EXPANDER ALONE RECONSTRUCTION - Dr Paul Smith Plastic …



LATISSIMUS DORSI FLAP RECONSTRUCTION

By Dr. Paul Smith

SURGERY:

This surgery is done either at the time of your mastectomy, or after the mastectomy has been done and your breast cancer treated. It is usually used for patients that have had a history of radiation or want to minimize the scars on the breasts. It does require a scar on your lateral chest under your arm or along your bra-line on the back.

Taking the back muscle is always a concern for patients. This muscle is used to do chin ups, or pulling your body up! It will not limit you from reaching up, taking things off of high shelves or prevent you from playing golf, tennis or swimming. It will not limit your activities of daily living. One patient that worked out at the gym routinely was able to do 120lb pull downs on the lat machine. After her bilateral mastectomy and bilateral latissimus dorsi flaps, she was only able to do 90lb pull downs. It may weaken that motion, but it will not be eliminated.

The surgery takes about 3 hours for one side. Based on the amount of skin that needs replacing and the length of the scars, it may take longer. Doing bilateral latissimus dorsi flaps usually takes about 6 hours.

You will have drains placed at the time of surgery that will exit your skin on your lower lateral chest. These are small tubes that come out of your skin and drain any excess blood or fluid. Each drain will be secured into place with a single small black suture. Your incision will be sutured closed with absorbable sutures, so no stitches will need to be removed later. There will be small strips of cloth adhesive over your suture line called steri-strips. These should remain in place until they fall off by themselves or in about two weeks, whichever comes first. On top of this you will have a white piece of telfa covering the incision which is secured into place with a thin piece of clear tape called tegaderm. You will then go to the recovery room; Dr. Smith or a member of the plastic surgery team will talk to your family, in about 30 minutes to an hour you will go to the hospital ward, usually on the 5th floor. You will spend the night in the hospital, possibly two nights. You will be able to have dinner, and should expect to get out of bed to a chair that evening. You may also be asked to get up and walk around the nurses station. Your pain will be controlled by pills, usually percocets. If you need more pain medication, you will have a small button that you can push called a PCA that will give you morphine. These medications may cause nausea, so there will be other medications to help prevent this. You will be taught how to take care of your drain, and will be discharged home the next day with pain killers, antibiotics and a stool softener.

DRESSINGS:

At home it is OK to shower the next day. The dressings placed over your incision in the operating room are water-proof. Take these dressings off on the third post operative day. If you don’t there is a chance you could get blisters on the skin around the edge of the tegaderm. If you see any blisters, remove the tegaderm immediately. This is not an allergy, it is dependent on your own skin tissue characteristics. If the white telfa under the clear tegaderm does happen to get wet or get soiled with blood, do not leave a wet dressing on your skin! Take the tegaderm and telfa off of your skin, leaving the steri-strips in place. It is OK for the steri-strips to get wet in the shower. Don’t allow the water jet from the shower to directly hit them, just let the water roll over your shoulders gently. Just blot them dry when you are done. Do not soak in a tub or get in a pool or hot tub until the steri-strips are off in about two weeks.

DRAIN CARE:

When you are at home, expect the drains to be uncomfortable. This is normal. You can “strip” the drain three times a day for the first two days, and then no stripping is required after that. You will need to dump the drainage into a measuring cup twice a day and record how much comes out. The drain cannot be removed until it is putting out less than 30cc’s for 24 hours. You should remove the telfa and tegaderm on post operative day 3. It is also OK for the water to hit directly on the drainage tubes coming out of your skin. It is important to keep this area clean. Use soap and water to clean them and dry them off with a clean towel. Apply a small amount of antibiotic ointment (Bacitracin, Neosporin, Polysporin or any local antibiotic cream you have at home) to the drain site after the shower.

You should not resume any exercise activity until the drains are out. Do not go for long walks around the block or go shopping for 3 hours or go to a baseball game where there is a lot of physical activity. Use your common sense! You want to take it easy until the drains are out of your body. The more exercise and activity you are involved in, the longer the drains will be in, because the motion will not allow the skin to adhere down to the underlying muscle and tissue. This does not mean to keep your arms still and remain immobile in bed! Again, use your common sense, you can do normal household activities, dress your hair, prepare dinner, etc. but do not strain yourself.

The drains will stay in until they are putting out less than 30cc’s a day. This usually takes between 10 and 14 days. If they are still putting out more than this by three weeks, the drains will still come out.

If the drains are removed before this, you will develop a seroma, which is a fluid collection under the skin that can potentially get infected, and will require drainage with a needle through the skin. This usually requires more than one drainage; typically three to four drainages spaced one week apart. Seromas can cause pressure that is uncomfortable.

