued and depressed for about 2 weeks but God as always has brought me through it and out of it and soon this journey will be over in just a few more weeks. How are you doing and where are you with your treatments and prognosis?
    Lorrie Balentine

    Lorrie, I just posted on

    Lorrie, I just posted on your other thread, since Carrie had listed a website that explained the many flap surgeries. I actually had one breast reconstructed using DIEP and one with the free TRAM flap. The surgeries are very much alike; it just depends on if they have to use any muscle and which blood vessels are used. Since one of my breasts had been radiated, and had some blood vessel issues, they chose the free TRAM flap in order to get the 'best' vessels, while the 'good' breast was reconstructed using the DIEP.

    I can't really tell a difference in the two breasts or the two sides of my abdomen.

    Joyce
  • Balentine
    Balentine Member Posts: 393
    jk1952 said:

    Lorrie, I just posted on

    Lorrie, I just posted on your other thread, since Carrie had listed a website that explained the many flap surgeries. I actually had one breast reconstructed using DIEP and one with the free TRAM flap. The surgeries are very much alike; it just depends on if they have to use any muscle and which blood vessels are used. Since one of my breasts had been radiated, and had some blood vessel issues, they chose the free TRAM flap in order to get the 'best' vessels, while the 'good' breast was reconstructed using the DIEP.

    I can't really tell a difference in the two breasts or the two sides of my abdomen.

    Joyce

    Hi Joyce,
    So are you happy with the results? And also how was the recovery, drains, pain, etc.?
    Lorrie
  • Balentine
    Balentine Member Posts: 393
    waffle8 said:

    Hello! Thats sounds like my
    Hello! Thats sounds like my standard answer some days.."I am doing fine".....Just did my first chemo. April 29..My lips and nose are so dry feels like a bad sunburn.. Still itching like crazy but the nausea has finally let up....But everyday is better so I am just trusting the Lord to get to the end..I have same t/c 3 more to go. Will be glad to see July 4 get here since that will be end of chemo....Thanks for letting me know...Babette

    1st chemo
    Hi Babette,
    I had the same side effects with my 1st chemo.....nose, lips, and also my vaginal and rectal are were just raw and hurt....I used vaseline on these areas and it really helped so you might want to try that. I never have had any nausea though. What is encouraging though is I only had those symptoms with my 1st chemo....did not have it with my last two chemos. The only side effect I am getting now is total fatigue on days 3 and 4 especially after chemo. Make sure you are drinking an ensure every day the week of chemo - that really helps alot. Drink lots and lots of water and try to eat well...veggies and fruit. Also make sure that when you feel tired that you rest...don't overdo things. My 3rd chemo took me a bit longer to recover...instead of feeling better within 4 days it took more like a whole week. I was just so fatigued and started getting some depression but I am feeling much better now. My last chemo will be 5/17 and I can hardly wait. Was your diagnosis IDC Stage 1? How large was your lump? Mine was 2.2cm and no nodes. Keep in touch Babette and you will get through this. Constantly stay aware of God's presence in your life...sometimes when it gets hard I imagine God just holding me and sometimes I envision riding horseback on the beach with My Lord....something I have always wanted to do but have not done....I am a horse lover. You need to find your peace and strength in God and on this network...this is a place of understaning and support like no other....like no other but our Lord and Savior. Love and hugs,
    Lorrie
  • jk1952
    jk1952 Member Posts: 613
    Balentine said:

    Hi Joyce,
    So are you happy with the results? And also how was the recovery, drains, pain, etc.?
    Lorrie

    I am very happy with the

    I am very happy with the results, and I would highly recommend it. Recovery, drains and pain are all about the same as people described for the DIEP. It's a long surgery, so it does take a while to regain strength after being under the anesthesia for so long. I was amazed by how difficult it was to walk down the street, when I first tried. But, every day I felt better and better. I was out of work for eight weeks, and if forced, I probably could have gone back sooner. I was doing a little work at home when I felt like it after a couple weeks. But, it was sitting at a computer; it wasn't being active. You do need lots of help with housework and meals. I could take care of myself, but was appreciative of help with things around the house.

    I only took the narcotics for two days after surgery and was able to control the pain with Tylenol or Motrin. The morphine caused a terrible flush, which was quite uncomfortable and I had a bad headache the day after surgery, so these bothered me more than the actual surgeries. Because I didn't continue taking the painkillers, I was able to start driving after only 2-1/2 weeks. I was told that if I could twist to see and felt that I could react if needed, I could start driving.

