Postoperative Discharge Sheet - Latissimus Doris Breast Reconstruction

The aim of this information sheet is to provide you with the day-to-day information that should help guide you through your post operative recuperation at home.

General Advice

Pain
It is usual to suffer mild discomfort in the donor site particularly the middle to low back area for the first month or so. It is recommended that for the first week or two you take regular painkillers to control this discomfort and to assist in your mobilisation exercises.  Our ladies often complain of discomfort and a woody hardness in the back when they sit against firm backed chairs.  This settles with time.

Bathing
On discharge from hospital a clinic appointment will be arranged for a wound review the following Monday.  Until this wound review has been completed you are advised not to get either your breast or your back wound wet as this will increase the risk of developing an infection. Therefore, you will need to wash carefully with a sponge or flannel.  Once your wounds are assessed in the Dressing Clinic, if they have healed, you will then be advised that you can commence bathing and showering normally.

Exercises
The physiotherapists or nursing staff will explain a range of exercises for you to undertake to encourage return of full movement of your shoulder.  The goal is to recover a full range of movement, being able to elevate your hands completely above your head by one month post operatively. To start with you will experience stiffness and limited range of movement during these exercises and gradually this range of movement will increase.  The extent of movement you can achieve on a daily basis should be limited by comfort.

Bra Wearing
There are no hard and fast rules for when you can commence wearing your bra following latissimus dorsi breast reconstruction.  The general advice is that you may start wearing your bra the day before discharge from hospital.  The aim of bra wearing is simply to support the newly reconstructed breast which will be swollen for several weeks.  Gentle support in a sports bra should provide some degree of comfort during the early post operative period.  You do not need to wear a bra in bed at night, but whilst upright in the day, most ladies find wearing a sports bra beneficial.  However, if you find it uncomfortable it is perfectly safe to leave the bra off.

Household Chores
You should do nothing for the first week after surgery.  For the second week after surgery you are safe to potter around making cups of tea, washing up etc and then between two weeks and a month after surgery you can return to light household chores such as ironing, but you should avoid lifting anything heavy during this period.  After a month from surgery you may return to full normal duties gradually within the limits of comfort.

Driving
You should only return to driving once you are sufficiently confident to undertake an emergency stop without hesitation.  Until you have achieved this degree of confidence you should not drive.

Sexual Activity
It is safe to resume sexual activity once you feel comfortable.

Returning To Work
This depends on the type of work you do.  You are recovering from a fairly major operation and it may take a good number of weeks before you regain your capacity for full concentration.  Physically, you should be able to return to light office type work after three to four weeks and more heavy manual work between four to eight weeks, returning earlier if your employer can offer you light duties.

Smoking
As you will have been advised pre-operatively, smoking is associated with a 60 fold increase in complications and you should have been advised to stop smoking prior to the operation.  If you are determined to start smoking again after the operation, you should not do so for at least three weeks or until your wounds have healed, whichever is the later.  Once the wounds have healed, smoking is unlikely to have any detrimental effect on either your breast or your back.

Massaging The Areas 
The wounds are best left completely alone for the first six weeks.  Six weeks after your operation your wounds will be as strong as they are ever going to be.  The scars are likely to be quite firm, red and possibly slightly raised or lumpy.  At this time you will be advised to moisturise and massage regularly with E45 cream, spending about five minutes massaging each scar every day.  The E45 cream simply acts as a lubricant to stop you rubbing the top layer of skin off and the important part of the massage is the pressure applied with your fingertip or thumb.  You should rub along the length of the scar and not across it as this will stretch the scar.  This pressure should start off fairly gentle until you are comfortable and then increase the pressure of the massage until you are rubbing your scars quite firmly. This will speed up the healing process and soften your scars.

Breast Self Examination
The mastectomy operation removed the vast majority of your breast tissue, but may occasionally leave small amounts of breast tissue just underneath the breast skin.  There is no chance you can develop breast cancer in the muscle or fat which has been brought forward from your back.  However, there is a very small chance that you could develop another breast cancer arising from any residual breast tissue left under the skin.  For this reason it is wise to examine your reconstructed breast on a monthly basis at the same time that you examine your normal breast, looking for any small lumps which develop underneath the skin.  It is quite safe for you to start examining your reconstructed breast after about six weeks, and in the early months it is important that you become familiar with how this reconstructed breast feels.  There will be some hard areas and some soft areas within the breast.  Once you have become familiar with the feel of your normal breast, the aim of subsequent routine self examination is to detect any changes from the norm.

