Breast reconstruction

Reconstruction timeline

Anna – Plastic surgeon: The most important thing is to get your cancer treated first. We can reconstruct you and in some cases at the same time. But even if we can, it doesn't mean that we have to because, if you're not ready or not sure what you want with the reconstruction, then we can always do what's called a delayed reconstruction. Some people aren't actually suitable for an immediate reconstruction anyway, and we have to do a delayed reconstruction for that but most important thing, get the cancer treated first and then we worry about the reconstruction and what it looks like down the track.

We have lots of options as plastic surgeons - what we can offer you and we can go through that with you when you're ready - whether that's before your initial cancer surgery or whether we do that later on so don't ever feel like you're rushed or pushed into making a decision. If you're not ready, then we can wait and do it later.

Justin – Plastic surgeon: In some circumstances, the cancer treatment involves radiotherapy as well as intensive chemotherapy. For some patients they will have things like Herceptin, which is separated at months apart and those patients can have a stage reconstruction or potentially a small flap done at that time, however in those patients we'd like to delay it until they're absolutely through their chemotherapy.

One of the important things is to make sure patients are at their fittest and healthiest when they approach an operation and the best thing is to delay those operations until the patient is ready, both physically and mentally.

Andrew – Plastic surgeon: If someone's in the midst of their chemotherapy or radiotherapy, we would normally wait a minimum of 6 months until offering a reconstruction. We can’t safely perform reconstructive surgery during chemotherapy and with radiotherapy, the effect of that on the tissues takes a certain amount of time to settle down sufficiently for us to perform a reconstruction safely. So, when we see patients who were in the midst of their postoperative adjuvant treatment, we normally would suggest that they defer reconstruction for 6 or 12 months.

There is the situation where patients are having neoadjuvant chemotherapy so chemotherapy before the mastectomy. Now in that context, they’ll finish the chemotherapy and normally have a mastectomy within about 6 weeks. They can safely have an immediate reconstruction at that point so that's a slight difference.

Owen – Breast Care surgeon: Once the chemotherapy is finished and all the blood counts are returned to normal, then it's usually safe to do whatever form of surgery is required. Having said that, there are some women who are going to finish chemotherapy and then need to have radiation and if there’s a need to have radiation and if a woman has had an implant-based expander placed, then that needs to be, preferably, fully expanded, or close to full expansion before the radiation starts. There's a process that occurs during chemotherapy to get that implant expanded and then she’s ready for her radiation.

Sometimes, implants are placed prior to radiation to create a pocket. There are some surgeons that favour, even if they intend to perform an autologous reconstruction, sometimes it's favoured to create a bit of a pocket by putting an expander in beforehand, but these are just some of the nuances and different ways that reconstruction can be approached.

Mastectomy

Emma – Breast care nurse: Mastectomy, in simple terms, is the removal of the breast so how that’s interpreted or how that’s enacted, it can be done in many different ways. I guess the old fashioned (why do I want to say 'old fashioned' cause that’s not right), but what most people think about when they think of a mastectomy is a side to side chest wall incision, a flat chest wall and then a nipple areola complex is gone so, that’s what we call a simple mastectomy but I guess, that can be a very appropriate mastectomy in the right circumstance, and still a tool that’s used regularly today.

I guess there are variations on how mastectomies can be performed now, particularly when women are interested in having a breast reconstruction so, components of the breast skin or the nipple areola complex can be preserved whilst removing most of the parenchyma which is the actual underlying breast tissue. Usually we remove 95-98 plus per cent of the breast tissue, but it’s never 100 per cent removed, even when you have one of those more traditional type mastectomies.

Owen – Breast surgeon: A total mastectomy is done usually when a two-stage operation is going to be done. A subcutaneous mastectomy or a skin-sparing mastectomy or a nipple sparing mastectomy is usually done when some form of volume replacement is going to be done immediately.

Now there are problems or more risks with doing skin-sparing or nipple sparing mastectomies because you’ve got to leave more tissue behind, and you’ve got a greater risk of problems with blood supply to that tissue. Again, those nuisances need to be discussed in detail with the patient beforehand.

Jen – Breast care nurse: A mastectomy is removing all your breast tissue, almost entirely. They might leave a small percentage of tissue so to me, it’s kind of like oranges – your breast aren’t oranges but going in and removing all the inside and then just popping the skin back and you’re left with a flat chest. There is a small percentage of breast tissue left there – maybe 2 to 3 per cent, but it’s very easy to kind of see and feel and you often have a straight scar from mid chest to under the arm at nipple high, straight across the chest.

If you’re a larger lady and you’ve got like lumps and bumps under your arms (which some of us do), sometimes you’ll be left with lumps and bumps underneath this scar. They’re not always completely flat so talk to your surgeon about that – what kind of outcome you might have and if you’ve kind of got a bit of fat under this arm [points to right side of her under arm], you’ll notice the fat under this arm [points to left side], once we remove this breast because we don’t remove the breast tail or adipose fat tissue, it’s there.

