În ultimul deceniu, lumea jocurilor de noroc s-a schimbat radical în România, în special cu apariția noi cazinourilor online. Această tendință, alimentată de progresul tehnologic și de comoditatea jucătorilor, a transformat complet modul în care românii se bucură de jocurile lor preferate.
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Breast reconstruction after partial or complete removal of breast(s) can be a very physically and emotionally rewarding procedure for many women. It offers the ability to not only create a new breast, but also can dramatically improve a woman’s self-image, self-confidence, and quality of life.
Reconstruction of a breast can be accomplished through many different plastic surgery techniques. The best procedure for your breast reconstruction depends on your goals for reconstruction and your medical history. Overall, the results of breast reconstruction can be relatively natural in appearance and feel; however, a reconstructed breast will never look or feel exactly as the previous breast.
Breast reconstruction typically involves several procedures performed in multiple stages. It can begin at the same time as the mastectomy or may be delayed until a patient has healed from mastectomy and recovered from any additional cancer treatments that may be necessary. Breast reconstruction is achieved through several reconstructive plastic surgery techniques following mastectomy including:
This procedure can be performed by your breast surgeon in one stage (direct to implant reconstruction) or in two stages (tissue expander first followed by implant). In general, reconstruction with implants following either route has the fewest scars and is the least invasive of all the breast reconstruction surgery options. This type of reconstruction may also involve the use of Alloderm, an acellular dermal matrix used to support the pocket created for the implant or tissue expander.
A tissue expander is a balloon placed at the time of the mastectomy and adds about 1 hour of extra surgery time. This procedure usually entails one day in the hospital. During follow-up office appointments, the expander is gradually filled with salt water until you have reached your desired size. When chemotherapy and/or radiation therapy (if necessary) are completed, the expander is removed and the permanent implant placed. This takes about one hour and is done on an outpatient basis.
After healing from the second surgery, a nipple can be created with skin taken locally from the reconstructed breast. A tattoo is added later in the office for the areola color.
Reconstruction with implants can also be accomplished in a single stage. This reduces the number of surgeries needed to complete the reconstruction, but offers less flexibility with size, and entails slightly more risk. If you are interested in single-stage implant reconstruction, please ask us about it.
Recent advances in technique have allowed for the placement of tissue expanders above the chest muscle, directly under the skin, in some patients. This reduces discomfort after surgery because the muscle is not lifted or cut to accommodate holding the tissue expander, and can avoid deformity of the breast reconstruction when the chest muscle is flexed. Not all patients are candidates for this type of reconstruction.
Flap techniques use a woman’s own tissue (muscle, fat, and skin) to create or cover the breast mound. Most often, tissue is taken from the back (Latissimus flap) or the abdomen (TRAM flap, DIEP flap). In the case that reconstruction is only needed for one breast, a woman may also wish to have a surgical procedure so that the unaffected breast will more closely match the reconstructed breast. This can be done at the time of mastectomy or later, depending on your preference for symmetry.
The Deep Inferior Epigastric Perforator Flap (DIEP flap) is a specialized form of the TRAM flap requiring the use of microsurgery techniques. An incision is made along the lower abdomen. Skin, soft tissue, and blood vessels feeding the tissue are removed. These blood vessels are then matched to supplying vessels at the mastectomy site and reattached under a microscope.
With the DIEP flap, no muscle is removed. This leaves the muscles in place and preserves abdominal strength. The result in the abdomen is much like a tummy tuck, and the result in the chest is a reconstructed breast that is soft, warm, and more natural feeling. This procedure takes at least 4-5 hours in the operating room and often requires 3-5 days in the hospital.
In some circumstances, breast reconstruction will be performed using a combination of implants and the patient’s own tissue. This can be termed “hybrid” breast reconstruction. In our practice, we most commonly perform hybrid reconstruction when using a latissimus dorsi flap as this flap alone does not usually offer enough volume to recreate the entire breast mound. In some instances, we may also place implants in addition to performing abdominal tissue reconstruction for patients who do not have enough abdominal tissue to recreate the entire breast mound. Hybrid reconstruction offers a more natural appearing reconstruction than implants alone, and can be especially useful in patients who have had radiation therapy.
