Breast Reconstruction for Surgical Daycare

Breast Reconstruction for Surgical Daycare
Breast Reconstruction
for Surgical Daycare
Mastectomy
 Tissue Expanders
Implants
 Nipple Reconstruction
 Liposuction(fat grafting)
 Abdominal Scar Revision (Dog Ears)
after TRAM or DIEP
General Information
This pamphlet provides general information to help you
understand more about breast reconstruction and the
recovery period after surgery. Some of the information
may not apply to you. Your surgeon will provide you with
more details about your type of surgery. Do not hesitate
to ask questions.
The aim of breast reconstruction is to match the
opposite breast as closely as possible in shape. However,
the reconstructed breast will not perfectly match the
appearance, movement and sensation of the other breast.
The reconstructed breast may also feel firmer and slightly
cooler. People with darker skin colour may have darker
scars than those with fair complexions. In some cases,
surgery is required to balance the size and shape of the
breasts. This “balancing” may involve lifting and reducing
the size of the natural breast.
Breast reconstruction may have 2 to 3 steps depending
on the type of reconstruction.
Step 1:Make a new breast mound with a tissue expander
and implant or your own tissue transfer, for
example-TRAM (Transverse Rectus Abdominal
Musculocutaneous flap), or DIEP (Deep Inferior
Epigastric Perforator flap)
Step 2:Remove expander and replace it with a permanent
implant
Step 3:Make a nipple, followed by tattooing to colour the
nipple & areola (the circle around the nipple)
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The surgeon may also:
• smooth the incision line (remove small skin flaps
referred to as “dog ears”) in the stomach area if
necessary (after TRAM or DIEP flap)
• improve the shape of the breasts by removing fat
(liposuction) from one area and injecting it around
the new breast
Smoking may cause complications in the healing process.
Therefore, it is important to stop smoking at least two
weeks before and after the surgery. Contact your family
doctor if you need help to stop smoking. If you use Nicoderm
patches to stop smoking, it is important that you stop using
these two months before surgery, as Nicoderm patches have
negative health effects similar to smoking.
 Prophylactic Mastectomy plus Breast
Reconstruction
In order to reduce the risk of developing breast cancer,
a prophylactic (prevention) mastectomy may be done
to remove one or both breasts. Women who decide to
have prophylactic mastectomy often choose to have
breast reconstruction surgery, either at the same time as
prophylactic mastectomy or at a later time.
 Reconstruction using Tissue Expanders
(Alloplastic)
Tissue expanders are used in most alloplastic (nonbiologic
material such as plastic) reconstruction. This can be
done either at the time of the mastectomy (immediate
reconstruction) or later (delayed reconstruction). The expander
is placed behind the chest muscle (pectoralis muscle).
In the weeks following surgery, after the surgical site
has healed, the expander is inflated with saline solution
(salt water) by a valve. The tissue expander stretches the
overlying muscle and skin until the new breast mound
reaches a size that is slightly larger than the natural
breast. A second operation is required (daycare procedure)
to remove the expander and replace it with a permanent
breast implant.
In reconstruction of both breasts, the expander procedure
allows better selection of breast size. The tissue expansion
process may require a few months of frequent doctors’
appointments to complete the inflation process.
Most women return to work or normal daily activities
within two to four weeks
Women receiving prophylactic mastectomy will have one of
the following procedures:
• Simple or total mastectomy: The nipple, areola, and
all of the breast tissue are removed. The lymph nodes
under the arm and chest muscles are not removed.
• Subcutaneous mastectomy: All of the breast tissue is
removed, but the nipple is left alone.
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 Reconstruction using Implants
The simplest method of reconstruction is the insertion of
a breast implant under the chest muscle to create a breast
mound. This method (one-stage implant reconstruction) is
suitable when the opposite breast is small and non-sagging.
It also requires insertion of a compound called Alloderm.
AlloDerm® is made from donated human tissue from which
the cells have been removed so that your body will accept it.
It joins together with your healthy tissue. It has been used for
years to replace missing or damaged skin and cover wounds.
• Another choice is to place a final implant after the tissue
expander is removed (two-stage).
• The implants are made from a silicone shell and filled
with a saline solution (salt water) or silicone. Implants
may not last a lifetime. Their life spans vary and they
may have to be replaced or adjusted in the future.
 Nipple Reconstruction & Tattooing
A new nipple is formed from your own skin on your
reconstructed breast, or from the nipple on your other
breast. This is usually done about 3 months after the first
surgery. The areola may be created by tattooing a few
months after the nipple is reconstructed.
 Liposuction (fat grafting)
Fat is removed(liposuction) from one area and injected
around the new breast to improve the breast shape.
 Abdominal Scar Revision (Dog Ears)
After a TRAM or DIEP flap, the incision line is smoothed by
removing small skin flaps (“dog ears”) in the stomach area.