Future Mammograms
Again, as the breast tissue has almost been completely removed from the reconstructed breast side there will be no detectable breast tissue and therefore no need for routine mammography of the reconstructed breast.

Complications

Bruising
Bruising is very common following breast reconstruction and usually resolves over the first three weeks.   Just occasionally a bleed may occur into the breast or into the back, known as a haematoma. This can happen at any time over the first two weeks after surgery, either in hospital or after you have been discharged home.  If this happens, the breast or the back area may swell significantly and there may or may not be new bruising evident.  This is usually associated with some pain.  If this happens you should telephone the ward for advice.  If you have developed a haematoma, then you may need to re-admitted, have a scan to confirm it and have to return to theatre to have the haematoma evacuated.

Infection
It is fairly common for part of the wound to be a little slower at healing than other areas and may leak a little blood or clear fluid over the first two weeks or so.  This will be managed by our nurses in the Dressing Clinic.  However, occasionally an infection may develop.  This usually presents with a patch of redness and localised tenderness around the wound and may or may not be associated with an increase in the amount of fluid discharging from the wound.  This red area will feel much warmer than a non infected area on the same breast.  If this situation occurs please contact the ward for further advice.  Infections usually respond rapidly to a course of antibiotics.

Seroma
Very infrequently a fluid collection may develop in your back in the first few weeks after surgery. If this fluid collection is small nothing needs to be done.  Occasionally, this collection may be moderately large and cause some discomfort and interfere with your choice of clothes. 

This is usually treated by inserting a needle into the collection and sucking the fluid off.  After such drainage the collection usually returns, but is smaller and may or may not require further drainage. Eventually this smaller collection will resolve completely but it may take many weeks to do so.
 
Constipation
The combination of post operative loss of appetite, pain killers and reduced mobility all contribute to post operative constipation.  This is usually identified and treated whilst you are still with us in hospital.  However, it is still common for our ladies to experience some degree of constipation whilst at home and if this happens to you, please do not hesitate to pick up the telephone and contact the ward.

Fat Necrosis
Occasionally a small amount of the tissue that has been used to reconstruct your breast may not receive enough blood supply to keep it alive and an area of fat may die.  This usually presents itself four to six weeks after surgery as a tender lump in the breast.  Occasionally, liquid fat may discharge out through the wound or more usually is re-absorbed by the body over a period of several months.

Capsule Formation
If your breast has been reconstructed using a combination of a latissimus dorsi flap and a breast implant, there is a risk that you may develop a capsule around the implant.  If a capsule develops you will notice that the breast becomes firmer and may change shape with the breast riding higher than the opposite breast.  With progressive tightening of the capsule you may experience discomfort.  Capsule formation usually occurs after several years, but it has been known to occur within the first year of surgery.  Capsules are usually treated by removing the implant and the capsule together and reinserting a new implant. If you think you are developing a capsule, you should either visit your family doctor or contact your Plastic Surgeon’s Secretary.

Adjuvant Surgery

As will have already been explained to you, breast reconstruction usually requires several procedures before you obtain the desired goal of symmetrical breasts. Normally the following procedures will not be undertaken until at least nine months has elapsed following your reconstruction operation.  This necessary delay allows the reconstructed breast to settle into its final position and shape, allowing us to then predictably reshape or match your opposite breast.

Reshaping Of The Reconstructed Breast
The reconstructed breast may require some degree of reshaping, for example, tucking the skin, liposuction to reduce unwanted fullness or excision of dog ears and skin folds.

Nipple Reconstruction
Nipple reconstruction is a 30 minute procedure, usually undertaken under local anaesthetic on a day case basis to create a nipple.  The reconstructed nipple will initially be bigger than your normal nipple but will shrink with time.  The drawback of this procedure is that unfortunately about half of them almost completely flatten with time.

Nipple Areola Tattooing
About six weeks after your nipple reconstruction tattooing can be undertake to closely mimic the colour and size of your normal areola.  Tattooing is a 30 minute procedure, done under local anaesthetic so there is no discomfort involved and you go home on the same day.

Reshaping Of The Normal Breast

1. Mastopexy: If your normal breast is particularly droopy then this breast can be lifted and reshaped.
2. Breast Reduction: If your normal breast is much larger than the reconstructed breast then the breast can be reduced in size and altered in shape to achieve symmetry.
3. Breast Augmentation: If your reconstructed breast is larger than your normal breast and you prefer the larger breast, in which case the normal breast can be augmented by inserting a silicone implant.