After healing from the breast mound reconstruction surgeries, a nipple can be created with the skin taken locally from the reconstructed breast. A tattoo is added later in the office for the areolar color.
Lumpectomy that removes at least one quadrant of the breast often leaves a deformity that is significant after treatment. In these instances, your oncologic surgeon will most likely recommend you discuss your options with Dr. Fine for reconstruction after lumpectomy.
The filling of lumpectomy defects can be accomplished endoscopically, using the latissimus dorsi muscle from the back and the overlying fat. The use of endoscopic surgical procedures allows Dr. Fine to harvest muscle and tissue from the back while avoiding a large incision.
Endoscopic latissimus dorsi flap reconstruction requires an incision under the arm. In the case where axillary lymph node dissection occurs simultaneously, this incision can be extended slightly to gain access to the muscle. Through this incision, the muscle is mobilized with the use of the endoscope, and is pulled forward to fill the defect left after the lumpectomy. This procedure has the ability to create a better-contoured breast with minimal scars.
Placing implants after lumpectomy can help reduce asymmetry or distract the eye from contour deformities after lumpectomy. This approach to lumpectomy reconstruction is complicated by radiation, which is often performed in patients who have opted for lumpectomy and is, therefore, not a good reconstruction option for some patients. Please ask us more about this option at your consult with us if you’d like to know more.
Breast reconstruction after lumpectomy can also be performed using rearrangement procedures which may include a breast lift or breast reduction. Scars for this type of reconstruction can vary depending on the rearrangement procedure that is best for your breast size and shape and the location of your lumpectomy scars. Scar patterns may be coordinated with your breast surgeon to optimize the outcome.
You may remove the gauze dressing 24 hours after surgery and then shower. Keep the steri-strips in place; they have been applied with a skin adhesive, so you can wash over them without loosening them. Steri-strips will gradually loosen along the edges and usually fall off within 7-10 days after surgery. If your steri-strips fall off earlier than 7 days after surgery, it is okay; if they are still in place after 10 days, you can remove them yourself or they will be removed in the office at your first post-operative appointment. You may continue to cover the incisions with gauze if you want to, but it is not necessary.
You may have one or more bulb suction-type drains (JP drain) in place when you are sent home. Please strip and empty the JP drain 2-3 times daily, or more often if the bulb fills up. To strip the drain, firmly grasp the tubing closer to your body, and use your other hand to squeeze and slowly slide your thumb and index finger down the tube. Always stabilize the tube with one hand while stripping the tube with the other. After emptying the drains, squeeze the bottle to create suction and replace the cap while squeezing to maintain the vacuum.
Make sure to measure and record drain output for each drain during every 24-hour period, and bring your record to your post-operative appointment. After the drainage has decreased to 30 mL or less in a 24-hour period, please call our office to arrange a time for the removal of the drains. Drains are usually removed within 1-2 weeks.
You will be on antibiotics while the drains are in place. If you run out of antibiotics and still have your drains, please call our office for a refill. PLEASE NOTE: If you had a TRAM, you only need to finish the antibiotics given to you; if drains are in longer than your antibiotic coverage, that is okay.
The drains can get wet in the shower, but should be supported while showering. To secure JP drains, used a ribbon, shoestring, or lanyard around the neck.
Some patients experience leakage around the site of their drains. This is okay. Reinforce the area with gauze to protect your clothing and continue to strip and empty the drains as instructed.
Drain fluid usually starts out red in color and slowly changes to lighter red, then pink, or even yellow. These colors are all normal and expected. Drainage fluid may also have noticeable particles and strands in it; this is also normal.
Drainage varies from patient to patient and can also vary from side to side. If you notice a difference in output between your drains, this is okay. In general, you should note a decrease in your drain output over time.