We like to look at each case and talk to each woman and obviously, I think we have a low threshold that if a woman is very keen to have a prophylactic mastectomy because of symmetry; because she has some risk and some family and genetic risk. You’ve also got to keep in mind, many women see us with a tiny early breast cancer that we can get very easily with a wide local incision or a lumpectomy, and they come in saying, “Look, I want both breast off” out of fear of cancer. Breasts don’t act like twins and your risk may not be to the other breast so the evidence suggest that your risk is actually in a high risk breast cancerous to the body is spreading so, don’t think that removing the other breast is going to get rid of that risk of breast cancer - I think that’s important and up front, if your headspace is going, just get rid of them, you’ll feel better. We can’t put them back on. One healthy breast being matched with say, a reconstruction, might be just a fine thing to do. But do we do prophylactic mastectomy’s for women because they’re struggling emotionally or they’re struggling for symmetry and they know there’s no risk? Yes, we do, but talk to your clinician; talk to your treating team.

Michelle – Breast care nurse: A prophylactic mastectomy is a mastectomy where they remove the breast tissue when there is no cancer in the breast. There are a few reasons that they might do a prophylactic mastectomy. The main reason, in Queensland, is because, you may be at a high risk for getting breast cancer in the future because you’ve got a genetic mutation - one of the BRCA genes or one of the other genes that leads to a much higher incidence of breast cancer in the family – high family risk, so very often, we offer prophylactic mastectomies in those instances.

There are times where the psychological anguish of the remaining breast because it could be very different in size, shape and all the rest of it. Sometimes that’s discussed too but it really needs to be discussed very, very closely with your treating team and if the reason for a prophylactic mastectomy is because of fear of recurrence, that’s not always a good indication for removing a breast so it’s a very good time then to come and speak to your treating team and just run through exactly what your risk is with cancer in the other breast.

Immediate reconstruction

Andrew – Plastic surgeon: An immediate reconstruction means that the breast is reconstructed at the same time as a mastectomy. The benefit for people is that they will go to sleep with a breast, and they’ll wake up with a breast or be it, possibly a different appearance to the breast. Depending on the way the breast is reconstructed, that breast might look very similar to the breast that they had when they went to sleep or it might look different with a view to progressively changing that reconstruction but, it can be done at the same time as the mastectomy.

The main contra-indications that we would have depend on the modality, so if we’re talking about an autologous reconstruction, our contra-indications can include high BMI; it can include people who are active smokers; it might include that patient’s co-morbidities, so if they have many other medical problems that would preclude a relatively lengthy aesthetic, then they might not be a fit candidate for that kind of reconstruction. Equally, if a patient is considering an implant reconstruction, then there are relatively contra-indications in the same context.

A very large breast can be a relative contra-indication to an implant reconstruction; the morbidly obese patient with a high BMI and from my point of view, I think that, when a patient does need radiotherapy, an implant reconstruction does worse than an autologous reconstruction, so I typically try and sway toward an autologous reconstruction if a patient needs radiotherapy.

Owen – Breast surgeon: No reconstruction should interfere with the pathway of the cancer treatment because that’s the priority, but there isn’t any reason why that can’t occur at that same time or if a woman isn’t sure about what she wants to do or she’s not comfortable to make that decision. It is a decision that can be deferred, so a reconstruction doesn’t have to happen immediately – it can be just as good or equivalent doing it as a delay.

Sometimes, again, it depends very much on the woman herself. Some women can’t even contemplate not having something done immediately – they don’t want to wake up flat chested; don’t want to have to deal with wearing prothesis, so in that situation, we can talk about some immediate reconstructive options. If a woman isn’t sure she can make that decision, it’s a lot to absorb at the one time so I think in that situation, unless you’re very, very sure you want reconstruction, its better to defer that decision.

Staged reconstruction

Andrew – Plastic surgeon: A staged reconstruction by its name implies that there are stages. Those stages can mean different things. A staged reconstruction might entail having a tissue expander placed at the time of a mastectomy, which allows us to preserve the skin of the breast for example and prevent it from shrinking and contracting. That tissue expander can be replaced either with a silicone breast implant or it can in fact be replaced with an autologous reconstruction. The latter is a less common solution but to my mind, it is an increasingly popular one because it allows us to treat the cancer very quickly in a way that is less reliant on access to the reconstructive service so for example, if someone doesn’t have access to autologous surgery, they could have a tissue expander placed and then subsequently be referred for an autologous reconstruction elsewhere so that’s an option we may find ourselves using more down the track. It just implies that there’s multiple steps to the reconstruction. It’s very rare that we perform immediate reconstruction that isn’t done in a single stage.

Michelle – Breast care nurse: A stage reconstruction is where the treating team will remove the breast, put some saline expanders or air expanders into the cavity that’s created and slowly stretch the skin and muscle up to create a pocket for the reconstructive surgery and then the reconstructive surgery, the implants, or the autologous reconstruction, gets done at a later stage.

