Reconstructive Breast Surgery

Internal Rotation flaps:

In this surgery the cancer is removed like a slice of cake with the overlying skin. The breast issue is then freed up on the inside and rotated to fill in the missing segment. This usually involves a small cut about the nipple which is moved a short distance to compensate for the skin loss, and there is a second scar around the outside of the breast extending into the under arm area.

Suitable for:

Women with larger cancers in normal or large breasts or moderate sized cancers in a small breast.
Inner half (particularly upper inner – the cleavage area) cancers.

Not suitable for:

Centrally placed cancers.

Advantages:

It gives a good cosmetic result and retains the shape of the breast even though the volume may be reduced by about one cup size. (Up to one cup size discrepancy is common and rarely noticeable – most women who have never had breast surgery are uneven one side to the other if they look carefully).

Disadvantage:

There is additional scaring of the breast even though the scars tend to be hidden in the normal folds and skin lines of the breast.

It takes about 40 minutes longer for the surgery over simple wide local excision, but to go home the following day is still normal.

Steps in the procedure:

A skin-deep incision is made all the way around the nipple.

A rectangle of skin is cut from the edge of the nipple to the edge of the breast over the cancer.

The breast tissue (including the cancer) deep to the incised skin is taken right down to the muscle.

A circumferential cut is made extending into the axilla.

A small triangle of skin is removed from the lower axilla and the axillary gland surgery performed.

The breast is freed up deep in the breast at the site of the cancer excision.

The nipple is moved a little medially using a crescentic skin de-epithelialising incision.

The breast tissue is opposed with deep stitches.

The skin is closed in the usual way over a drain if required.

Rotation flap incisions

 

Red represents the areas of incisions and skin removal

Rotation Flap final scars

Tissue expander reconstruction:

Courtesy of Breast Reconstruction.org

Please follow the link: http://www.breastreconstruction.org/index.htm (open in a new window).

I highly recommend this site for its comprehensive and easily understood information.

Below you can find some of the information from this site:

Preparing for reconstructive Surgery:

Preparing for surgery is an essential part of the equation to ensure you have a smooth operation. Before the day of your surgery you may want to print this page to reference the guidelines that we have found to be the most beneficial. Depending on the procedure you are having performed, some of these guidelines may not apply to you.

Pre-Op Instructions

It is important to follow the instructions given to you at the time of your pre-operative appointment. These may include but are not limited to having blood tests, a chest x-ray, and an EKG. You will be asked to stop taking aspirin as well as any blood thinners, medications containing vitamin E and any non-steroidal anti-inflammatory medications such as those containing ibuprofen. You may be instructed to take a stool softener. Narcotic pain medication tends to cause constipation, and taking a stool softener twice a day for a few days prior to surgery may prove to be quite beneficial.

Risks of Smoking

If you are a smoker, your plastic surgeon should have already talked to you about the risks associated with smoking and reconstruction. Some plastic surgeons will not operate on a smoker, because it will negatively affect the healing process after surgery. Smoking produces nicotine and carbon monoxide which will cause the blood vessels in your skin to constrict, resulting in poor wound healing. In the setting of a tissue expander, skin on the breast will be compromised and could result in loss of the tissue expander. TRAM flaps in particular are more likely to have complications such as fat necrosis. Also, smoking increases the risks related to anesthesia. It is essential to quit smoking as soon as possible after your diagnosis, to allow as much time as possible for your body to recover from the effects of smoking prior to surgery.

Preparing your home

The most important thing you can do to ensure a smooth transition from the hospital to the comfort of your home is to prepare as much as you can in advance. Lifting restrictions apply to every type of reconstruction. It is essential that you adhere to all of the lifting restrictions given to you by your surgeon. A good rule of thumb is that if it is heavier than the Sunday New York Times, then you should not be lifting it during your first week home from the hospital. If you have pets, you will be unable to lift large bags of pet food or kitty litter. You should prepackage these items into smaller containers that are no heavier than 2-3 pounds. If your family consumes a lot of juice, or drinks water by the gallon, you may want to consider getting juice boxes or smaller bottles of water for easier lifting. Planning meals in advance, or having friends assist with meals can be very helpful. You should not vacuum or do laundry, and you should avoid repetitive motion like scrubbing pots and pans. While it may be nice to get a break from regular household duties, some women have a hard time allowing their house to get a little messy, or to let others do the chores (because as we all know, women do it best), but this is no time to be Superwoman. These lifting restrictions are in place for a reason, and you do not want to do anything to compromise your reconstruction.