    I had six drains initially: two in the abdomen and two in each breast. I went home with four, one in each breast and two in my abdomen. I wore loose comfy clothes and pinned the drains to the insides of my tops or to the wasteband. When I took a shower, I pinned them to a 'lanyard' around my neck. They were a pain, but the alternatives are worse. I had no problems when they were removed: I really didn't feel it.

    Hope this helps. It is major surgery, but it was so good for my well-being to wake up with breasts. It really helped in my healing process.

    Joyce
  • Ritzy
    Ritzy Member Posts: 4,381 Member
    Balentine said:

    Hey
    Hello Babette,
    I am doing fine. I will have my 4th and final chemo on 5/17...Yippee! The 3rd one knocked me down and I was totally fatigued and depressed for about 2 weeks but God as always has brought me through it and out of it and soon this journey will be over in just a few more weeks. How are you doing and where are you with your treatments and prognosis?
    Lorrie Balentine

    Just wishing you good luck
    Just wishing you good luck Lorrie with your surgery! And, early congrats on your soon saying goodbye to chemo! Huge accomplishment!

    Sue :)
  • jphilpo
    jphilpo Member Posts: 177
    jk1952 said:

    I am very happy with the

    I am very happy with the results, and I would highly recommend it. Recovery, drains and pain are all about the same as people described for the DIEP. It's a long surgery, so it does take a while to regain strength after being under the anesthesia for so long. I was amazed by how difficult it was to walk down the street, when I first tried. But, every day I felt better and better. I was out of work for eight weeks, and if forced, I probably could have gone back sooner. I was doing a little work at home when I felt like it after a couple weeks. But, it was sitting at a computer; it wasn't being active. You do need lots of help with housework and meals. I could take care of myself, but was appreciative of help with things around the house.

    I only took the narcotics for two days after surgery and was able to control the pain with Tylenol or Motrin. The morphine caused a terrible flush, which was quite uncomfortable and I had a bad headache the day after surgery, so these bothered me more than the actual surgeries. Because I didn't continue taking the painkillers, I was able to start driving after only 2-1/2 weeks. I was told that if I could twist to see and felt that I could react if needed, I could start driving.

    I had six drains initially: two in the abdomen and two in each breast. I went home with four, one in each breast and two in my abdomen. I wore loose comfy clothes and pinned the drains to the insides of my tops or to the wasteband. When I took a shower, I pinned them to a 'lanyard' around my neck. They were a pain, but the alternatives are worse. I had no problems when they were removed: I really didn't feel it.

    Hope this helps. It is major surgery, but it was so good for my well-being to wake up with breasts. It really helped in my healing process.

    Joyce

    Joyce
    Hey Jotce,

    My surgery is coming up on June 14th & I have been so interested in your postings about your surgery. What did you wear home from the hospital? I know that probably seems silly, but I want to know EVERYTHING! I know with the drain & all, it must be hard.

    THANKS
  • jk1952
    jk1952 Member Posts: 613
    jphilpo said:

    Joyce
    Hey Jotce,

    My surgery is coming up on June 14th & I have been so interested in your postings about your surgery. What did you wear home from the hospital? I know that probably seems silly, but I want to know EVERYTHING! I know with the drain & all, it must be hard.

    THANKS

    I thought that I had just
    I thought that I had just posted a response. Fortunately, I had copied much of it from another post I had done a few months ago. Hope it helps. (The answer to your sepcific question is sweats and a loose, butoon fron top).

    As far as the hospital is concerned, I'd take a toiletries bag with toothbrush, toothpaste, deodorant, tissues, etc. They'll probably give you everything that you need, but I'd rather use my own. You will want loose fitting button or zipper front tops, and you'll have to take loose fitting PJ's or sweats, since you won't be able to wear normal pants for a while. I took a bathrobe and did use that some. I love to read, but I couldn't really concentrate well enough in the hospital, so magazines were good, as was my iPod. Although some hospitals won't allow cellphones, mine not only allows them, they encourage that you use one. It's easy to carry and you won't have to try to reach for a phone. You won't want to reach for anything for a while. I didn't need any cash, but it's probably good to have a little. For a couple days, you'll probably be very happy to be in the hospital gown, so try not to overpack, since there is limited space in the room.