Delayed reconstruction

Justin – Plastic surgeon: So delayed reconstruction is one that isn’t performed at the same time as a mastectomy. Generally, we would see those patients who require adjuvant therapy – these are ones who are requiring chemotherapy, post-operative radiotherapy or both and in those patients, they are not ideal immediate reconstruction patients because the radiotherapy can cause issues with the flap; they can cause issues with the implants, and so we would delay their reconstruction until their definitive cancer treatment is performed.

Owen – Breast surgeon: The delayed reconstruction is really when, no form of reconstruction is done at the time of the mastectomy and the woman comes back at a later date. If a woman has had a mastectomy and chest wall radiation, then some of those options are reduced because implant-based reconstruction is generally not an option or is difficult to do in that situation but if she’s not had chest wall radiation, she’s still quite suitable for any form of autologous reconstruction, provided she has enough tissue to build a breast, or she’s suitable for implant-based reconstruction, providing she has an expander to stretch up the cavity to put in a later permanent implant.

Tissue expanders

Justin – Plastic surgeon: Tissue expanders are part of a staged reconstruction. There are several varieties that can be used. Some are filled with saline, other ones are filled with air.

Every surgeon will have their preference on which one they use. Think of them as a temporary implant. They go in a silicone covering and they will be slowly inflated over time to help expand the chest wall and expand the skin to allow an implant to be put in at a later date.

Penny – Consumer: The best way I can describe (a Mum would understand), is that it feels like you’re in-gauged – like you milks coming in. You’re really hard; it’s really tight; I do notice that my posture – you try and protect yourself.

Steph – Breast care nurse: The first 3 months for a tissue expander, it will sit up fairly high and with gravity as your best friend, it will start to pull the tissue expander further down a little bit.

The first 3 months for tissue expanders, you won’t look very attractive; it won’t look like it what you’re going to have because it’s not – it’s after the change over from the tissue expander to the implant that you’ll find that, yes, this is mine; I can embrace it; it looks good.

After the permanent implants has been put in, you need about 3 months or so for all the swelling to settle.

Michelle – Consumer: Tissues expanders are ugly. They’re not pretty; they’re lumpy, bumpy, wonky, big and boxy and uncomfortable and look terrible. They don’t faintly resemble what your final outcome will look like so be prepared for that.

I’m so grateful that she said that to me because, even though I was prepared for it, the very first time I looked in the mirror, I was pretty shocked at how awful they looked naked – they looked ok in a bra or a singlet top. Although I was shocked, I knew that they were going to look awful, because I’d been told that, so it was like, oh gee, she wasn’t wrong there was she?

It’s just a process you go through. It’s not permanent. It’s just a temporary thing but be prepared that even if you go straight to implants or tissue, there’s going to be swelling as well from the surgery you’ve just had, so it’s going to take a little bit of time to settle down to be your final product. Just talk to your doctor or your breast care nurse if you have any concerns.

Breast implants expanders

Andrew – Plastic surgeon: The implants that we use for breast reconstruction are the same silicone gel implants that are used for patients having cosmetic breast augmentations. The difference relates to the way that we can impact on the breast with that implant, having removed all the breast tissue.

For a patient having a cosmetic operation, they have the natural breast, which is simply being made larger. The benefit of having that existing breast tissue is that it disguises the effect of the implant. If you take away the beast tissue, there’s no buffer to disguise the implant and its effect and an implant isn’t natural tissue – doesn’t behave like natural tissue; doesn’t feel or look like natural tissue, so when you take away the disguising effect of the breast itself, and you simply have an implant after a mastectomy, it can give an acceptable breast shape but it will never look, feel or behave the same way as a normal breast does.

The implants are exactly the same – they are silicone gel. They are not designed to be permanent. They do need to be, either replaced or revised, roughly speaking, every 10 to fifteen years for most patients and after mastectomy, complications associated with silicone breast implants occur at a higher rate when we compare that to, when they’re used in a cosmetic operation.

If a patient, after a mastectomy, have a higher incidence of capsular contracture, which is the situation where the body’s scar tissue tightens around the breast implant, can distort the appearance of that breast implant and can be associated with pain. Their risk is about twice as high as in a cosmetic operation. If you add radiotherapy into the mix, their risk of capula contracture is at least 4 times high as high.

The biggest risk with an implant reconstruction is infection. If the patient gets an infection around an implant, the body can’t fight that infection easily and often that will lead to the implant needing to be removed and the reconstruction then has to be abandoned for a period of time before, possibly, reattempting a reconstruction later on down the track – that could be 12 months, 2 years which depends on a lot of issues.

Where an implant reconstruction has failed, often a patient won’t be able to have a subsequent implant reconstruction – they might need to convert to an autologous reconstruction.

Owen – Breast surgeon: We can never replace what was there before. We can never reproduce exactly the breast a woman had before. If a woman is very happy with the look and feel and shape of a breast, then she may be disappointed with what the outcome is going to be after reconstruction.

Sometimes women are not happy with the breast shape they’ve got, or they’ve contemplated having a reduction or contemplated having a lift, in which case, sometimes they’re happier with the reconstructed breast – it may be smaller; it may be uplifted but nevertheless, it’s not going to be the same as the breasts they had before.

