After Mastectomy, Now What?
Reconstructive surgery is considerably less painful after a mastectomy thanks to advances in pain control.
April 9, 2009
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YahooMyWebA woman who is diagnosed with breast cancer and will undergo a mastectomy faces a difficult decision during this tumultuous time: whether to have reconstructive surgery. It’s a personal decision between a woman and her doctor, but there is some good news for women who want reconstructive surgery but are worried about pain and recovery from yet another procedure. New advances in pain control reduce the need for narcotics while controlling pain and speeding recovery. New devices deliver local, numbing anesthetics directly to the surgical site through a specially designed antimicrobial catheter. Manufacturers of the On-Q PainBuster report that a randomized study showed that use of the system was associated with a more than 50 percent reduction in surgical site infections when compared with narcotics.
SmartWoman spoke with, chief of plastic surgery at Johns Hopkins Bayview Medical Center, about reconstructive surgery and this new system.
Dr. Michele Shermak
Q: How soon after a mastectomy can a patient have reconstructive surgery?
Dr. Shermak: Breast reconstruction has been traditionally performed in an immediate or a delayed fashion. Immediate reconstruction is performed at the time of mastectomy and delayed is performed within months to years after the cancer treatment. More recently plastic surgeons have discussed the “immediate delayed” reconstruction, where the mastectomy procedure is performed and the patient returns within a week or two after the final pathology is determined and the need for additional chemotherapy, radiation or surgical treatment. The severity of the cancer, possible need for postoperative radiation treatment, and patient preference all impact timing of the reconstructive procedure, and this should be discussed first with the breast cancer surgeon and then with the plastic surgeon.
Q: How is a breast reconstruction after mastectomy done?
Dr. Shermak: Breast reconstruction may be broadly described according to timing and type of reconstruction. We discussed timing in the previous question. Types of reconstruction fall into two major categories: implant-based and autologous tissue-based.
Implant reconstruction begins with the placement of a deflated implant called a tissue expander. This expander is partially inflated at the time of placement and filled to its full volume in the clinic setting in multiple sessions. After another four to six months, the tissue expander is replaced with a permanent implant that is either saline or silicone.
Autologous tissue may come from the back, abdomen or buttock region. A TRAM flap uses donor muscle, fat and skin from a woman’s abdomen to reconstruct the breast. The flap may either remain attached to the original blood supply and be tunneled up through the chest wall, or be completely detached, and formed into a breast mound.
Alternatively, your surgeon may choose the DIEP or SGAP flap techniques which do not use muscle but transport tissue to the chest from the abdomen or buttock. A latissimus dorsi flap uses muscle, fat and skin from the back tunneled to the mastectomy site and remains attached to its donor site, leaving blood supply intact. Occasionally, the flap can reconstruct a complete breast mound but often provides the muscle and tissue necessary to cover and support a breast implant.
Breast reconstruction is staged. A second surgery is necessary to apply artistry to reach symmetry. The nipple may also be reconstructed in a second stage, although sometimes it is performed in the first stage.
Q: Do most women opt to have reconstruction after mastectomy?
Dr. Shermak: I tend to see a skewed group, i.e. those who desire reconstruction. The difficulty in dealing with breast cancer for many women can be eased with reconstruction, helping women feel whole and restored. Reconstruction restores not only the breast removed but also body image, which is very important. Reconstruction is not for everyone, but it is important for women to discuss it with one another; sharing personal experiences is valuable to those seeking information.
Q: Is a fear of pain a factor in their decision?
Dr. Shermak: Pain can be a very real fear for patients. However, there have been recent advances in medicine that have greatly improved patients’ post-operative pain management, such as non-narcotic pain pumps, which I discuss with my patients when they come in for their initial consultation.
Q: What are the advantages to having the surgery done?
Dr. Shermak: Breast reconstruction is a physically and emotionally rewarding procedure for a woman who has lost a breast due to cancer or other condition. The final results of breast reconstruction following mastectomy can help lessen the physical and emotional impact of mastectomy. The creation of a new breast can dramatically improve a woman’s self-image, self-confidence and quality of life.
Q: How does using a pain pump, such as ON-Q, benefit the patient?
Dr. Shermak: The patient will feel more comfortable and experience almost no pain. Because their pain is managed in the local area where the pain is coming from, they take fewer narcotic painkillers, which can cause constipation, nausea, vomiting and grogginess. They are also discharged from the hospital sooner because they are feeling so much better.
Q: What do you as a physician like about using it?
Dr. Shermak: It makes me feel more confident that my patients’ pain is well managed and they are comfortable. It allows them to recover faster and take fewer narcotics and actually treats their pain better than narcotics alone. This means they can be discharged from the hospital sooner, sometimes after just one night.
Q: What can women expect in terms of recovery after reconstructive surgery?
Dr. Shermak: Recovery depends upon the mode of reconstruction. With implant reconstruction, recovery is limited to the chest region. About three weeks after expander reconstruction, more fluid can be placed in the expander in the clinic, and the implant can be filled at each visit spanning one to two weeks. With rotation of back or abdominal tissue for reconstruction, there may be more difficulty with recovering, but the marcaine pain pump can assist with this recovery. In-hospital stay typically lasts one to three nights. Pain should be minimal if the surgeon uses a non-narcotic pain pump to manage their pain after surgery. They may also prescribed narcotic painkillers, for patients who may need more medication. Patients are given specific instructions that may include: How to care for the surgical site(s) following surgery, medications to apply or take orally to aid healing and reduce the risk of infection, specific concerns to look for at the surgical site or in their general health, and when to follow up with their plastic surgeon. Healing will continue for several weeks as swelling decreases and breast shape and position improve. Patients should continue to follow their plastic surgeon’s instructions and attend follow-up visits as scheduled.
Q: When can they return to work and normal activities?
Dr. Shermak: This may vary from patient to patient and what their surgeon recommends. Following your physician’s instructions is key to the success of your surgery. It is important that the surgical incisions are not subjected to excessive force, abrasion, or motion during the time of healing. Your doctor will give you specific instructions on how to care for yourself.
Q: Are you using this pain pump in any other surgeries, and if so, why?
Dr. Shermak: Yes, I also use a pain pump for my body contouring patients. Body contouring is performed to tone up lax tissues or after major weight loss. It improves the shape and tone of supporting tissues and removes excess sagging fat and skin. These procedures may be performed in ambulatory surgery centers that allow discharge right after surgery, and the pain pumps make this a viable option.
This is a great blog, thank you! I was looking for breast reconstruction surgeons recently and ran into The Patients Advantage. They have a great way to find the best surgeons and it is completely free. Check them out (www.ThePatientsAdvantage.com).
I had a partial mastectomy 10yrs ago followed by 39 treatments of radiation. No reconstruction at the time. Would implant surgery be a possibility at this time? Is there any recent data?