    Onto recovery. With this surgery, you'll probably have six drains initially, although some may come out before you go home. Drains are a pain, but they are critical to your recovery, so don't try to rush them. While you are dressed, they'll be pinned to some of your clothing, but showering is a different story. I used a 'lanyard' around my neck when I showered, and pinned the drains to it. It didn't get wet and weighted down like washcloths or towels do. You'll have a hard time stretching and getting in and out of bed. I found a recliner to be very helpful. With time, I recovered the range of motion and could return to normal activity, without any type of physical therapy.

    Unlike the reconstruction with expanders, you won't be able to bind your breasts, because you need to keep the blood flow unconstrained. I used camis and tank tops with a loose shelf bra for eight weeks before I was allowed to wear a bra again. You'll likely have an abdominal binder for a period of time. It really does make you feel better!

    Things I would have at hand: at least four extra pillows (you'll sleep on your back and you'll want them to support your arms, legs and extra support for head), Tylenol or Advil for when you come off the painkillers, baby aspirin (my doctor wanted me to take it for a few weeks after surgery), thermometer (if you don't have one, in case you're worried that you might have an infection), antibiotic cream and bandages (they could come in handy), and a cellphone nearby. My husband did email updates to friends and relatives, so he didn't have to take as many calls, and he could let people know when I was ready for calls or company. He also ran interference with phone calls and sometimes told the person that I was resting or had crashed after doing too much (which I did often).

    Joyce
  • jphilpo
    jphilpo Member Posts: 177
    jk1952 said:

    I thought that I had just
    I thought that I had just posted a response. Fortunately, I had copied much of it from another post I had done a few months ago. Hope it helps. (The answer to your sepcific question is sweats and a loose, butoon fron top).

    As far as the hospital is concerned, I'd take a toiletries bag with toothbrush, toothpaste, deodorant, tissues, etc. They'll probably give you everything that you need, but I'd rather use my own. You will want loose fitting button or zipper front tops, and you'll have to take loose fitting PJ's or sweats, since you won't be able to wear normal pants for a while. I took a bathrobe and did use that some. I love to read, but I couldn't really concentrate well enough in the hospital, so magazines were good, as was my iPod. Although some hospitals won't allow cellphones, mine not only allows them, they encourage that you use one. It's easy to carry and you won't have to try to reach for a phone. You won't want to reach for anything for a while. I didn't need any cash, but it's probably good to have a little. For a couple days, you'll probably be very happy to be in the hospital gown, so try not to overpack, since there is limited space in the room.

    Onto recovery. With this surgery, you'll probably have six drains initially, although some may come out before you go home. Drains are a pain, but they are critical to your recovery, so don't try to rush them. While you are dressed, they'll be pinned to some of your clothing, but showering is a different story. I used a 'lanyard' around my neck when I showered, and pinned the drains to it. It didn't get wet and weighted down like washcloths or towels do. You'll have a hard time stretching and getting in and out of bed. I found a recliner to be very helpful. With time, I recovered the range of motion and could return to normal activity, without any type of physical therapy.

    Unlike the reconstruction with expanders, you won't be able to bind your breasts, because you need to keep the blood flow unconstrained. I used camis and tank tops with a loose shelf bra for eight weeks before I was allowed to wear a bra again. You'll likely have an abdominal binder for a period of time. It really does make you feel better!

    Things I would have at hand: at least four extra pillows (you'll sleep on your back and you'll want them to support your arms, legs and extra support for head), Tylenol or Advil for when you come off the painkillers, baby aspirin (my doctor wanted me to take it for a few weeks after surgery), thermometer (if you don't have one, in case you're worried that you might have an infection), antibiotic cream and bandages (they could come in handy), and a cellphone nearby. My husband did email updates to friends and relatives, so he didn't have to take as many calls, and he could let people know when I was ready for calls or company. He also ran interference with phone calls and sometimes told the person that I was resting or had crashed after doing too much (which I did often).

    Joyce

    weight
    Did you notice any weight loss after your surgery? I have gained about 12 pounds since chemo, rads,femara etc... I am hoping this could be a "perk".

    THANKS
  • jk1952
    jk1952 Member Posts: 613
    jphilpo said:

    weight
    Did you notice any weight loss after your surgery? I have gained about 12 pounds since chemo, rads,femara etc... I am hoping this could be a "perk".