It’s important to have that very individual discussion with that very individual situation so that a woman has a realistic expectation of what can be delivered. I think if you build the expectations up too high, then it’s a recipe for disappointment but if you go into reconstruction with the view that you’re going to build something that’s going to give a shape; its going to give function, then most women are going to be happy to have a functional result.

Anna – Plastic surgeon: When we’re using things like implants, it’s not like doing a cosmetic augmentation, so that’s important to know. It’s never going to be the same if you don’t have the breast tissue there over the top of it. Same thing if were using your own tissues, it’s never quite going to be the same shape; not going to have the same sensation.

Our whole aim is to try and get you looking like you haven’t had breast cancer surgery when you’re in your clothes and you’re in your bra; you don’t have to wear an external prothesis, we just want to get you looking good in your clothes. Sometimes we can get you looking great with your clothes off as well, but you’re always going to look different.

Breast implant associated anaplastic large cell lymphoma or ALCL, is a relatively new entity that we’ve, in more recent times, we’ve discovered what it is and proved that it does have an association specifically with breast implants. It’s a rare type of T cell lyumphoma.

Mostly people present, on average, every 7 to 9 years after their implants have been put in and it usually presents as a unilateral - one sided swelling in the breast with seroma, which is that blistery, yellow kind of fluid that can form.

If you have breast implants and you present with something like that, or you feel some funny masses or anything, it’s important to go and see your surgeon about it. That said, don’t want to make anyone panic either. It is rare. We do know that it is associated with more higher textured implants.

There are certain types of implants on the market that have a higher rate than others – other types of implants that have a much, much lower rate so do discuss with your surgeon what type of implants they used – I think that’s important. They can tell you the exact risks – its anywhere between 1 in 2,800 implants to 1 in 86,000 implants.

When you’re looking at different types of range, generally, if you present with just the lyumphoma associated with the seroma, the treatment is to just take the implants and the capsule around the implants out, and the prognosis for that is very good.

The 5-year survival is 100 percent. Its slightly lower if you present with a mass. In those cases, you may need chemo or radiotherapy for that but, it is rare. We do know its there so do discuss it with your surgeon and if you do have implants, make sure you’re aware and have your implants checked up regularly.

Autologous reconstruction

Andrew – Plastic surgeon: The patient can have a reconstruction where we can put warm, soft, healthy, living tissue onto the chest in order to rebuild a breast. That can involve harvesting tissue from any number of sites but by far the most common, and what we’d consider the gold standard option, is to harvest tissue from the abdomen. That involves taking a piece of skin, with the fat tissue and some blood vessels from the abdomen. The tissue that’s removed is a little bit like the tissue that gets removed in a tummy-tuck – its not the same as a tummy-tuck, but a little bit like that. That tissue with those blood vessels can be moved to the breast and by doing micro-surgery, we can hook those blood vessels up to other blood vessels in the chest and that allows us to then shape that healthy, now living tissue with a blood flow, into a breast and it gives a great reconstruction. That’s called a DIEP flap - when you just take the skin and the fat with the blood vessel. The alternative to that is called a TRAM flap – that’s a slightly older fashion operation which involves sacrificing the muscle in the abdomen along with the skin and the fat, and that has implications in terms of a patients’ recovery and morbidity at the donor site for that tissue.

There are other ways of rebuilding a breast using your own tissue. We can do what’s called a Free flap, where we completely detach it and do micro-surgery and can take tissue from the thigh, sometimes the buttocks, but these are second line options. Typically, they’re not the first choice; they’re not performed anywhere near as commonly so therefore they’ve got a slightly higher risk. If a patients’ a candidate to use the abdomen, that’s always our first choice.

We can also do what’s called a Pedicle flap – that means we don’t have to do microsurgery – its still attached in some fashion and the most common option there is to use tissue from the side of the chest or the back. That can allow for a reconstruction of a partial breast defect or it can allow for a breast reconstruction, but we would still need to use an implant in most cases to give the patient volume.

Using the tissue from the tummy, we get enough tissue to rebuild a breast completely without needing to ever add an implant, which a lot of patients are a bit adverse to.

The risks of autologous reconstruction primarily relate to the bit of tissue that we’re moving to reconstruct the breast, for example, if we’re doing a Free flap, which involves microsurgery, the risks might be associated with the microsurgery itself – it’s just plumbing. If the blood can’t flow into the piece of tissue that’s being used to rebuild the breast, then that tissue will die, and it would need to be removed. The risk of a Free flap failure has gone down significantly over the last 20 years and the commonly quoted risks of failure in that circumstance is about 2 per cent in the literature. Most busy units have a risk lower than that – about 1 per cent.

Justin – Plastic surgeon: With your own tissue, generally we look at the available tissue we can use. That can be a combination of both muscle, skin and fat. In some cases, we use just the skin and fat; in a lot of circumstances we’ll use all 3.

