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Care and teaching of breast reconstruction patients is aimed at preventing complications, detecting potential problems and enhancing physical and emotional healing.
Inactivity places women at risk for developing DVT and PE. Patients taking Tamoxifen have added risk. Thus, patients are encouraged to take walks and increase the distance daily until they have resumed their preoperative level of activity. Over activity should be avoided in the first two to four weeks after surgery.
Most women are able to resume their normal activities within 6 to 12 weeks after immediate reconstruction and as early as 6 to 8 weeks for delayed reconstruction. However, some women experience significant fatigue for a number of months. Patients should not drive a car and should do only light household activities for at least 2 weeks after surgery. Arm and shoulder exercise should be done as instructed and according to the pamphlet provided by the hospital. If shoulder stiffness develops, the patient may benefit from seeing a physiotherapist after surgery.
Abdominal muscles exercise should be avoided until the plastic surgeon provides the patient with instructions at about 12 weeks after surgery.
After Tram Flap surgery, patients are instructed to protect their abdominal muscle for 3 months by avoiding lifting heavy objects or doing strenuous activity that involves the abdominal muscles.
As delayed wound healing is a potential complication of this surgery; patients are encouraged to consume a well-balanced diet high in (low fat) protein, fresh fruits, vegetables, grains and fluids. Taking a daily multivitamin and or zinc helps the wound healing process.
Most patients describe the pain after this surgery as mild to moderate. They are encouraged to take regular doses of analgesics to prevent pain from interrupting sleep or prevent them from moving about or deep breathing. Sleep deprivation due to pain increases fatigue, which in turn makes it more difficult to control the pain. Tylenol #3, extra strength plain Tylenol taken q 4 hours while awake or a prescription analgesic is normally effective for pain control. If not, the patient is encouraged to contact her plastic surgeon. Some women benefit from taking ibuprofen as well. Constipation should be avoided, as straining during bowel movement may increase pressure on the abdominal donor site, which increases risk for abdominal herniation.
The breast and donor site sutures are usually dissolvable. Steri-strips on the incisions should be left on until they fall off (typically about 2 weeks). It is normal to have some bruising, swelling and oozing around the incision lines. Discoloration (ischemia/necrosis) around the mastectomy or TRAM flap not noted by physician when the patient was discharged should be reported to the physician. The donor site should be well approximated but sometimes a narrow edge on the abdominal flap may be discoloured. This is most common where tension is the greatest in the suprapubic region.
If the patient has delayed wound healing that is draining, change the dressing daily. Topical antibacterial ointments may be applied to the wound. If there is significant wound necrosis daily dressings may be required for several weeks. As the necrotic tissue sloughs drainage will increase and require more frequent dressing changes.
Twenty-four hours after the drains are removed patients are encouraged to shower daily. Wounds with devitalized tissue are not a contra-indication for showering in most cases. Occasionally a surrounding cellulitis may develop requiring the patient to be seen by their surgeon. Most of these improve with antibiotics. Infections following this procedure are rare. When an infection occurs it should be reported promptly to the physician.
The skin surrounding the abdominal donor site may become hypersensitive to touch. This occurs when the nerves start regenerating in the area. This may feel like pins and needles, or diffuse burning. It may make wearing tight clothing at the waist uncomfortable. After the sutures have dissolved (2-3 weeks) the surgeon may suggest that the patient massage the reconstructed breast to keep it as soft as possible.
Many women are discharged with Jackson Pratt drains in-situ in the abdominal donor site and reconstructed breast. Patients are taught to strip, empty and measure the drain contents every 12 hours. The drains are maintained until the drainage is less than 30 mls for each drain in 24 hours. The surgeon will indicate when the drain should be removed. Before the drain is removed release the suction for a few minutes, remove the skin suture and with a relatively quick steady pull remove the drain.
A seroma may develop after the drain is removed. Patients are instructed to notify the plastic surgeon if they notice a swelling which when palpated feels like a fluid-filled pouch. If the seroma is small it may absorb, however larger seromas may need to be aspirated by a physician. Occasionally a drain may need to be re-inserted if the seroma persists. This is often done in the surgeon’s office or under ultrasound guidance at the hospital.
Emotional support needs of patients vary and often depend on the timing of the reconstruction surgery. If the patient has immediate breast reconstruction (at the time of mastectomy) she may be coping with the stress of the breast cancer diagnosis, waiting for pathology reports and be facing chemo or radiotherapy treatment. She and her partner may also experience distress for her lost breast and altered physical appearance.
The patient who has a delayed reconstruction has usually moved beyond the breast cancer diagnosis and treatment phase and is often able to cope more effectively with the recovery from breast reconstruction. Counseling services are available free of charge from the BC Cancer Agency for women and their families. Counseling in Cantonese and Mandarin is also offered.
While patients are in the hospital they are encouraged to view their reconstructed breast so that the nursing staff can provide them with support and answer questions or address concerns they may have. Some women postpone viewing their breast until they get home. If homecare nursing is involved in their care, patients may ask their questions about their reconstructed breast during home care visits. Patients need reassurance that the bruising and swelling will diminish over time and that the breast will eventually develop a more natural droop. Patients need to know that they may not have sensation in the reconstructed breast for a few years. Many women state that it takes time for them to integrate their new breast into the image they have of their bodies.
The care of these patients is very similar to that of TRAM patients, with the exception of references to the abdominal donor site. Recovery time is usually 3 to 6 weeks. Because the latissimus muscle has been transferred to the front of the body, the patient may experience movement in the reconstructed breast area when using the arm on the reconstructed side. This will initially be uncomfortable due to pulling on the chest but as things heal this will become less bothersome.
While the drains remain in place, these patients are required to take oral antibiotics.