POST OPERATIVE CONCERNS:

Expect to take at least six weeks off of work after your mastectomy. Some patients require 6 weeks, and others only require 2. It is not possible to determine ahead of time, how the surgery will affect you. So plan on telling your employer six weeks! You will see the plastic surgery team in one week. They will evaluate the incisions and possibly remove the drains. Despite what you have heard, drain removal is NOT a painful procedure. The drains used today are soft and very flexible, you will barely notice! You will then be seen on a weekly basis in the thursday expander clinic.

EXPANDER CLINIC:

Expander clinic is on Thursday. This is where a nurse or a surgical resident will place fluid in the tissue expander on a weekly basis. The fluid will be injected into a small port beneath your skin under your reconstructed breast. The needle stick does not hurt because the nerves have been removed in this area. The tissue will stretch during this process, and you may feel a pressure sensation or an aching muscle sensation for about three days after each fill. It is usually worse about 5 hours after the injection, then gets progressively less bothersome after that. You may require three to four weeks of filling based on the amount of fluid required to fill your mastectomy defect. Each week you will feel larger, you must make the decision when you think the amount is enough. When you feel the breasts are large enough, and you feel good in your clothes, then more fluid will be placed in the expander to overstretch the skin and muscle. You will see the plastic surgeon again and he will choose an implant that is slightly smaller than your last fill volume. For instance, if you feel good in your clothes when there is 480cc in the expander, then the expander team will put an additional 100cc in your expander for a total of 580cc. The plastic surgeon will then order a permanent implant that is 480cc in size, this will allow the new implant to fit in the breast pocket without tension, and will allow the skin and muscle to drape more appropriately over the implant.

EXPANDER EXCHANGE:

After the last fill, you will see Dr. Smith again to choose the proper implant. This surgery will be done 3 months after the last fill of your expander. Dr. Smith waits this long to allow the body to form a small scar around the expander, called a capsule, he can use this capsule to sew to if he needs to adjust the breast pocket. Many times one side may be higher than the other or more lateral than the other, so having the capsule to sew to can help adjust these asymmetries. Dr. Smith will talk to you about the types of implants. For breast reconstruction, silicone implants offer an advantage of feeling more natural, saline implants can be used for patients that feel uncomfortable with silicone implants. The advantages of saline implants are their adjustability in the operating room. One implant can be filled with slightly more fluid to adjust for volume differences between the breasts. Most patients now are electing to have silicone breast implants. There have been a number of studies refuting the claims in the early 1990’s that silicone breast implants cause autoimmune disease. The FDA recently approved silicone breast implants for use again in breast augmentation and breast reconstruction without the need to be a part of an ongoing study.

The surgery for the exchange is an outpatient procedure, this means you come in the morning, have the surgery and go home in the afternoon. There is minimal pain associated with this and the patient can return to work in about three days. There are no new incisions created at the time of the exchange. Dr. Smith will use your same mastectomy scar to place the new implant.  Again steri-strips, telfa and tegaderm will be applied.  Usually a drain is not required at this surgery unless a lot of dissection is needed.  The telfa and tegaderm are again removed by the patient on post op day 3. Dr. Smith will see you in one week in his clinic.  He will schedule the last surgery at this time which is the nipple reconstruction.  This is usually done 2 months after the exchange.

NIPPLE RECONSTUCTION:

This is also an outpatient procedure.  This is done approximately 2 to three months after the exchange of the implant.  Dr. Smith waits this long to determine what the ultimate shape and location of the breast will be.  If the nipples are put on too soon, continued changes in the location of the implant will cause the nipples to look displaced or crooked.  The nipples are created with the skin of the breast itself.  The skin is cut and folded to create a projecting nipple, but this leaves a raw area below the nipple that needs to be covered with a skin graft.  This skin graft is taken from the groin crease, the upper inner thigh, by an old c-section scar or any other inconspicuous place.  The skin incision to take the graft is approximately 3 to 4 inches long, but heals well with no significant scarring.  There will be no pain at the nipple site, only a small amount of discomfort from the skin graft donor site.  Patients only need to take the day after surgery off from work.

OTHER CONCERNS:

The entire process takes 6 months.

Dr. Smith guarantees that the breasts will look asymmetric when everything is completed. No two breasts are exactly alike and the location of the scars, the way the breast heal and the differences in the amount of fat left on the mastectomy flaps all play a role. Dr. Smith also guarantees that he will do his best to make the breasts as symmetrical as he can.

Additional procedures such as liposuction and fat grafting may be beneficial, but typically is not covered by insurance, and therefore can be discussed and booked at Dr. Smith’s private cosmetic clinic.

The possible complications with this procedure are:

1. Infection

2. Bleeding

3. Scarring

4. Muscle and nerve injury

5. Asymmetry

6. Deflation of the implant

7. Capsular contracture

8. And the need for further surgery

If infection does occur, it is imperative that it is caught right away, if it is, the reconstructive process can be salvaged. The patient may need to be admitted to the hospital, started on IV antibiotics, and the expander or implant may need to be removed, the breast pocket washed out and a new expander or implant placed. The earlier the infection is caught, the greater the likelihood that this will be effective.

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