With using your own reconstruction, we call it an autologous reconstruction – generally its tissues we would use from the back or the abdomen. There are, in some circumstances, one, where we use it from the upper thigh and it again depends on the patient and their circumstances - if they’ve had previous surgery in their abdomen. It depends on what they want from that surgery and if they’re happy to accept the risks associated with those types of surgeries.

DIEP is a type of flap that we use – we get from the abdomen. DIEP is an acronym that stands for ‘deep infery epigastric perforated flap’. Essentially what it describes is the blood supply to that bit of the abdomen and it’s the vessel that is used to supply that bit of tissue. It’s the flap that we ideally like to use because if doesn’t involve using any of the muscle from the abdominal wall, whereas a Tram flap uses part of the muscle from the abdominal wall. Not everybody is an ideal DIEP candidate and it really is based on anatomy of somebody’s abdominal wall. If your anatomy is favourable, we can do a DIEP flap. If your anatomy is not as favourable, then we generally have to use some variety of Tram flap. It’s hard to distinguish, just by looking at someone – we generally have to do a scan and assess their anatomy before deciding which flap that we would use.

A Tram flap is very similar to a DIEP flap. It’s the same tissue; it’s the same incisions; same blood supply, but the difference is that we have to incorporate a bit of muscle in that flap as a result of the anatomy or as a result of the particular orientation of the flap.

A lot of that is technical and it’s easy to go through to discuss exactly what that looks like with the patients when they come in.

An LD ... LD stands for ‘latissimus dorsi’ and it is a muscle in the back that we can use to bring around to create a breast shape in the front, on top of an implant. It’s a hybrid, or a combination type reconstruction as we’re using both an implant as well as a flap and a little bit of skin. Those are ones that generally we use in patients who aren’t great DIEP or Tram candidates, as well as patients who don’t particularly want a long surgery or don’t like the risks associated with the DIEP or the Tram reconstruction.

TUG is a type of flap that is used from the upper groin. It stands for Transverse Upper Gracilis. It’s very similar to a DIEP or a Tram Flap in the fact that it’s a Free Flap, meaning that we disconnect it from the body and then reconnect it into the vessels in the chest wall. It is one that’s used in distance circumstances in patients who don’t want a large incision on the abdominal wall, or they don’t have enough tissue in the abdominal wall to create a breast. They do leave a reasonable scare and not all patients are happy with the risks associated with that operation.

Recovery

Andrew – Plastic surgeon: I get asked this a lot, mainly because people are often being told that an implant reconstruction is simple, quick and rapid to recover from whereas, an autologous reconstruction like a DIEP is a long operation and slow to recover – I completely disagree with that. What I see in my patients is that, irrespective of the nature of the reconstruction, patients are in hospital 4 or 5 days; they then go home and they have to recover for about 6 weeks before they’re fully healed, but they’ll often find that they’re a bit lethargic, bit tired, not quite ready to return to full function for about 3 or 4 months, and that is exactly the same for implant reconstruction and autologous reconstruction.

Junita – Breast care nurse: As a breast care nurse, I would tell the patients to make sure that they are aware that post-operatively, they will have 1 or 2 drains and they will possibly be going home with those drains and that generally a nurse in the community will be coming out every day to attend and manage those drains and the wound care as well.

Usually the dressings stay on up to 2 to 3 weeks depending on the type of dressing that the doctors are using. The dressings are always waterproof so the patient can shower over these. Its important to pat dry the area, not to rub it too much.

Also pain relief is a big thing to go home with so it’s important that they manage their pain relief well and take Panadol and Nurofen and other breakthrough medications regularly to aid this.

Michelle – Consumer: I wasn’t aware - I knew I was going to get drains, but I wasn’t really aware of them until the next morning when they were changing them to check the output into them and then, when I was wanting to get up to go to the bathroom to have a shower, I realised I had some ‘friends’ [holds up the drain] I had to take with me. I’ve still got one friend unfortunately cause my surgery was 2 weeks ago tomorrow. It’s just a tube that comes out here [points to the left side of her body] to drain blood and tissue so that it doesn’t build up under your skin. It just comes out of here [points to the tubing] down here [points to the pump attached to the tubing] and they just get changed every day. Initially, the nurses in the hospital do it for you and then they show you how to do it. It’s really easy. They’re just annoying cause, they’re the friends you just don’t want to have – they go everywhere with you.

Michelle – Breast care nurse: So post-operatively though, best to not lift anything for as long as the treating team have told you to not. Take your pain relief regularly. You’re much better off taking your pain relief and to be pain free so you can function normally than not take your pain relief and create rounding of your shoulders – that can really lead to some problems in your arms and shoulders.

Be aware of how your breast(s) look and feel immediately after the surgery. Watch out for any changes; any signs of infection or swelling and just report back quickly if you see anything that looks a bit untoward. Make sure you get hold of your treating team and let them know straight away.

Michelle – Consumer: So my breast care nurse had told me to get a zip up bra and I think actually a friend of mine that had had surgery told me to try and get a zip up top or you want button up tops you’d be able to wear, and you want them loose because you’re going to be a little bit swollen and you’re also going to be physically restricted with your movement.