Comfort After Surgery

Another way to prepare for surgery is by garment shopping ahead of time. Most patients, especially those undergoing bilateral surgery, will not be able to pull a shirt over their heads. For this reason, you want to get some soft, oversized button down shirts, or a front zipper sweatshirt. There are sweatshirts you can find at your local discount stores that have pockets on the insides, which are great for pinning or tucking surgical drains into. Patients having TRAM flap reconstruction, or any abdominal microsurgery, may want to purchase loose fitting pants as well. Pants that have an elastic waistband may pull on the already tender scar line from surgery. Many women find that oversized cotton, snap down pants work very well. You can pin or tuck the hip drains into the pant pockets, and because they are one or two sizes too big, they will not cause any abdominal discomfort. You may want to purchase shoes and slippers as well. After surgery, most patients find it uncomfortable to bend over to put on shoes or sneakers. Having a slip-on mule or sandal will be helpful. At home, you may want a slipper with a grip on the sole to ensure that you don't slip when you get out of bed, or go to the bathroom. You should pack these garments, or have your caretaker bring them to you on the day of discharge. If your caretaker drives an SUV, you may have trouble climbing in and out of it. Having a sedan may be more comfortable. Bring pillows to support your back and neck, especially if you have a long drive home from the hospital. You can use a pillow to press against your abdomen when you laugh, cough, sneeze, or when you put the lap belt over yourself in the car.

You should also set up your bed and bedside table in advance, so that when you arrive home from the hospital, all you have to do is climb in and relax. You will need a lot of pillows on your bed, including extra pillows for behind your back and under your legs. These will keep you in a position with you hips and knees flexed while you are in bed. You may want soft pillows for under your arms as well. On your bedside table you should have (all within arms reach), a hand held mirror, a your phone (if portable then take the charger), antibiotics, and pain medication. The remote control, and a few good magazines or books are great too. In the bathroom you should keep the measuring cups your doctor gives you to empty your drains into, and a pad and pen to write down the volume that the drains put out every time you empty them. You also may want to arrange for someone to drive you to your follow up appointments with your plastic surgeon. You will generally see your doctor on a weekly basis until all drains are removed, and you may not be able to drive for 2 to 4 weeks, until you are no longer taking narcotic pain medication.

It is normal to feel anxious before surgery. Getting your house in order, enlisting friends and family to help you care for children and help with household chores can let you relax. The most important thing is that after surgery you get plenty of rest in order for your body to heal. Knowing everything is taken care of in advance will give you the peace of mind that you need.

Expander Implant - Post Mastectomy Reconstruction

Post mastectomy reconstruction with a tissue expander and implant involves a staged approach. A tissue expander is a temporary device that is placed on the chest wall deep to the pectoralis major muscle. This may be done immediately following the mastectomy, or as a delayed procedure. The purpose of the expander is to create a soft pocket to contain the permanent implant. Tissue expanders are available in a variety of shapes and sizes.

Placing the Expander

At the time of the initial post mastectomy reconstruction operation, when it is first positioned on the chest wall, the tissue expander is partially filled with saline. Within a few weeks after this surgery, once the patient has healed, expansion can be started as an office procedure. The process of expansion takes place at one, two or three week intervals over several months. The timing of expansion can be coordinated with chemotherapy treatments. The amount of fluid that is placed into the expander at the time of the initial surgery will also determine how many expansions are later required. Today, with the use of a dermal matrix (such as AlloDerm®), the surgeon can usually place a higher volume of saline during the initial surgery. This may decrease the number of expansions needed later. The patient will be well on her way to having an immediate breast shape after the first operation.

Most expanders have a fill port that is built into the front of the device. This port is accessed with a needle through the skin. Expansion takes about one minute, and the amount of fluid that is placed is limited by the tightness of the patient’s skin. A typical volume for each expansion procedure is 50 cc's of saline (an equivalent of 10 teaspoons). Most patients do not have significant discomfort or pain after expansion. Discomfort can generally be managed with Tylenol, and the tightness should subside within 24 hours. 