Activity can increase your drain output slightly; this is okay. It is important to keep an active range of motion in your arms after surgery by doing the exercises we provide you as stretches. Limiting arm mobility can result in frozen shoulder, so it is important that you continue to use your arms. Avoid exercise while the drains are in place, but continue stretches.
Post-operatively, you will have a local anesthesia pump (“pain pump”) in place to help control pain. This consists of a small tube with a bottle at the end containing Marcaine. You may shower with the pump in place; just remove the cloth bag prior to showering. The pain pump usually lasts 48-72 hours after surgery. When the inner balloon appears empty, the medication is finished. You may remove and throw away the bottle. Remove the clear tape and steri-strips from your skin and gently pull the tubes out. This will not be painful as the skin is numb. Be aware that the tubes are long.
Leaking around the site of the pain pump is not uncommon. Fluid may appear clear to pink or light red in color. If your pain pump is leaking, you can reinforce the area with gauze to protect your clothing or may remove the pain pump if you desire. Leaking, in and of itself, is not a problem, but can be a nuisance.
Pain medication prescribed post-operatively should be taken as directed to relieve pain as it is important to be comfortable enough to keep moving. This medication should be gradually tapered or reduced to a point at which the narcotic you are prescribed (prescription pain medication, or Tylenol with prescription pain medication) will be used only at night time by two weeks post-surgery. If you feel the medication prescribed is too strong, pain pills may be cut in half, or try plain Tylenol (Acetaminophen) or Advil (Ibuprofen). If taking Acetaminophen, do not exceed 4,000 mg per day; please keep in mind that many narcotic pain medications prescribed also contain acetaminophen. We also recommend that you use a stool softener while taking pain medication as constipation after surgery and while taking narcotic pain medication is very common.
Constipation is common after surgery. It is caused by general anesthesia and the pain relievers used after surgery. This can be treated by taking a stool softener. We recommend you take a stool softener consistently, such as Colace, while taking pain medications. If you do not find the stool softener is working, you may try a suppository or enema. These can be purchased at your local pharmacy and are over the counter. If you are constipated and begin to feel worsening abdominal pain or vomiting, please contact our office.
Nausea is common after surgery. This can be related to the medications you are taking or to constipation. Make sure to eat something prior to taking any pain relievers or antibiotics as this can often help avoid nausea associated with these medications.
You may resume your normal diet after surgery. Eating a healthy diet can aid in healing and improve energy levels after surgery. Multivitamins may also help.
You may shower beginning 24-48 hours after surgery. Clean incisions gently with soap and water and pat dry. Do not swim, bathe, use hot tubs, or use lotions or creams on the breast for 2 weeks after surgery or until the incisions have healed. Do not shave the affected underarm with a razor as your risk of injuring yourself is significantly higher due to numbness. Electric razors are okay.
Immediately after surgery, arm range of motion stretches are encouraged. Although arm exercises can increase drain output, maintaining range of motion is extremely important. For this reason, you should do arm exercises as stretches while the drains are in place. Once the drains are removed, you may progress to shoulder exercises.
After breast reconstruction surgery, it is recommended you avoid exercise that raises your heart rate and blood pressure for 2 weeks. Walking is encouraged immediately after surgery. After two weeks, you can return to aerobic exercise slowly. Avoid running or jumping and chest-specific exercises (chest press, push-ups, etc.) for 6 weeks. All types of exercise are permitted after 6 weeks.
Listen to your body. Start out slowly and gradually increase as tolerated. If you experience pain or discomfort, decrease the amount of exercise.
Do not lift anything that requires straining for 6 weeks. You may lift anything that does not require straining or struggling after discharge, but heavy lifting should be avoided for six weeks post-operatively.
You may not drive while taking narcotic pain relievers during the day. It is okay to drive while drains are in place as long as you are not taking narcotics during the day. You may drive whenever you are capable and confident of the movements of driving and are no longer taking narcotics during the day. Always wear a seatbelt while in a car. Use a pad or pillow on your chest if necessary for comfort. A seatbelt is a life-saving device.