My surgery was 13 days ago. I can reach up, etc., now but initially, it hurts a little bit or you’re a little bit restricted. I’m wearing one now cause today, I just had another fill made of my tissue expanders and I managed to lose one of my drain friends, so I’ve still got 1 drain in. I’ve got a zip up top that I can use and underneath, it’s got a zip up sports bra and the charming tissue expanders.

There’s lots of things available from all sorts of stores. You can get these zip up little sports tops from Kmart, Target, Best and Less, Big W – all those sorts of places; bra shops and get shirts and things all over the place that zip up. It’s much easier to be in something like that. If you’re having a mastectomy, you are going to have a drain in I think almost always. These things come from your side here [points to her left side of her body] you can really only wear a 2 piece – you can’t wear a dress because it’s got nowhere to exit so just be prepared with the clothing that you pack to take into hospital to be comfortable.

Steph – Breast care nurse: A lot of the time, as a woman, when you go through this, you are a mother as well. We tend to multi-task. This is when you need to be more aware of what you can and can’t do after your discharge.

I always advise patients to be resting and not do anything – you’re only allowed to pick up a cup of tea and get your family members to do everything.

When you’re home, it’s most important that you rest; no heavy lifting; no taking the washing off the line; no pushing the wheelie bin out; no picking up toys; no doing grocery shopping.

Physiotherapy

Jaala – Physiotherapist: The role of physiotherapy really varies from the type of surgery you have. A physiotherapist might be a part of your multi-disciplinary team and what we do is, we might see you before you have surgery and teach you some exercises and things you can do to help you move after surgery, also help strengthen your arms after you’ve had your surgery. You may also come across us after you’ve had your surgery in hospital and during this time, we’ll teach you how to get up out of bed, get you moving and get on your way to getting recovered.

If you find that you’re having difficulty recovering from surgery - you’re not able to get back into your usual activities like work or sport or being able to care for yourself or for others, that might be an important time to get referred to see the physiotherapist. The best way to go about that is talking to your surgeon and seeing how to get referred to the physiotherapist in your local area.

Depending on the type of reconstruction you have, you may have some restrictions to your arm movement - the amount you can move your arm and also in the way you can move it, so its really important to discuss with your surgeon before you decide on the type of surgery you’re going to have, what these restrictions may be and then how they may impact your ability to care for yourself, to care for others and also get back into your usual activities like work and sport. What you’ll do is discuss this with your surgeon and then after surgery, you’ll be guided by your physiotherapist on how to get back into those activities.

If you do have a reconstruction that involves taking a flap of tissue from your abdomen, you will have lifting restrictions and activity restrictions for at least 6 weeks after surgery. Discuss with your surgeon what these restrictions are and how they will impact your activity. Really think about how that will impact your life, being able to care for yourself and others and getting back into work and your physical activity. With this type of surgery, you may also have longer term changes to your abdominal strength, and this may play an impact on the decision to have this type of reconstruction.

There are some special techniques to help look after your abdomen when you rest and when you move so when you’re lying in bed, its good practice to adopt the ‘banana position’.

[video presentation] Sit with the head of the bed up and pillows under your knees so you have a bend in the middle. Avoid having your abdomen in a stretch position as this will be more uncomfortable and will put undue strain on your surgical side.

To get out of bed, you’re going to use a ‘slide-line’ technique so what we want you to do is rolling onto your side, making sure your tummy is nicely supported, using your arms to push yourself up, so you’re going to come onto one elbow and then push yourself up into a sitting position. Then, when you’re in sitting, make sure you’re sitting in a bit of a leaning forward position, so this will make sure you’re not putting un-necessary strain through your stomach.

When you’re standing, just stand up like normal, but you might find it more comfortable to have your pelvis tilted forward, so you’re standing, a little bit like a ‘crook’ position with your knees slightly bent and so then, when you’re walking, try and keep that pelvis in that tucked position, with your knees slightly bent, just to reduce the stretch on your tummy. Over time, you’ll find that you’ll be able to stand up a bit straighter and move with a bit more ease.

Sometimes you might be given an abdominal binder to wear by your surgeon. This is a stretchy, elastic band which goes around your waist and helps to support your stomach.

If you are given one of these bands, you need to wear it when you’re upright and moving – best ask your surgeon what their protocol is.

Regaining your shoulder movement is very important after surgery. It can take up to 4 to 8 weeks to fully regain your movement, depending on the restrictions your surgeon gives you.

In a latissimus dorsi reconstruction, you might find that the movements feel a bit strange in your breast tissue because the shoulder muscle has been taken from the back and wrapped forward into the breast. It can feel like when you’re moving your arm, that your breast tissue itself is moving and some people can find that a bit distressing. What we find is it may take 3 or 4 months for that to completely settle down and for the breast tissue to feel like breast tissue rather than feeling like arm muscle. What we also want you to do is to follow the recommendations by your surgeon by getting back into movement and activity, so they may recommend seeing a physiotherapist after your surgery, and they will help guide your through some strengthening exercises to regain the strength and movement and get back into your normal activities.