Once expansion is completed and the patient is medically cleared for another operation (about one month after chemotherapy), the second stage of reconstruction is performed. This is an outpatient procedure that involves exchanging the expander for an implant, and creating a more refined breast shape. The initial tissue expander placement, and subsequent exchange for an implant, each take about one hour in the operating room.

Tissue Expander and Implant Post Mastectomy Reconstruction

Expander-Dermal Matrix and Implant - Post Mastectomy Reconstruction

Choosing Your Implant

Together with your surgeon, you will decide which implant best suits your individual needs. There are two general categories for implants: saline-filled, and the new generation of silicone cohesive gel-filled implants. Saline implants have historically been more commonly used in breast reconstruction, and between 1992 and 2006 they were the only fully-approved devices in the United States. Silicone gel implants prior to 1992 were often well received by patients, but were sometimes associated with microscopic gel-bleed or leakage. This led to their removal from the marketplace in 1992. However, due to certain advantages over saline implants, product development continued worldwide. FDA studies in silicone safety led to FDA approval of the latest generation of silicone implants in 2006. The advantages of gel implants are that they tend to be softer; with a feel that is more like natural breast tissue. Also, gel implants can have less rippling and visibility as compared to saline implants. Both types of implants come in numerous shapes, sizes, and profiles. There are smooth and textured designs (some surgeons use textured implants to reduce the risk of capsular contracture). Most importantly, the choice of implant style should be determined by the patient’s body shape.

Once a patient has completed her exchange, she will immediately feel more comfortable than she did with the tissue expander. The degree of tightness and discomfort should continue to decrease once the implant has settled and healed. In two to three months, the next stage of surgery will be performed to reconstruct the nipple areola. If desired, additional contouring procedures, such as fat injections, can be performed to adjust breast shape at this third stage. In some patients, further contouring and shaping procedures may be needed. For patients with a unilateral breast reconstruction, it is very common to require an adjustment procedure on the opposite breast (such as an augmentation, reduction, or lift), in order to achieve better symmetry. For patients undergoing bilateral reconstruction, symmetry using implants is easier to achieve.

You are an ideal candidate for expander implant post mastectomy reconstruction if you:

• have no available flap options
• do not desire a flap operation
• do not have compromised tissue at the mastectomy site
• have no history of previous radiation to the breast or chest wall
• are having prophylactic mastectomies
• want bilateral reconstruction
• are of a reasonable size and body weight
• agree to have an operation on the opposite breast to help improve symmetry

You are not an ideal candidate for expander implant post mastectomy reconstruction if you have:

• compromised tissue at the mastectomy site (numerous surgeries or infection)
• been previously radiated (refer to effects of radiation)
• advanced disease
• autoimmune disease (may be a contraindication for gel-filled implants)
• a Body Mass Index greater than 30

The above mentioned characteristics are considered relative contra-indications for the use of tissue expanders because each is associated with a higher risk of complications.  This does not rule out the use of expanders and implants in all patients with these conditions.

Reconstruction Recovery

Post-Operative Expander Implant

If you have not yet had your surgery, you may want to start by reading the Preparing for Surgery content in this section. If you have taken the time to prepare for surgery, all that will be left to do upon arriving home from the hospital is rest and heal. In this section you will find tips to help you with your reconstruction recovery. It is important to remember that everyone is different, and we all heal at our own pace. What works for some, may not work for others. We hope this section will serve as a helpful guide for you.

Reconstruction Recovery in the Hospital

After mastectomy and tissue expander reconstruction, you may wake up feeling groggy as you awaken from the anesthesia. You will have compression sleeves on your legs that help with circulation. You will be on pain medication, and usually have two drains for each breast that are under your skin and exit from your underarms. If you had any lymph nodes removed, you may feel especially tender in your underarm area. You will be wrapped in a post surgical bra which may feel tight across your chest, and you may have limited arm mobility. This pain should become easier to manage within a few days.

Once you are moved from recovery into your hospital room, you can try to get out of bed with assistance, and use the bathroom on your own. You will be shown how to use an incentive spirometer, which is a breathing device that helps you expand your lungs. The sooner you are up and slowly moving around, the sooner you can go home and recover in the peace and quiet of familiar surroundings. The nurse will teach you how to care for the drains, and what you need to do at home. You will be given a prescription for pain medication, and possibly an antibiotic. Please refer to Preparing for Surgery for tips about the car, and what to wear home. When you get home you will need plenty of rest. Be sure to stay hydrated. The sooner you can stop taking the narcotic pain pills and switch to Tylenol, the easier your recovery will be.

