Immediate Postoperative Period
Post-operative pain is greater after plastic surgical procedures that involve muscles being either cut or divided. Placing an implant or expander beneath the pectoralis major muscle, for example, is much more painful than placing an implant in front of the muscle.
The same principle applies to autologous breast reconstruction. A Transverse Rectus Abdominis Myocutaneous (TRAM) flap involves cutting and removing a piece of the rectus abdominis muscle, whereas in a Deep Inferior Epigastric Artery Perforator (DIEAP) flap the muscle fibres are simply separated to gain access to the perforating (feeding) blood vessels. TRAM flap reconstruction usually therefore causes more post-operative pain than a DIEAP flap, in which the pain is described as being either low or moderately severe. For any procedure in which part or all of an abdominal muscle is sacrificed, it may be necessary to wear an abdominal binder for a prolonged period of time.
Wound healing is normally complete within the first three weeks. There may be a feeling of tightness where tissue has been removed, for example in the abdomen following a DIEAP flap, or in the chest, after an implant has been inserted, but this is normal and will gradually ease off after the first two months.
Breast reconstruction usually requires a recovery period of between four and six weeks. If your work involves only light duties, such as administration, you may be able to start back again sooner. However, anyone performing heavy manual work should take the full six weeks recovery.
Every patient who undergoes general anaesthesia is admitted to the recovery room after surgery. Specialized medical and nursing personnel are available there to monitor and take care of you. The recovery room may contain several patients at any one time and can be busy. You may need to remain there overnight or in an adjacent side room equipped to deal with patients requiring continuous medium or high dependency care.
In recovery, your general condition and breast reconstruction are assessed. If you have undergone microsurgical free tissue transfer, regular monitoring of the flap takes place and is of the utmost importance. Your nurse will initially check the flap every hour, both visually and manually to evaluate blood flow. The earlier a problem is detected, the higher the chance of a successful outcome. This regular monitoring interferes with sleep and your first night after surgery is quite restless.
When you wake up in the recovery room you will also notice the following:
- Your chest is covered with a retractable blanket, so that your reconstruction can be easily assessed.
- Intravenous and / or intra-arterial catheters: usually two intravenous catheters are placed in the arm opposite to the side of the reconstruction. These are used to administer fluid, blood (if required) and medication. In patients with a history of heart and / or blood pressure problems, an arterial catheter may also be inserted for more detailed monitoring. The catheters are removed once you start eating and drinking again.
- Gastric tube: this is introduced through your nose to drain excess fluid from your stomach and prevent reflux of gastric contents into your lungs. The gastric tube is usually removed before you wake up and only in exceptional circumstances, remains in place for the first 24 hours.
- Urinary catheter: this measures your urinary output and is also placed for your convenience. This catheter is removed when you are able to walk to the bathroom, approximately 48 hours after surgery.
- Blurred vision: protective ointment is applied to your eyes during surgery. It may cause some blurred vision but this usually resolves within hours.
- ECG cables*: used to monitor your heart function and rhythm.
- Blood pressure cuff*: this regularly inflates to record your blood pressure.
- Pulse oximeter*: a device placed on one of your fingers or toes to measure the amount of oxygen in your blood and your pulse rate.
- Oxygen: may be temporarily administered via your nose or mouth if, as a result of the anaesthesia, your own breathing is insufficient.
- Compression stockings: to prevent deep venous thrombosis and pulmonary embolism, special antithrombotic stockings are worn for your entire hospital stay. In addition to the stockings, you will receive subcutaneous injections of low-molecular heparin once a day. For reconstructions involving gluteal or thigh flaps, specific compression underwear is put on at the end of your procedure.
- Calf compression pumps: are used if you are at high risk of deep venous thrombosis and / or pulmonary embolism. These are removed once you can mobilise.
- Drains: a number of plastic tubes are placed at the site of your breast reconstruction and at the donor site. These remove any excess blood or fluid that accumulates in your wounds. The drains remain in place until the fluid output is minimal, which may take several days.
- Positioning: you will be placed in a sitting (DIEAP flap) or flat (gluteal or thigh flap) position following microsurgical breast reconstruction. Positioning is not as critical following implant based reconstruction. You will immediately be encouraged to move your arms and legs to prevent deep venous thrombosis and pulmonary embolism. The day after surgery patients are asked to get up and sit out of bed
- Pain: everyone’s pain threshold is different but post-operative pain is usually minimal. Almost always, it can be controlled with simple analgesia such as paracetamol. If you experience pain, you must inform your nurse. Higher doses and more potent drugs can be administered if necessary.
- Diet: no food or drink is allowed on the morning of your operation. You may however rinse your mouth with water. Post-operatively start with sips of water or clear non-carbonated drinks and then build up to a normal diet as you feel able.