After you have your surgery, your surgeon will tell you how much movement you’re actually allowed to have for your arm, and it will vary on the type of surgery that you have. Generally, if you have reconstruction with tissue expanders, you’ll be able to move your arm within comfortable limits, but initially, you’ll have a drain in under your arm, and you’ll go home with that drain. It generally stays in for about 7 to 10 days. Whilst your drain is in, only move your arm to shoulder height. This is so we don’t cause any irritation to the movements. You can still kind of wash your hair and do anything you need to do, but just keeping it at that shoulder level. Once your drain comes out, you can start moving your arm higher.

You may see a physiotherapist who’ll give you some exercises to do and these exercises will start on day 1. The first exercises are designed to help with circulation and just making sure that your arms are moving. What we like to start with on day 1 is just doing some nice elbow bends [demonstrates the elbow bending movement]. We like to do 10 each of these – nice and slowly and smoothly. You’re trying to do them at least 3 times a day so when you have breakfast, lunch and dinner, is a good time to do it.

The second exercise is just bending and straightening your wrists [demonstrates these movements]. If you like, you can lean your arm on the side of the table and do it. The same, doing 10 of those.

The last one is opening and closing your fingers so really helping with that circulation and to pump the fluid from your fingers back up into your arms. It’s important to do it in the order of going down from the shoulder towards your fingers. This helps with your lymphatic flow. Lymphatic flow is part of your lymphatic system and that can be interrupted as part of your surgery that you have.

Scars are often a daunting and very big part of your recovery after surgery. Depending on the type of surgery you have, you might have one or your might have a few scars. That will be at the reconstruction site as well as if you’re using a tissue flap, so that might be coming from your tummy muscles, or some of the muscles on your back - you’ll also have a scar there.

Scars are a natural part of healing and when scars heal, you get all these collagen fibres and they can get a bit stiff and a bit lumpy but, over the next 3 or 4 months they generally soften and flatten out. What we’re looking for in a mature scar is that it’s a nice pale colour; its flat and smooth and its not sensitive or itchy or causing you any discomfort when you’re touching it. We do find that sometimes these scars do get a little bit raised, a bit firm and a bit tight. If they’re tight, we often find that they can impact on the way you move your arms or your body so its very important to do some scar management.

After you’ve had your incisions healed, it might have some stitches, steri-stripes or a dressing over that. Once they’re all removed and your skin is completely healed, so there’s no scabby bits or open bits, then you can start doing some scar massage.

What we want you to do is doing some moisturising every day. You can use any type of cream like Sorbolene or Aqueous cream - something that’s doesn’t have any smells or perfumes in it that might irritate your skin and then just doing some gentle massage over the area. This can be done multiple times throughout the day as you can.

The techniques we use for the massage are just doing some small circles in the area. If I imagine I have a nice scar on my arm, with those 2 fingers [index and middle finger], do some small circles, going clockwise for 5 and then anti-clockwise. I’m going to do that for the whole length of my scar. If you find an area that is a little bit tight when you move it up and down, you can also do that up and down area as well. The important thing is that, if you get any soreness or gets red or painful from doing this; if you get any open sections in that scar, or any bleeding or oozing, then we really don’t want you to do scar massage. That’s something that you need to show your doctor or your breast care nurse about it and get more guidance on.

If you’re finding that your scar isn’t healing or causing you discomfort or tightness, it’s a really good idea to get referred to see your physiotherapist to help with your scar management. They can teach you some more techniques as you need.

When you get home, you might be very keen to get back into your usual activities, but you might find your arms are a little bit soar. This is very normal. What’s important to do is just gradually get back into things – things like sweeping or mopping or even putting the washing out might be a bit strenuous to start with so, just breaking it down to smaller amounts and asking for help when you really need to.

You may also find you need to take a few more rests than you would have previously, and this can be from an energy point of view because having surgery is a big toll on your body as well as the tiredness and the strain in your shoulder.

If you do have some restrictions though and these can include not being able to lift anything heavy, then you might need to modify the way you’re doing things. Its very important to seek guidance from your surgeon before you return to any vigorous activity, any heavy lifting. If your job is quite physically demanding, you just need to have guidance on when its safe for you to return into those activities.

Being in good, physical health is very important before you have a surgery. It can help you recover better after your surgery.

Currently the Australian guidelines recommend exercising on most days of the week so we’re trying to achieve a goal of 150 minutes which does seem quite large but broken down, it comes down to doing about 30 minutes of walking, jogging, cycling or swimming or anything that gets your heart moving, most days of the week.

You can also look at doing something intensive like going for a run or doing an aerobics class 3 times a week. We also recommend doing some strength training to help the large muscle groups in your legs and your arms.

Doing regular exercise helps to reduce the risk of post-operative complications like infections. It also decreases the chance of developing cardiovascular disease, diabetes and osteoporosis.