Reconstruction Recovery at Home
Some women have an easier time with their in the beginning than others. You probably will be too tired to shower during the first week, but if your surgeon gives you permission, and you feel up to it, you can shower. You may need someone to help you. You will need to pin all of your drains either to a Velcro drain belt, or you may be given something in the hospital like a gauze necklace to support the drains around your neck. It may help if you have a shower stool (you can get them in most drug stores) so you can sit down in the shower, and someone can help you wash. Alternatively, you may buy (or obtain from the hospital) packs of disposable wash cloths. As the drains come out, it will be much easier to shower.

Early in your reconstruction recovery, you will most likely see your surgeon weekly until the last drain has been removed. You cannot rush removing the drains; as bothersome as they may be, they are essential to proper wound healing. Generally once an individual drain produces less than 20 to 30 cc's in a 24 hour period, your surgeon will remove it. In most patients, the drain removal does not hurt.

Resuming Activity

Every day it is important to try to stretch a little more. Getting back mobility in your arms and relieving the tightness in your chest will really speed up the healing process. Your surgeon may recommend certain stretches for you to do at home. The most common includes walking the wall with your finger tips. Similar to the “Itsy Bitsy Spider” that you probably sing with your children or grandchildren, standing parallel to the wall, you can slowly walk your arm up the wall leading with your fingertips. For the first few days, you may only be able to go as high as your breast. Within a few weeks you should be able to walk the wall with the full range of your arm, and reach high over your head. With every passing day the feeling of tightness in your chest will ease.

The Next Step

Once your tissue expanders are completely filled and ready for your exchange surgery, you may start to feel the anxiety of entering the hospital for surgery all over again. You can rest assured knowing that almost every patient finds expander exchange to be a much easier procedure than the mastectomy and expander placement. The firmness of the tissue expander will be immediately lifted, and replaced with the softer feel of the final implant. Although you may still awaken from surgery with feelings of tightness across your chest, this pain will ease at a much faster rate, and you will likely not have any drains.

Keep in mind that it takes time for swelling to go down and for your body to heal after surgery. If you are having a procedure done to your opposite breast such as reduction or lift, you will require more time to heal. Almost always, these surgeries are outpatient, and you will be resting comfortably in your home within a few hours. Getting a first peek at your new breasts is exciting, and can evoke many feelings. If your surgeon has asked for you to keep a surgical or sports bra on following surgery, trying to sneak a peek isn't worth it. No one can wrap or bandage you better than your surgeon or the nurse, and it may be better to do the unveiling in your surgeon’s office.

Limitations

As part of your reconstruction recovery, it is essential that you adhere to all lifting restrictions your surgeon has set in place for you. You should not engage in any strenuous activity. Doing laundry, vacuuming the house, and lifting heavy objects may result in wound healing problems. After everything you've just been through, give yourself a break! Take time to rest and heal

Intimacy

Many women have asked when it is safe to resume sexual activity. Physically, it is safe once your drains are removed, and you feel up to it. Emotionally, it will take as much time as you need. Some women feel uneasy about not having nipples. If this is the case, wearing a camisole may make you more comfortable. The general concern is wondering how your partner will feel. If you are comfortable and confident with the process of reconstruction, you can ease any concerns your partner may have. The most common concern partners may have is that they will hurt you if they touch you the wrong way. It is helpful to communicate and be receptive to what your partner is saying. If you find yourself having a hard time emotionally, it may be helpful to talk with other women who have already had reconstruction, or to seek help from a counselor.

Reconstruction recovery is part of the overall reconstruction process. It may take several procedures to achieve the final aesthetic result you desire. Stay committed to your goals and communicate them to your surgeon. Always remember that every day gets better than the one before, and in time, the scars will fade, and surgery will become a distant memory.