- Bowel movements: morphine containing medication administered during your anaesthesia may cause post-operative constipation. If this becomes problematic, stool softeners can be given to stimulate bowel movements.
- Other medication: you may be given additional drugs intravenously or orally depending on your recovery. Any normal medication can be restarted after a few days but always check with your nurse or surgeon before doing so.
- Flap monitoring (autologous tissue only): this is performed clinically. The flap color, consistency, temperature and capillary refill are all regularly assessed. The flap and surrounding skin temperature are compared using special skin adhesives that detect any change. Flap monitoring is initially very frequent: every hour during the first post-operative day, every 2 hours during the second post-operative day and every 4 hours during the third post-operative day. In the event of any change in the flap, you may need to return to the operating room to solve the problem.
* Removed when you leave the high dependency area.
Once at home
Please do not start smoking once you go home. You run the risk of compromising the blood flow to your breast reconstruction and developing complications.
Your biggest enemy will be fatigue. This is due to a combination of wide surgical undermining, prolonged anaesthesia and a reduced number of red blood cells in your circulation. Your operation has created large wounds underneath your skin that need time to heal and this requires a lot of energy!
We recommend that you listen to your body and periodically take some rest throughout the day. Do not drive or perform strenuous physical activity for the first 6 weeks of your recovery. Also try to arrange some help around the home. It is important though that you remain mobile and continue light exercise or short walks.
Everyone recovers at their own pace but it generally takes between 2 and 5 weeks. After 6 weeks, you will be able to resume most daily activities such as, housework, your job, sport and normal sexual relations.
DIEAP flap reconstruction patients should not lift objects that weigh more than 2 to 3 kg (a handbag or small household object) for the first 6 weeks. This prevents a rise in intra-abdominal pressure and tension on both the internal and external wounds.
For gluteal or thigh flap reconstruction patients, the weight lifting restriction is less severe. You must however not put too much pressure or tension on your donor site scars. Cushions can be helpful to prevent this during the first few weeks of your recovery.
Avoid direct pressure on your breast reconstruction at all costs: do not place heavy objects or tight garments (a bra or clothing) around your breast and do not lie on the flap itself. Touching the breast is however completely harmless.
You may experience emotional instability and mild depression following this type of surgery. Please share these feelings with your breast care nurse or plastic surgeon. Although these feelings are usually transient, professional support can be arranged, if required.
The area around your breast(s) and donor site will remain swollen for 6 to 8 weeks as a result of fluid accumulation (oedema). This can lead to difficulty finding clothes that fit but be patient, as it will gradually resolve over the next few months.
If you notice an increase in redness, temperature, swelling or pain at your breast reconstruction or donor site, please immediately contact your plastic surgeon. Fever or any other unusual symptoms should also be reported as soon as possible.
Post-operatively, 2 or 3 out-patient appointments are scheduled, to check your wounds and assess progress. The subcutaneous sutures dissolve themselves and do not need to be removed. The skin glue will peel off after 2 to 3 weeks. There is normally no need for bandages or additional wound care. If you do have a problem with wound healing, your plastic surgeon will provide precise instructions on the type of dressing required.
Approximately 48 hours after surgery you will be allowed to shower. Avoid soap containing fragrances or dyes and rubbing the wounds. Keep showers short and do not take a bath for the first 4 weeks. When finished, you can dry your skin with a towel or cold air from a hairdryer. Avoid hot air as your skin sensation may be temporarily reduced following surgery and you can inadvertently burn yourself. Once the wounds are healed and the scabs have fallen off, start moisturising your scars with a hypoallergenic lotion or cream.
Remember to eat a balanced diet, containing plenty of calories, minerals (especially iron) and vitamins. This is not the time to diet! Healthy foods include red and white meat, fresh fruit and vegetables. Do not hesitate to contact your plastic surgeon’s office, if you have any questions or concerns.
Six months after your primary surgery, a second surgical procedure is frequently arranged to adjust the shape and volume of your breast reconstruction, revise scars or perform nipple reconstruction. If necessary, the contralateral breast can also be augmented, reduced or lifted.
In the long-term, you will be regularly followed-up by members of the specialised multidisciplinary breast care team (breast surgeon, oncologist and plastic surgeon). Final adjustments can be made to your reconstruction to optimize the aesthetic result. Your General Practitioner also plays an important coordinating role and can help with many basic problems and questions.
Breast Reconstruction with Expanders and Implants
Read about breast reconstruction guidelines with implants in the following documents. These reports have been put together by a special guideline committee of the American Society of Plastic Surgeons (ASPS), using only data from sources and publications with a high degree of evidence based medicine (EBM). Breast reconstruction guidelines for autologous tissue will be available by the end of 2014.