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After Surgery
Care of the Incision
• All of the incisions are closed with stitches (sutures) that
dissolve and small tapes (Steri-strips). Do not remove the
Steri-strips. Leave them in place until they fall off naturally.
• You may have some bruising, tenderness and some slight
bleeding around the incisions. This is normal and will
improve over time.
• If the wound(s) starts to bleed after you are home, press
firmly on the area for a few minutes. If the bleeding does
not stop after pressing for 10 minutes, call your surgeon
or go to an emergency department.
• Bras: Follow any instructions your surgeon tells you
about a certain type of bra to wear.
Tissue Expanders or  Implants:
One stage breast reconstruction- an implant is placed with
AlloDerm®
• Remove the dressings after 2 days but leave the paper
tapes to fall off naturally.
• Keep the incisions clean by showering every day once the
drains are removed. Gently pat the area dry with a clean
towel; do not rub the area.
• Avoid tub baths until your incisions are fully closed
(about 2 weeks) since soaking in the tub may increase
the chance of infection. \
• If an expander is used to reconstruct your breast, at
first the size of the breast will be smaller than your
natural breast because the expander is only partially
filled with saline when it is placed in position. The breast
may also seem too high in position. This is normal.
• Bra: 2–3 days after implant surgery, begin wearing an
underwire bra. Wear it 24 hours a day for 3 months.
Remove for bathing.
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Nipple reconstruction
• Leave the dressings around the nipple for 5 days after
the surgery.
• Keep all dressings dry. Do not shower during this time,
you may sponge bath.
• After 5 days, remove the dressing. There may be small
tapes (steri-strips) on your breast. Leave these in place
until they fall off naturally.
• Avoid soaking the area (swimming, using hot tub, tub
baths) for 2 weeks. Soaking the area may increase the
chance of infection.
• Wear loose clothing, no bra. Try not to sleep on your
stomach for 2 weeks.
• There may be some bruising, tenderness, swelling,
slight bleeding and scabbing around the wounds. These
are normal signs and will improve over time. Put
polysporin ointment on the wounds if scabbing occurs.
Drain care
• If you go home with drains or need dressings changed,
your surgeon or a Home Care Nurse will remove the
drain. This will be arranged while you are in the hospital.
• Before you leave, the nurse will review the instructions
for how to empty the drain and prevent the tubing from
blocking. You will be given written instructions about
the drain. It is important to make sure the drain(s) is
working to prevent the collection of fluid inside the
wound area. If fluid is not coming out of the drain, notify
the Home Care nurse, or your surgeon.
• Until the drain is removed, sponge bath only. Showering
may allow bacteria to enter the reconstructed breast and
cause infection. You may shower 24 hours after all drains
are removed. Then shower every day to keep the area
clean. Gently pat the incision dry with a clean towel; do
not rub the area.
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• Avoid soaking the incision (eg. tub bath, hot tub) until
your incisions are fully closed(2 weeks) since this may
increase the chance of infection.
• As long as your drain remains in, continue to take
antibiotics if prescribed by your doctor.
• After the drain is removed, some fluid may leak from
the opening. If that occurs, cover the area with a
sterile dressing.
Seroma
• When the drain is removed, sometimes fluid keeps
building up and you may develop a pocket of fluid called
a seroma.
• The body may absorb seromas if they are small. If they
are large, the surgeon may need to remove the fluid. This
procedure is done in the surgeon’s office and may have to
be repeated.
Pain
• You may have pain and/or a feeling of tightness around
the new breast. If you had a partial mastectomy and
lymph glands were removed from your armpit, you may
also have some numbness in the upper inner arm and/
or breast. Therefore, it is important to avoid using a
hot water bottle, heating pad or other heated devices as
these may cause burns.
• You will receive a prescription for pain medication.
However, if the pain is mild to moderate, you may prefer
plain or extra strength Tylenol. Some pain medication
will cause constipation. A high fiber diet and drinking
plenty of fluids will prevent constipation. If you are
constipated, ask your pharmacist to recommend a mild
laxative or stool softener.
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Activity
• Most people are able to resume their normal activities
and return to work within two to four weeks.
• Exercise is important in your recovery. Walking daily
is ideal exercise. However, avoid high-impact aerobics,
jogging, lifting heavy objects and swimming for 4 weeks.
• Avoid holding your shoulder forward on the side of your
surgery as this may cause the shoulder muscle to tighten.
• Your surgeon may recommend a physiotherapist to help
with arm range of motion after your surgery.
• Do not lift anything heavier than 5 kg (10 lbs) for the
first 4 weeks.
Exercises
• Each exercise is to be done 3–5 times daily.
• Repeat each exercise 10 times, unless instructed to do
otherwise.
• Do exercises until you feel a gentle stretch.
• Do your exercises in front of a mirror, if possible and
check for equal arm movements.
• Do not make any quick, jerky movements or push into pain.