SIEA Flap, TRAM Free Flap

With advances in microsurgery over the last decade, there are several new procedures that are being widely sought after by women. While the pedicled TRAM flap is still the standard of care in the United States, some surgeons have expertise in advanced microsurgical techniques, which provide women with more elegant, optimal solutions when utilizing abdominal tissue. These options allow for achieving better aesthetic results with fewer donor site complications. Nevertheless, these are longer procedures with potential for other complications such as total flap loss. The success rate in transferring tissue in this manner is very high in the hands of surgeons who perform microsurgery regularly, in institutions with experience monitoring these flaps. However, if blood vessel thrombosis (clotting) occurs in the transplanted flap, urgent re-operation is required for flap salvage, or total flap loss will result. Before proceeding, the patient should ask the microsurgeon as to their volume of experience, and their overall rate of success.

DIEP Flap

DIEP Flap Reconstruction

The deep inferior epigastric perforator (DIEP) flap is based on the deep inferior epigastric vessels, an artery and vein at the bottom of the rectus abdominis muscle. These vessels provide the primary blood supply to the skin and fat of the lower abdomen. In the DIEP flap, the lower abdominal skin and fat is removed without having to harvest any of the rectus abdominis muscle. Instead, blood supply is provided through the perforator vessels that are teased out from the rectus muscle, using a muscle incision alone. The surgeon will apply judgment in the operating room to determine how many perforators are needed to provide sufficient blood supply for the DIEP flap to survive.

Once the DIEP flap is raised, a microscope is used to transplant the tissue to a recipient set of blood vessels on the chest wall. The tissue is used to create a breast shape without having to be tunneled under the skin (as in the pedicled TRAM flap).

In order to avoid using any muscle, it will take longer to harvest a DIEP flap than a TRAM flap. However, this results in the advantage of minimizing injury to the abdominal wall muscle, resulting in less pain, and a lower risk of hernia formation as compared with TRAM flaps.

SIEA FLAP

 

SIEA Free Flap Reconstruction

 

Click Image to Enlarge

An alternative free flap that utilizes the skin and fat of the lower abdomen is the superficial inferior epigastric artery (SIEA) flap. The SIEA flap involves no incision through the abdominal muscle because it does not utilize the deep inferior epigastric vessels. In an SIEA flap, incisions are made in the skin and fat only, allowing the flap to be transferred based on the superficial inferior epigastric vessels. This allows for even less post-operative pain, and no risk for hernia.

As with the DIEP flap, the SIEA flap is first harvested and then transplanted to the chest wall where a microscope is used to attach the flap vessels to a recipient set of blood vessels on the chest wall. The tissue is then used to create a breast shape.

Unfortunately, only a minority of patients are candidates for the SIEA flap because the superficial vessels are very small, limiting flap volume, and increasing the risk of flap loss. In some patients, these vessels may not be present because of previous surgery such as Caesarean-section or hysterectomy.

TRAM Free Flap

TRAM Free Flap Reconstruction

 

The TRAM free flap is similar to the DIEP flap in that this type of flap is also based on the deep inferior epigastric vessels. In the TRAM free flap, the lower abdominal skin and fat is removed along with a small portion of the rectus muscle. The portion of muscle removed carries these blood vessels with the flap.

Using a microscope, the TRAM free flap can then be transplanted to a recipient set of blood vessels on the chest wall. As with the DIEP or SIEA flaps, the tissue is used to create a breast shape without having to be tunneled under the skin (as in the pedicled TRAM flap).

The advantages of this surgery as compared to a pedicled TRAM flap are two-fold. First, only a small amount of the rectus muscle is used, with less post-operative pain and less risk of abdominal bulge or hernia. Second, the blood flow to the skin and fat is much greater than that of the pedicled TRAM flap. This allows more abdominal tissue to be safely transferred, and patients who are not optimal candidates for the pedicled TRAM flap (diabetics, smokers) can usually be accommodated.

The disadvantage of the TRAM free flap is that the small amount of muscle used is still more than in the DIEP and SIEA flap approaches where no muscle is utilized. As such, compared to DIEP and SIEA flaps, the risk of abdominal wall weakness is slightly higher when the TRAM free flap is utilized.

Choosing the Abdominal Free Flap

In planning breast reconstruction with abdominal microvascular free flaps, the surgeon should explain the risks and limitations of these approaches. Ultimately, the final choice of free flap depends on the patient’s anatomy. In the course of surgery, the superficial vessels used for an SIEA flap are first encountered. If these vessels are adequate in size and could support the needed flap volume, an SIEA flap may be performed without incising or harvesting any muscle. Otherwise, the perforators from the deep system are exposed in order to elevate a DIEP flap. If these perforator vessels are sufficient, then the DIEP flap is completed. If the perforator vessels are found to be inadequate, the operation could then be converted to a free TRAM flap.