The average return to work time after tissue expander reconstruction is 2 weeks; after latissimus flap, the average return to work is 4 weeks; and after abdominal tissue reconstruction, 6-8 weeks. We will work with you on helping you return to work when you feel ready.
Please follow up with our office 1 week after surgery for your routine post-operative appointment. After drains have been removed, you will need to follow up with our office to begin expansions if you had a tissue expander or latissimus flap breast reconstruction. These usually begin between 2 and 4 weeks postoperatively and may happen once per week. The number of expansions varies between patients. If you had a TRAM, once drains are removed, we usually ask you to follow up between 3 and 6 months to discuss any desired revisions and/or nipple reconstruction.
Bunching at the incisions is normal and often resolves as you heal. If fullness or folding along the incision persists, this can be revised at your second surgery.
Your reconstructed breast will appear flatter in the front than your natural breast; this is normal.
This can be improved at your second stage surgery, but will not completely resolve.
It is normal to find lumps and bumps on the breast after surgery. These are due to the nature of the mastectomy and scar tissue. If you find a lump or bump on your breast, continue to watch and feel the area. If you feel the lump increases in size, please alert either your plastic surgeon or breast surgeon.
A small degree of asymmetry is normal after surgery. Asymmetry can be due to the placement of the implants on your chest, or may be due to asymmetries in your anatomy. It is important to note that asymmetries you have before surgery will likely still be present after surgery. Some degree of asymmetry is expected and sometimes unavoidable, and can be improved at your second surgery.
Bruising after surgery is normal. This can appear anywhere from purple to green or yellow in color. Bruising may also spread downwards due to gravity. This is normal and does not mean your bruising is worsening.
Discoloration of the incision can sometimes be seen after surgery due to a change in blood supply associated with mastectomy. Sometimes, this color change will appear similar to a bruise, slightly purple in color. These areas may blister or ooze slightly. These areas may also turn into a scab. If you notice any of these findings along your incision, this is not an emergency. We will continue to watch it over time. In many cases, you will be able to heal this area on your own. In some cases, we will aid your healing by removing the scab and reclosing the area. This can happen in the office.
You cannot rely on your feelings in the operative area; feelings alone are not an indication of a problem. When you have a change in sensation, it is important to look at the breast and feel with your hands; feelings with findings you can also see with your eyes or feel with your hand are important. Zingers, itching, burning, cold, lightning bolts, and numbness are all very common sensations felt after breast surgery. They do not indicate there is a problem, and are all normal parts of healing and recovering after mastectomy. These sensations can be felt on the chest, the armpit, and along the inside of the arm.
You may have many strange sensations after surgery in the surgical site, most of which are very normal and do not need to be reported to your surgeon. The following list describes findings that are concerning and should be reported to your surgeon:
It is okay to sleep on your sides once the drains have been removed. Sleeping on your stomach is not recommended for the first 6 weeks. A good tip to help you sleep on your back after surgery: place a pillow under your knees and on each of your sides. Putting a few pillows under your head and shoulders to prop yourself up can also help with sensations of tightness across the chest.
Many women experience a sensation of tightness in the armpit after mastectomy and reconstruction. In some women, this sensation may persist after the initial post-op period. This is called cording. It is usually felt in the armpit and front of the chest, and can extend down the arm, possibly all the way to the wrist. Continuing shoulder range of motion exercises can improve this. Physical therapy may be indicated if exercise alone is not able to resolve the symptoms.
This surgery is most commonly performed under sedation. This means you will be sleepy and relaxed in the operating room, but may not be completely asleep. Most patients have no recollection of surgery when it is performed under sedation. This type of anesthesia does not require a breathing tube as you will be breathing on your own, and allows for a quicker recovery with less risk for postoperative nausea and vomiting. The surgery itself usually takes 1 to 1.5 hours. You will not be allowed to drive yourself home afterward, so make sure to arrange a ride. Most patients return to work within 1-3 days. The need for narcotic pain control after this surgery is often extremely minimal. Most patients take narcotic pain relievers for the first night and possibly the next day only. You will most likely not have additional incisions other than the initial mastectomy incision. There are no drains used in this procedure.