    THANKS

    I lost a few pounds

    I lost a few pounds initially, but then I started retaining some fluid in my abdomen, so it was a bit hard to measure. A year later, I weigh about the same as I did before the surgery. But, I've had a really hard/busy year at work, so I haven't exercised like I should.

    Joyce
  • DebbyM
    DebbyM Member Posts: 3,289 Member
    Balentine said:

    Hi Joyce,
    So are you happy with the results? And also how was the recovery, drains, pain, etc.?
    Lorrie

    Just wishing you good luck
    Just wishing you good luck Lorrie with your surgery!


    Hugs, Debby
  • Balentine
    Balentine Member Posts: 393
    Ritzy said:

    Just wishing you good luck
    Just wishing you good luck Lorrie with your surgery! And, early congrats on your soon saying goodbye to chemo! Huge accomplishment!

    Sue :)

    Waiting til next summer to do surgery
    I have decided to wait until next summer to do the muscle sparing free tram flap since I work at an elementary school and the surgeon said I could not do it this year until August because I finish my chemo on 5/17 so I am going to wait until next summer to do it. That way I will have the summer to recooperate. I also now can put off being scared until next year. Thanks for all of the information. I did look at some before and after pictures on some sites that people told me about and the end results do look really good. I hope mine comes out that good. The surgeon has done over 300 reconstructions and seems very confident so it made me feel alot better. Thanks and God bless.
    Lorrie
  • jphilpo
    jphilpo Member Posts: 177
    Balentine said:

    Waiting til next summer to do surgery
    I have decided to wait until next summer to do the muscle sparing free tram flap since I work at an elementary school and the surgeon said I could not do it this year until August because I finish my chemo on 5/17 so I am going to wait until next summer to do it. That way I will have the summer to recooperate. I also now can put off being scared until next year. Thanks for all of the information. I did look at some before and after pictures on some sites that people told me about and the end results do look really good. I hope mine comes out that good. The surgeon has done over 300 reconstructions and seems very confident so it made me feel alot better. Thanks and God bless.
    Lorrie

    surgery
    Lorrie, I am so happy that you have made your decision. I think it's a good one. I too work at an elementary school & am having my surgery on June 14th so I can have the rest of the summer to recooperate. I finished my treatments in February of this year. Please pray for me, as I am scared too.

    Jean
  • DianeBC
    DianeBC Member Posts: 3,881 Member
    jphilpo said:

    surgery
    Lorrie, I am so happy that you have made your decision. I think it's a good one. I too work at an elementary school & am having my surgery on June 14th so I can have the rest of the summer to recooperate. I finished my treatments in February of this year. Please pray for me, as I am scared too.

    Jean

    Sending good luck and
    Sending good luck and prayers to the both of you, Jean and Lorrie that you have a successful surgery! That is great if you both have the summer off to recuperate.


    Hugs, Diane
  • jk1952
    jk1952 Member Posts: 613
    DianeBC said:

    Sending good luck and
    Sending good luck and prayers to the both of you, Jean and Lorrie that you have a successful surgery! That is great if you both have the summer off to recuperate.


    Hugs, Diane

    Hope your surgeries go well

    Hope your surgeries go well and be sure not to rush your recuperation. Do as much as you feel you want to, and then let others take care of you!

    Joyce
  • Angie2U
    Angie2U Member Posts: 2,991
    jk1952 said:

    Hope your surgeries go well

    Hope your surgeries go well and be sure not to rush your recuperation. Do as much as you feel you want to, and then let others take care of you!

    Joyce

    Good luck to you on your
    Good luck to you on your surgery's!
  • KMLNP
    KMLNP Member Posts: 5
    jk1952 said:

    I thought that I had just
    I thought that I had just posted a response. Fortunately, I had copied much of it from another post I had done a few months ago. Hope it helps. (The answer to your sepcific question is sweats and a loose, butoon fron top).

    As far as the hospital is concerned, I'd take a toiletries bag with toothbrush, toothpaste, deodorant, tissues, etc. They'll probably give you everything that you need, but I'd rather use my own. You will want loose fitting button or zipper front tops, and you'll have to take loose fitting PJ's or sweats, since you won't be able to wear normal pants for a while. I took a bathrobe and did use that some. I love to read, but I couldn't really concentrate well enough in the hospital, so magazines were good, as was my iPod. Although some hospitals won't allow cellphones, mine not only allows them, they encourage that you use one. It's easy to carry and you won't have to try to reach for a phone. You won't want to reach for anything for a while. I didn't need any cash, but it's probably good to have a little. For a couple days, you'll probably be very happy to be in the hospital gown, so try not to overpack, since there is limited space in the room.