The length of surgery for abdominal microvascular free flaps can range from five to seven hours for one breast, and seven to twelve hours for both breasts. The hospital stay is typically three to five days, and the recovery can take several weeks before returning to a regular activity level. Secondary procedures after free flap breast reconstruction can be done after about three months; however, if chemotherapy is needed, any additional surgery must await completion of treatment. At that point, the patient can have revisions to the breasts and abdomen, and the nipple areola can be reconstructed. Such additional procedures are typically done as outpatient surgery with a rapid recovery.

You are an ideal candidate for abdominal microvascular free flap breast reconstruction if you:

• desire autogeneous reconstruction, and want to minimize muscle loss
• do not want or are not a candidate for implant reconstruction
• have enough lower abdominal wall tissue to create one or both breasts
• have compromised tissue at the mastectomy site
• have been previously radiated
• have had failed implant reconstruction
• are having immediate reconstruction at the time of skin-sparing mastectomy
• are having delayed reconstruction following prior mastectomy
• desire reconstruction to fix a lumpectomy or quadrantectomy defect
You are not an ideal candidate for abdominal microvascular free flap breast reconstruction if you:
• do not have enough lower abdominal tissue to create the flaps
• have had previous abdominal surgical procedures such as abdominoplasty (a C-section scar is usually okay)
• cannot tolerate anesthesia for long periods
• do not wish to have a lower abdominal scar

Post-Operative Abdominal Flap

If you have not yet had your surgery, you may want to begin by reading the Preparing for Surgery section for TRAM flap and other abdominal flap reconstruction. If you have taken the time to prepare for surgery, all that will be left to do is rest and heal. In this section you will find tips to help you recover, and learn about how surgery might affect you. It is important to remember that everyone is different, and we all heal at our own pace. What works for some, may not work for others. We hope this section will serve as a helpful guide for you.

In the Hospital

Upon waking up from surgery, you may be confused as you awaken from anesthesia. Others may feel sharp and alert as soon as their breathing tube is removed. If you have never had surgery with a breathing tube, it is important to remember not to fight it when the doctor takes it out, and take a nice deep breath once it is removed. Your throat may feel raw and you may have trouble speaking at first, but this will wear off soon. If you feel any nausea, do not be afraid. You will be surrounded by a team of doctors and nurses that will take care of you, no matter what may arise.

Once in the recovery room, you will have strong pain medication, and you will probably sleep a lot. You will have compression sleeves on your legs that help with circulation. You will also be given an incentive spirometer, which is a breathing device that helps you expand your lungs. Nurses will check on you often, especially if you have had microsurgery, to make sure the blood supply to the flap is not compromised. You will probably be visited by a pain management specialist to help make you as comfortable as possible. A computerized pain medicine pump may be attached to your IV that allows you to receive pain medicine at the touch of a button. The drains will usually be secured together to make it easier to monitor your drain outputs. Most patients will have two drains for each reconstructed breast and two drains in the abdomen. The nurses will care for your drains, and during that time you will learn how to care for them yourself.

The day after surgery, you will be helped out of bed into a chair. A catheter in the bladder from the operation will drain continue to drain urine so you will not have to go to the bathroom by yourself yet. This catheter will be removed when you are more comfortable and mobile, usually by the second or third day after surgery. You will have more pain in the abdomen than in the breasts. If you are having a sentinel lymph node biopsy, or other nodes removed, you may feel sore, especially if the drains exit from under your arms. Most of the breast area will feel numb. You will be slightly hunched over, and you may have feelings of tightness and discomfort in your abdominal area. Getting in and out of bed is usually the hardest part in the beginning. You won't have the benefit of a hospital bed once you get home, so it's helpful to have someone give you support. From a reclining position, with your feet as close to the floor as possible, your caretaker should place their right hand on your lower back, and hold your left arm or hand in their left hand. On the count of three, you want to get up, using their hand on your back for a little push. If you try this, and do it too slowly, you will feel pulling on your abdomen. After a few tries you will find what works best for you. You have to will yourself to get up, and walk in the hall, or in your hospital room. The sooner you can do this, the sooner you can get out of the hospital. Many people think they should stay in the hospital longer, but this is unnecessary. You will heal and rest much more comfortably in your own home.