It is possible that you will have an adjustable implant with a port that comes off of the side of the implant. It is either the size of a dime or a quarter and can be felt beneath the skin. This port may be accessed to add or remove saline. The port is most often removed at the same time as the nipple reconstruction.
The nipple reconstruction is performed two to three months following your final implant reconstruction. Should you need or desire any surgical revisions to the actual breast, it will have to be completed prior to the nipple reconstruction. The nipple is done most often in the office, but may also be performed as an outpatient procedure in the operating room under light or no sedation if you desire other revisions. You will need about 24 hours to recover.
Your surgeon will use your own skin on your breast to create a prominence. It will be sutured into place. The sutures are typically dissolvable.
The nipple and areola are done at two separate times. The areola is the final phase of the reconstruction process and is typically done two to three months following the nipple reconstruction. This is done in our office by Jeff Paetzold. The tattoo takes approximately one hour for each side. You may not swim for 2 weeks following the tattoo.
Implants are more round and fuller at the top than natural breasts. They appear similar to breasts in a bra. For this reason, they do not necessarily look “natural” but their appearance is usually pleasing to reconstruction patients.
Reconstruction with tissue from your back or your abdomen can have a more natural appearance; these types of reconstruction will feel softer, will change with your weight, and will move more like natural breasts.
Breast cancer can recur in breast tissue. Ask your breast surgeon or oncologist about your chance of recurrence. Implant reconstruction and tissue-based breast reconstruction (latissimus flap or TRAM flap) do not change your risk for recurrence of breast cancer.
If you had implant breast reconstruction, gaining or losing weight will not change the size or appearance of your reconstruction. If you had TRAM flap reconstruction, your reconstructed breasts will change weight with you just as your abdomen used to.
Numbness at the site of your mastectomies is normal and to be expected. Most women regain sensation in this area, but it will be about two years until you are able to determine exactly how much sensation you will have. You may experience sharp, shock-like sensations while your nerves are ‘waking up.’ This is normal and will improve for up to two years.
No, you do not need to have a mammogram following a mastectomy. You will need to continue yearly mammograms on the unaffected breast, if applicable.
You may begin arm exercises after your drains are removed. ‘Wall walking’ is an example of an exercise that will help to improve your range of motion. As soon as you are able you may use the exercise positions as stretching positions, this will help keep mobility without increasing drainage. Just reach out in the direction of the exercise and hold the position for 5-10 seconds and then move on to the next one. You may repeat this 3-4 times per day.
No. MRI is recommended by the Federal government to assess for potential leak of the implant. Because we know that implant leakage does not cause any major health concerns, we only recommend getting imaging to identify rupture if you notice a change in the appearance or feel of the breast that is consistent with rupture.
Not all expanders will cause a metal detector to alarm, but it is possible. If you are planning on traveling, let our office know so that we can provide a note explaining the nature of the device.
Please notify our office in the event that you are to have an MRI while you have an expander. This may or may not be possible, depending on the type of device.
Is the dimpling under my breast after my second-stage surgery normal?
Yes, as part of your second stage revision, we may place sutures at the bottom of the breast under the skin. This can cause the fold at the bottom of the breast to appear dimpled. As the sutures dissolve, this dimpling will go away and the fold will appear smooth. Increased pain in this area is normal after surgery if sutures were placed.
MAC stands for Monitored Anesthesia Care and is most commonly called “twilight”. It involves sedation of varying levels to keep you comfortable during your procedure. During a MAC procedure, you will most likely sleep, but you may be slightly aware that you are in the operating room. Most patients have no recollection of the procedure or their time in the operating room. MAC anesthesia allows for a quicker recovery period and reduces nausea and vomiting.
Each patient will scar differently. Scars are unpredictable. You may put anything over-the-counter on your scar, but time is the best healer for all scars. If your scars appear to be red or raised, please notify our office to talk about options for improving their appearance.