If you have started exercising – even if you’re a regular exerciser, starting small and gradually building up after you have your surgery, is very important. You need to be guided by your surgeon about what you’re able to do. Seeing a physiotherapist is a really good idea to help you guide your exercise progression after surgery and help you get back to the things you were doing before you had the reconstruction.

Breast sensation and appearance

Jen – Breast care nurse: We create lovely lumps with or without nipples and they are just that – they are a mound that looks good in clothes and dressed - naked, you will know that’s a reconstruction.

Andrew – Plastic surgeon: If you’ve got the ability to preserve the skin, with or without the nipple, then rebuilding a breast is far easier - you’ve got a lot more options. The final aesthetics are often, heavily determined by what’s left behind. If you could simply fill the space that was there previously occupied by the breast gland, it’s a good reconstruction; it’s an easier reconstruction; you’ll get a better aesthetic outcome. If we’re dealing with a situation where the breast has been completely removed and someone has a long scar, rebuilding that breast is harder. You can make a good shape; you can make something that is soft and comfortable but, it will always look very, very different to a real breast. There’s a huge impact from the nature of the mastectomy to the reconstructive outcome.

Jen – Breast care nurse: Depending on the type of surgery - I guess implant surgery, I would expect them to look, kind of fairly high and round. You can usually see the implants; you can see the rippling, cause again, you’re kind of removing the inside of an orange and putting a tennis ball in and shutting it; it’s pretty hard and firm and obvious. It might feel tight and firm; it might feel numb and tingly; it takes a little while to adjust to that; it might feel colder than normal body temperature and some women will say they feel a bit heavy as well because they are – they can be. I think over time that settles and all women adjust to that.

With a tissue transplant, it would feel tight and firm but more natural – a more natural feeling.

Justin – Plastic surgeon: Post-surgery is certainly a big thing in terms of sensation. Probably the big thing is post-mastectomy is the biggest change so as a result of removing the breast, there’s a lot of nerves that are divided, meaning they’re removed and as a result, there’s a lot of loss of sensation, both the nipple as well as the skin on the chest – that’s going to be the biggest change.

The reconstruction that any plastic surgeon would do, unfortunately, can’t reconstruct that so, initially, you’ll feel the weight of an implant or the flap but ultimately, the sensation will never be the same as what you originally had and that includes both nipple sensation as well as skin sensation.

Some patients will report that they do get some kind of sensation over time. That’s very dependent and very individual. Some patients who have had radiotherapy don’t get great sensation long term and that’s because of the scar tissue that’s created from the radiotherapy. Patients who haven’t had radiotherapy generally report a much better sensation after the reconstruction – its variable.

The big thing with implants is that implants will always feel like implants. They will always feel like a slightly foreign body placed inside the chest just because of the nature of what they are. Certainly, using your own tissue to make a reconstruction is excellent because it always incorporates and it’s your own tissue, so they always feel much more natural. Using your own tissue, either from the tummy or your back, will always be far superior reconstruction than implants in that regard.

Andrew – Plastic surgeon: The biggest issues for patients is how it feels. After a mastectomy, the breast is numb all the time. Patients often tell us that they weren’t informed about the fact that they wouldn’t be about to feel their breasts after a mastectomy, which is something we are conscience of. We do try and tell every patient. How it then feels to touch, again, depends on the nature of the reconstruction.

If they have a tissue expander or an implant reconstruction, the breast will be quite hard and often feels a bit cold. Over time, as that patient ages, the implant reconstruction won’t change- it won’t age with them.

An autologous reconstruction will feel soft and warm and over time, it will also age with the patient – it will gain and lose weight with the patient, so there is that. It means that it’s a more dynamic, natural reconstruction that changes as the patient themselves change.

Penny – Consumer: The surgeons and my breast care nurses made sure that, prior to having the double mastectomy, what’s going to be there is not necessarily going to be what it’s going to be like after you have the tissues expanders. You are going to have all your breast tissue removed but you do have like a little bit of fluid in there so there was something there but, over time, with your expanders, you get the jest of maybe what the size-wise may look like. The actual breast is not ever going to be the same as you were prior to having the double mastectomy.

I guess you don’t necessarily have to rush into it if you don’t want to when it comes to reconstruction. If you’re not ready to see that or come to terms with that, you can take your time with it – that may not be something that you want to do.

Knowing prior to having a double mastectomy, to me, it’s never going to be the same again. You do come to terms that things are going to be different.

There are bras out there; there are things that you can, to give you that feel; it’s not like you can’t ever wear a bra again or you can’t ever wear something nice. You do have to adjust it in a way, but I think that it’s a different norm – it’s never going to be normal again – it’s a new normal but that new normal is a good normal because even though I’ve had lumpectomies, mastectomies - I’ve tried the reconstruction and it didn’t work; I now am lope-sided; I have 1 boob and don’t have another. I’m cancer free and I think that’s where you’ve got to go back to the start again and gain perspective and go, "Do you know what? I’m cancer free; I’ve got my health and I can enjoy life with my family".