Recovery at Home

Upon discharge from the hospital, your nurses and doctor will go over what you need to do at home. You will be given a prescription for pain medication, and an antibiotic. Please refer to Preparing for Surgery for tips about the car, and what to wear home. When you get home you will need plenty of rest. Be sure to stay hydrated. The sooner you can stop taking the narcotic pain pills and switch to Tylenol, the easier your recovery will be. Some women have an easier time in the beginning than others. You may be too tired to shower during the first week, but if your surgeon gives you permission, and you feel up to it, you can shower with the help of a caregiver. If you have a deep tub, you may have problems climbing over it. You will need to pin all of your drains either to a Velcro drain belt, or you may be given something in the hospital like a gauze necklace to support the drains around your neck. It may help if you have a shower stool (you can get them in most drug stores) so you can sit down in the shower, and someone can help you wash. Alternatively, you may buy (or obtain from the hospital) packs of disposable wash cloths. As the drains come out, it will be much easier to shower.
You will most likely see your surgeon weekly until the last drain has been removed. You cannot rush removing the drains; as bothersome as they may be, they are essential to proper wound healing. Generally once an individual drain produces less than 50 mls in a 24 hour period, your surgeon will remove it. In most patients, the drain removal does not hurt.

Resuming Activity

During this time, it is important that every day, little by little, you start to stand up straight. By the third week, you should no longer be hunched over. Do not be afraid to stand up straight; it is normal to feel tightness in your abdomen. The sooner you are standing up straight, the sooner you will be able to admire your new breasts in the mirror. Flap breasts may feel hard at first, but with every week that passes, the swelling will subside, and the breast will get softer and softer. Early after surgery, you do not need a bra, but if you feel you need something, many women recommend shelf bra camisoles, that are soft. You don't want anything that compresses the reconstructed breast too tightly, and you don't want underwire bras that may irritate your healing scar. You will notice changes in the breasts especially over the first eight weeks. Keep in mind that during the second surgery, your surgeon will address any areas of aesthetic concerns you may have.

The abdominal discomfort you experience should begin to subside once the drains are removed. Sleeping will become more comfortable, however, it may take time before you are able to sleep on you stomach. Some women find that getting a prescription from their surgeon to attend physical therapy helps them get back into normal activities more quickly. It is important to find a physical therapist that has experience with breast cancer patients. You do not want a physical therapist that deals only with sports injuries.

Within four to eight weeks you should be back to most of your normal activities. You will still have some tightness in your abdomen. This is completely normal and can last for a few months. It is important to listen to your body. While you may feel fine driving and doing household chores, it may require a little more time before getting back to advanced Yoga or Pilates classes.

Intimacy

Many women have asked when it is okay to resume sexual activity. Physically, it is safe once your drains are removed, and you feel up to it. Emotionally, it will take as much time as you need. Some women feel uneasy about not having nipples. If this is the case, wearing a camisole may make you more comfortable. The general concern is wondering how your partner will feel. If you are comfortable and confident with the process of reconstruction, you can ease any concerns your partner may have. The most common concern partners may have, is that they will hurt you if they touch you the wrong way. It is helpful to communicate, and be receptive to what your partner is saying. If you find yourself having a hard time emotionally, it may be helpful to talk with other women who have already had reconstruction, or to seek help from a counselor.

The important thing to remember is that every day is better than the one before. The pain you feel in the hospital will soon become a distant memory. The scars will fade over time, and once you have completed the final stages of reconstruction, you will regain a sense of wholeness that will truly help you to move beyond cancer.

Nipple Areola Reconstruction

Creating the nipple areola is the final component to making your breast reconstruction complete. There have been numerous approaches to nipple reconstruction over the last 30 years, and with several options available, surgeons can utilize whichever method is most suitable for their patients. There is no one absolute best method of nipple reconstruction for all patients. Some patients are comfortable without having a nipple, and do not wish to have further surgery. Others choose the non-surgical option of tattooing without reconstruction. This allows color pigmentation to simulate the nipple areola without the contour of an actual nipple. Still, the reconstruction of the nipple areola helps to put the finishing touches on the new breast after a long journey in reconstruction.