• Abdominal exercises will be started when your plastic
surgeon feels you are ready (approximately two months
after surgery).
• It is normal to feel some discomfort with exercise but
if you have a significant increase in pain or swelling,
consult your doctor.
Exercises to begin the day after surgery:
1. Hand pumps and elbow bends
a) Make a fist and then
stretch fingers straight.
b) Bend and straighten
your elbow.
2. Shoulder shrugs
3. Shoulder circles
Roll shoulders backwards.
Repeat, rolling shoulders forward.
4. Neck stretch
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Shrug shoulders up to your ears.
Relax and let them down.
Breathe in when you lift and breathe
out when you lower.
Tilt head to one shoulder to stretch
opposite side of neck and hold for 5-10
seconds. Repeat to opposite side.
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5. Shoulder blade squeeze
Sit or stand with your arms
by your sides and your palms
facing your sides.
Gently squeeze your shoulder
blades together and down.
Hold for 5–10 seconds then
relax and return to the start position.
6. Arm lifts
Clasp hands and raise arms
overhead, keeping elbows
straight. Lower slowly.
Begin in lying position and
progress to sitting.
Exercises to add in at Week 2
(after breast drain is removed):
7. Winging it
Lie on your back and
touch your fingertips
to your ears with your
elbows pointed to
the ceiling.
Move elbows apart and
down to the bed, hold 2 seconds and then
bring then back up to starting position.
8. Wall walking
a) Facing a wall, “walk” fingers up the
wall as far as you can. “Walk” back
down. (Both arms)
Some people feel some numbness and tingling around their
surgery site(s). The exercises we give you should help with
this. Sometimes gentle rubbing or stroking the area with
your hand or a soft cloth after it has fully healed can also
help make it feel better.
b) Stand sideways to a wall, and “walk”
fingers up as far as you. “Walk” back
down. (Affected arm)
9. Snow angels
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Lie on your
back with
your arms
at your sides
and elbows
straight.
Move your arms out and over your
head and then back to your sides.
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How long do I need to do these exercises for?
Continue these exercises until both arms are moving
equally easily. This may take 2–3 months.
From 6 weeks onwards
As you feel stronger you can gradually start increasing your
physical activity and strengthening exercises. It is important
to build up slowly. You may want to consult your doctor or
physiotherapists to help you plan a suitable program
Physical activity (eg walk, bike, swim, aerobics and yoga)
There isn’t one activity or sport that is better than another.
What is important is keeping active. Find what you enjoy
and make a plan to allow you to gradually get into or go
back to the activity.
Aim for 150 minutes of aerobic activity a week
Physical activity will help you maintain a healthy body
weight and prevents many chronic diseases. It will also keep
your arm strong and moving well and will help you control
swelling in the arm.
Make an appointment with your surgeon for follow
up 1 week after surgery. Call your surgeon.
Call your surgeon if any of the following happens:
• New drainage or green/yellow drainage from the incision
or drain site
• Increased redness and/or heat around the incision, or
change of color over the breast
• Increased or new pain or swelling of the breast or armpit
• A temperature of 38.5˚C (100.5˚F)
• A seroma has formed after the drain is removed
• You have redness or aching in your calves and/or
shortness of breath
If you cannot reach your surgeon, contact another doctor
(family doctor, walk-in clinic, urgent care centre or
emergency department)
Call 911 or other emergency services if you have sudden,
severe chest pain or shortness of breath.
Strengthening
Some ways to keep building strength:
• Slowly getting back to household chores, gardening or
yard work.
• Exercises with light weights (1-2 lbs), if you don’t
have weights you can use unopened soup cans or filled
water bottles.
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Resources
If you feel that learning about your condition will help
relieve your anxiety and fear of the unknown or if you would
like information about support groups, the Cancer Society
has a telephone information line and volunteers will provide
you with excellent information: 1-888-939-3333.
• Cancer Connection in Vancouver: 604-675-7148
• Breast reconstruction website:
www.vch.ca/breastreconstruction
• Ivo Olivotto MD, Karen Gelmon MD, David McCready
MD, Kathleen Pritchard MD, Urve Kuusk MD.
The Intelligent Patient Guide to Breast Cancer:
Information about risk, prevention, symptoms, signs,
diagnosis, stage, surgery, radiation, chemotherapy,
prognosis, treatment of/for breast cancer. 4th Ed.
• Healthlink BC - Just three numbers - 8-1-1 - on the
phone or online at www.HealthLinkBC.ca means
easy access to non-emergency health information and
services. Translation services are available in over 130
languages on request. For deaf and hearing-impaired
assistance (TTY), call 7-1-1.
For more copies, go online at http://vch.eduhealth.ca or
email phem@vch.ca and quote Catalogue No. FE.327.B7413
© Vancouver Coastal Health, October 2015
The information in this document is intended solely for the
person to whom it was given by the health care team.
www.vch.ca
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