Scar Management

Some patients may develop Hypertrophic (scar that are raised, wide and red), or Keloid (Scar that have a raised shape that extends beyond the borders of the initial scar)

Scars take approximately one year to reach their final, “mature” form. As such, usually it is advisable to wait at least one year until scar revision or treatment options are undertaken.

Avoid sun exposure to the scar area during the first year of healing.

Hypertrophic scar tend to develop due to tension at the area of scar. Over time, if the area of skin becomes more relaxed, the scar may be amenable to revision by surgically removing it and “re-doing” the scar. There is still a chance of recurrence, but often scar revision is quite effective in hypertrophic scars. Steroid injection into the scar may also improve the scar quality.

Keloid scars are more difficult to treat and have a high chance of recurrence. Some treatment options include steroid injection into the scar, excision with injection of steroid at the time of excision, compression therapy, and radiation therapy.

Drain Care

Drains are a simple device that may be placed at the end of surgery to help remove fluid and blood from any areas that may be prone to collect them.

You may have to go home with drains if the output remains too high to be removed.

The drain output will usually be blood mixed with body fluids (clear/straw colour fluid), and will become less bloody as days pass from your surgery, and more straw coloured. You may notice small stringy bits of blood, which are normal bits of clot and tissue.

If you start to notice a large increase in bright red bleeding in your drains, or cloudy or foul smelling drain outputs, let your surgeon know or proceed to the emergency department if you are feeling unwell or have sudden changes to your breast.

The nursing team will show you how to care for your drains before you leave hospital. General steps include:

1. Wash your hands

2. Release suction valve of drain bulb

3. Record amount of fluid collected

4. Discard fluid in toilet

5. Squish bulb to re-establish suction, then plug the suction valve hole.

6. Secure the drain bulbs on your clothes so that they don’t catch on things when you are moving around the house.

Abdominal Binders Post Surgery

Abdominal Binders can be worn after reconstruction using your abdominal tissue. These provide some compression of the tissue and help prevent collection of fluid under the skin. They sometimes also feel very comfortable for patients to wear when they first start walking around after surgery.

There are areas of your abdomen that may feel quite numb after surgery - be mindful to check your skin once in a while to make sure the binder isn’t rubbing the skin, since you may not be able to feel it!

Nipple Tattoo vs. Nipple Reconstruction

If you have had a mastectomy or lumpectomy which required the resection of your nipple areolar complex (NAC), you can also choose whether you would like nipple and areolar reconstruction. This can be done as an outpatient, typically as a small day procedure or under local anesthetic, and you would not have to be admitted to hospital.

Nipple and areolar reconstruction can be done through a combination of surgical procedure and tattoo, or tattoo alone.  The surgical procedure involves using the skin of the reconstructed breast to make a nipple mound. This is can be done both in the setting of implant based reconstruction or autologous/flap reconstruction, and is usually done at least 3-6 months following surgery.

The surgeon you are working with may choose to tattoo the areola first, prior to nipple reconstruction, or after the nipple reconstruction has healed.

It is also possible to simply tattoo the nipple areolar complex, without nipple reconstruction. With proper shading and contouring, these are often made to look 3-dimensional and provide the optics of a projecting nipple.

There are also nipple prostheses available, which are removable devices made to look and feel like nipples.

Implant Lifespan

Implants used in reconstruction are typically silicone, although saline implants are still sometimes used. The newer generations or implants (4th and 5th generation of silicone implants) that are used today have quite a long lifespan. Although it is often stated that implants need to be exchanged after 15-20 years, it is possible to have them longer without any added risk.

With time and gravity, breasts (with and without implants!) tend to sag a bit more. You may require a second surgery, lift or implant exchange if this becomes a concern.

Silicone implants also have a cohesive “gummy bear” like structure, and even if they rupture, they do not deflate or compress.

Radiation

Radiation therapy is a key part of breast cancer treatment. It is used to reduce the risk of cancer recurrence as well as to improve survival.  Radiation therapy uses special high-energy X-rays or particles to damage a cancer cell’s DNA. When a cancer cell’s DNA is damaged, its ability to grow and reproduce is impaired, and it dies.

Radiation therapy damages both cancer cells and normal, healthy cells in the treatment area. However, radiation affects cancer cells more than normal cells. 

 Radiation therapy can impact breast reconstruction in several ways.  Overall, radiation has a more detrimental impact on women who have an implant reconstruction.

·      When considering patient satisfaction with results:

o   Radiation reduces patient satisfaction with results of implant-based breast reconstruction.

o   Radiation does not change patient satisfaction with results of a tissue (“autologous”) reconstruction.

·      When considering the chance of a complications after breast reconstruction:

o   Radiation doubles the risk of a complication in women with an implant reconstruction

o   Radiation does not increase the risk of a complication in women with a tissue (“autologous”) reconstruction.

Reconstruction using your own tissue is often the best option in the setting of radiation. However, not all patients want this type of reconstruction and not all patients are good candidates for a tissue reconstruction.Immediate & delayed implant reconstruction will be considered in certain women who have had or will have radiation. Speak to your surgeon about whether you are a candidate for reconstruction in the setting of radiation therapy

Internal Mammary vessels

vs.

Thoracodorsal vessels

When undergoing flap reconstruction, the surgeon must connect the vessels of the abdominal (or other flap) tissue to vessels in the chest - either then internal mammary or the thoracodorsal vessels.

Most often, the internal mammary vessels will be used to connect to the flap vessels. In order to access these, the surgeon needs to remove a small segment of rib cartilage near the centre of your chest. These vessels are a good size match, and also provide an optimal location for placement of the breast reconstruction.

Another option that may be used are the thoracodorsal vessels. These are located under your arm. Typically these can be accessed through your mastectomy incision, and only rarely would a second incision be needed. These are also a good size match. If the surgeon uses these vessels, after surgery you would have to be careful not to raise your arms so as not to disrupt the new blood flow to the breasts.

Pain Management after surgery

There is very good evidence to suggest that over the counter medications such as acetaminophen (ie, Tylenol) and Ibuprofen (ie Advil) have excellent pain management when taken together at regular intervals.

Opioids refer to medications such as Tramadol, Perocet, Codeine, morphine and hydromorphone. You may go home with a prescription for a small amount of opioids medication after surgery. Take these on an ‘as needed’ basis, but take them before your pain is very high, as it will be more difficult to address at that point.

Also remember to drink a lot of water or take a stool softer if taking opioids - these are very constipating!

Alloderm

Alloderm is a cadaveric acellular dermal matrix. (ADM). You may hear about Alloderm when you speak with your surgeon about implant-based reconstruction. Alloderm is a very useful tool that helps to support the lower portion of your implant after surgery. This helps with the breast contour after surgery. It is also associated with lower chances of capsular contracture, which can occur after breast implant placement.

The Other Breast

Although some women undergo mastectomy and reconstruction of both breasts, many women only have mastectomy and reconstruction on one side.

Depending on the shape of your breasts, it may be difficult to make the reconstructed breast match the contralateral breast. If that is the case, your surgeon may recommend what is sometimes referred to as a “balancing procedure.” This may involve a breast lift (mastopexy), breast reduction, or augmentation with implant.

Once you meet with your surgeon and decide on the type of reconstruction you are having, you can then discuss the best option for procedures to the other breast.