After optimal symmetry between the breasts has been achieved, the nipple areola reconstruction can be done. There are a number of factors that help determine which method of nipple reconstruction is right for you. These include the quality of tissue on the reconstructed breast, and whether you are having nipple reconstruction with or without a surrounding graft. Even more important, is your surgeon’s preference.

Historically, one technique included sharing a piece of the nipple from the opposite breast. This surgery is not used today, because it transfers breast tissue to the reconstruction that could potentially form a new cancer. Another method used in the past involved taking a full thickness skin graft from the labia to create a dark colored areola. This outdated technique leaves a scar in an undesirable location. Also, these grafts may be hair bearing, and areolar pigment is easier achieved with medical tattooing.

In modern approaches to nipple reconstruction, the nipple mound is created from skin taken as a local flap on the reconstructed breast. Various local flaps have been described, including the Skate flap, the C-V flap and the Star flap. Regardless of which approach your surgeon chooses, the outcome will be a nipple mound. The areola can then be either tattooed, or it can be reconstructed with a skin graft taken from elsewhere on the body. Common donor sites for the graft include the abdominal scar from a flap reconstruction, the inner thigh, or the buttock crease.

Nipple Areola Reconstruction (Skate Flaps and Skin Graft)

All nipple reconstructions lose some projection over time as part of the normal wound healing process. The risk of wound complications in nipple reconstruction is very low in patients with no history of prior radiation, but common in the radiated breast. In the case of failed nipple reconstruction, it may be necessary to revise the reconstruction with another local skin flap. Sometimes, the use of dermis or fat grafts, and fillers such as Radiesse, may be necessary to improve nipple projection. AlloDerm® has also been utilized by some surgeons at the time of nipple reconstruction to maximize projection and correct flattening. Nipple reconstruction is done as an outpatient, ambulatory procedure. The rate of recovery depends on what other revisions are done simultaneously, and where the donor site for the areola graft is located. Once you have healed, you will have the tattooing done in your surgeon's office. Refer to the Nipple Areola Tattoo section for details on this procedure. Also you may refer to the Post-Operative Nipple Reconstruction section to learn about care after nipple surgery.

Photos and Doctor Commentary

 

Nipple areola reconstruction after bilateral TRAM flaps

This patient underwent bilateral mastectomies and TRAM flap reconstruction.  Her nipple reconstruction was completed with skate skin flaps.  Each areola is a skin graft taken from the healed TRAM flap scar on the abdomen. This is the final appearance after nipple areola tattoo.

Nipple areola reconstruction after bilateral expander implants

This patient underwent bilateral mastectomies and expander implant reconstruction. Both nipples were reconstructed with skate skin flaps and each areola is a skin graft taken from her abdomen. The photo on the left is before nipple tattoo. The photo on the right is the final appearance after nipple areola tattoo.

Nipple Areola Tattoo

The finishing touch to breast reconstruction is having your nipple areola tattooed. This is usually done in your plastic surgeon's office. Tattooing is a simple, fast procedure. There is no need to be scared. If you are matching a new nipple areola to the existing breast, your plastic surgeon will mix various colors and shades to get the correct pigment. If you had bilateral reconstructions, your surgeon can use your preoperative photos to recreate the nipple color, or you can pick a new color that you like against your skin tones. As with any tattoo, the pigment will fade in time. Getting the right shade of color may require more than one tattoo procedure. If you are having nipple tattooing alone, with no nipple reconstruction, you may want to look for a doctor that specializes in giving your tattoo a three dimensional appearance.

If you have had a breast implant and regained some breast skin sensation, your plastic surgeon may need to give you an injection of local anesthetic. Most patients with flap reconstruction have little sensation. After drawing the outline of the areola, the surgeon will place the tattooing instrument against your breast. You may feel a pushing and vibrating sensation, as many small needles transfer pigment into your skin. The entire process can take as little as fifteen minutes.

Also you may refer to the Post-Operative Tattoo section to learn about care after nipple tattoo.

Photo's and Doctor Commentary 

 

Nipple areola tattoo procedure - and - Immediately after nipple areola tattoo procedure

The nipple tattooing process, completed as an office procedure, is shown here. Immediately after the tattooing is completed, the colors are difficult to see because the pigment mixes with the blood.

Final appearance after the tattooing has healed