    Onto recovery. With this surgery, you'll probably have six drains initially, although some may come out before you go home. Drains are a pain, but they are critical to your recovery, so don't try to rush them. While you are dressed, they'll be pinned to some of your clothing, but showering is a different story. I used a 'lanyard' around my neck when I showered, and pinned the drains to it. It didn't get wet and weighted down like washcloths or towels do. You'll have a hard time stretching and getting in and out of bed. I found a recliner to be very helpful. With time, I recovered the range of motion and could return to normal activity, without any type of physical therapy.

    Unlike the reconstruction with expanders, you won't be able to bind your breasts, because you need to keep the blood flow unconstrained. I used camis and tank tops with a loose shelf bra for eight weeks before I was allowed to wear a bra again. You'll likely have an abdominal binder for a period of time. It really does make you feel better!

    Things I would have at hand: at least four extra pillows (you'll sleep on your back and you'll want them to support your arms, legs and extra support for head), Tylenol or Advil for when you come off the painkillers, baby aspirin (my doctor wanted me to take it for a few weeks after surgery), thermometer (if you don't have one, in case you're worried that you might have an infection), antibiotic cream and bandages (they could come in handy), and a cellphone nearby. My husband did email updates to friends and relatives, so he didn't have to take as many calls, and he could let people know when I was ready for calls or company. He also ran interference with phone calls and sometimes told the person that I was resting or had crashed after doing too much (which I did often).

    Joyce

    This is such good
    This is such good information. I am having my surgery next week. I need a right mastectomy and the plan is for a muscle sparring flap. I just found this site today and have been reading everything I can over my lunch. It has been so helpful to hear how it has gone for many people. I am a nurse practitioner, worked as a nurse post op units for many years in my early days. I took care of a good many radical mastectomy patients so it is hard for me to get that out of my head. Such good info on what I will be able to wear post-op. I will have to do a bit of shopping for some loose fitting button tops this weekend. I kept thinking loose t-shirts but keep forgetting that my right arm might be a bit sore from the sentinel node biopsy. You talk about using a recliner. How did you sleep when you got home? I am a side sleeper, how long till I can do that again? (I'm guessing I will be so fatigued I would sleep standing up if I had to). I will be having a epidural for pain control for the first few days post-op. The doctor I have has been getting really good results with this instead of the morphine pumps. This has somewhat relieved my fear of the pain. Good to hear that you did not have alot when you got home. I hate taking meds that make me feel out of it.
    I am so glad I found this site. Thanks for all the info.

    Kathy
  • jk1952
    jk1952 Member Posts: 613
    KMLNP said:

    This is such good
    This is such good information. I am having my surgery next week. I need a right mastectomy and the plan is for a muscle sparring flap. I just found this site today and have been reading everything I can over my lunch. It has been so helpful to hear how it has gone for many people. I am a nurse practitioner, worked as a nurse post op units for many years in my early days. I took care of a good many radical mastectomy patients so it is hard for me to get that out of my head. Such good info on what I will be able to wear post-op. I will have to do a bit of shopping for some loose fitting button tops this weekend. I kept thinking loose t-shirts but keep forgetting that my right arm might be a bit sore from the sentinel node biopsy. You talk about using a recliner. How did you sleep when you got home? I am a side sleeper, how long till I can do that again? (I'm guessing I will be so fatigued I would sleep standing up if I had to). I will be having a epidural for pain control for the first few days post-op. The doctor I have has been getting really good results with this instead of the morphine pumps. This has somewhat relieved my fear of the pain. Good to hear that you did not have alot when you got home. I hate taking meds that make me feel out of it.
    I am so glad I found this site. Thanks for all the info.

    Kathy

    Hi Kathy, and welcome to the
    Hi Kathy, and welcome to the group that no one ever wanted to join. I'm glad that you've found the information helpful. You asked about the recliner. I am a side sleeper also, but I slept on my back after my surgery for about six weeks. I slept in our spare bedroom, since neither my husband nor I would have been comfortable in the same bed. I actually used five or six pillows: one under each arm, one or two under my knees and one or two under my head; also held one. It's really hard to stand straight or lie flat, so the pillows help.

    Joyce