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Overview

What is breast reconstruction?

Breast Cancer reconstruction is a specialized group of surgical procedures which recreate the breast, following a mastectomy.  These surgeries are performed by a reconstructive plastic surgeon, who has undergone training for breast cancer reconstruction. 

There are several different options to recreate the breast and Dr. Burgess guides her patients towards the best option for their individual situation with an optimal outcome.  The reconstructed breasts will look different from your natural breast, but they can look very nice and natural in bras and bathing suits.  Below is a general overview of breast cancer reconstruction and the possible options available in our clinic.

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Why Reconstruct?

Breast Cancer reconstruction is a very personal decision.  Not every woman will pursue breast cancer reconstruction after their mastectomy and not every woman is a good candidate for surgery.  However, depending on your unique situation, you may consider reconstructing your breasts for a myriad of different reasons.  Following reconstruction, many women feel a stronger sense of self-esteem and appreciate filling out clothing, bras and bathing suits.    Because breast cancer reconstruction is an elective process, there usually isn’t a strict timeline on when to start the reconstruction process.  Your doctor will assist you in choosing the best time frame to initiate the process.

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Am I a candidate?

If you decide you may be interested in reconstruction following your mastectomy, the next step is to see if you are a healthy candidate for surgery.  Your doctor will assist you in evaluating your health status, and ultimately if you would be an acceptable candidate for the reconstruction process.

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Which doctors do what?

General Surgeon/Breast Surgeon

Following your breast cancer diagnosis, you will meet with a general surgeon or breast surgeon who will perform your mastectomy.  Their job is to remove the breast cancer, either through lumpectomy or mastectomy and quite possible, questionable lymph nodes.  They may be the first to discuss the notion of reconstruction of the breasts with you. 

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Oncologist

After your diagnosis, you will also visit with an oncologist.  This physician looks over your cancer treatment and works to figure out your risks of recurrence and what medications or chemotherapies will be in your treatment plan, if any.  You may also require a radiation oncologist; if it is determined that radiation therapy is within the scope of your treatment plan.

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Plastic Surgeon

After meeting with your breast cancer surgeon and possibly your oncologist, you may visit with a plastic surgeon to discuss the possibility of breast reconstruction.  Often times, Dr. Burgess will visit with you before your mastectomy.  This in-depth consultation allows her to provide detailed information regarding the reconstruction process and to answer questions specific to your surgery.  We encourage your support person to attend as well.  Dr. Burgess’ services would only be needed if you decide to proceed with mastectomy surgery.  For many patients who choose to have a lumpectomy, reconstruction is not usually needed. 

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Immediate or Delayed Reconstruction

The timing of your reconstruction will depend on your unique set of circumstances.  Many factors play a role in determining what surgery will best suit you and your reconstructive goals, including your cancer treatments, such as chemotherapy and radiation, your physical anatomy and overall health.

Some patients may start their reconstruction process at the same time that their mastectomy is completed.  This is known as immediate reconstruction, where a breast surgeon will perform the mastectomy, followed by a plastic surgeon that will start the reconstructive process.  Other patients may end up waiting to start their reconstruction months to even years after mastectomy.  This is known as delayed reconstruction.  Delayed reconstruction is sometimes necessary if a patient has had radiation to the affected breast or is at high risk for radiation.  This allows time for the breast tissue to soften and recover from the radiation.  Still, other patients choose to wait to do reconstruction due to personal issues; such as waiting to be emotionally prepared for further surgery, fitting it into busy family schedules and getting time off of work.  Dr. Burgess will assist you in creating a surgical timeline that suits you.

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Prophylactic Mastectomy

Occasionally women decide to undergo a prophylactic mastectomy when they do not actually have a breast cancer diagnosis.  This is usually performed when they have a very prominent breast cancer family history, are BRCA positive or have extremely fibrocystic, hard-to-follow breasts. This is often done after patients have spoken with an oncologist and assessed their risk of developing breast cancer with a breast cancer surgeon.

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Unilateral vs. Bilateral Mastectomy

Once the decision has been made to have a mastectomy, patients need to decide whether they plan to remove just the affected breast or both breasts.  This decision is a very personal one, with many factors to be considered.  Your oncologist will review your risk of recurrence related to your specific diagnosis and treatment modalities.  They will help guide you in your decision and discuss the probabilities of developing a cancer on the unaffected breast in the future.

Patients also need to consider the emotional factor of removing both breasts.  Some women feel that they will worry about developing cancer on the remaining breast if it is not removed, while others want to preserve their appearance.  Choosing to have a one-sided or unilateral mastectomy at the time of diagnosis does not prevent you from having the other breast removed at a later date.  Again, reconstruction is an elective process, which usually has no firm time frames. 

A third factor to consider is the anatomy of the unaffected breast.  Your plastic surgeon will address these issues in your consult and guide you toward your reconstructive goals, whether it is unilateral or bilateral mastectomy.  For very large breasted women, sometimes a breast reduction to the unaffected breast to match the reconstructed side is a great option.  A breast lift or mastopexy, may be required to match a more moderately sized breast.  For smaller breasted women, an implant may be used to augment the natural breast and provide symmetry for the reconstructed side.

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Nipple-sparing Mastectomy/Skin-sparing Mastectomy 

A nipple-sparing mastectomy is an option for some patients, depending on tumor size, location, patient’s natural breast anatomy and type of breast cancer.  This may be an option for patients with small breasts that may have small tumors away from the nipple, pre-invasive cancers or no cancer, but wanting a prophylactic mastectomy.  This is a question for both your breast surgeon and plastic surgeon.  Some women feel strongly about keeping the nipple and areola intact when they have their mastectomy.  Not everyone is a candidate for this type of mastectomy.  Your surgeons will exam your breasts, and together with your breast cancer diagnosis, decide if you are a candidate.  Often times the remaining nipple-areolar complex heals well, but patients do run the risk of losing the nipple during their recovery due to blood supply issues.  Also, keeping the nipple areolar complex means you still have breast tissue on the nipple that may need surveillance or follow up.  Your plastic surgeon will discuss the pros and cons of this type of surgery with you, if you are a candidate.  Keep in mind that your plastic surgeon can surgically create new nipples and areolas if necessary.

A skin-sparing mastectomy preserves the skin of the breast, but not the nipple or areola.  The breast tissue is removed, but the vast majority of the skin remains after your surgery.  This surgery is best suited for a smaller breasted woman.  Again, your plastic surgeon and breast surgeon will determine what type of mastectomy surgery is appropriate for your specific condition.

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Chemotherapy and Radiation

Breast cancer reconstruction depends on input from your entire team of doctors.  The plastic surgeon relies on your oncologist to treat your cancer and will work around your course of treatments.

Chemotherapy refers to medications that work to kill cancerous cells.  Chemotherapy treatment involves intervals of intravenous infusions set up and managed by your oncologist.  Often times, chemotherapy and reconstruction may be undergone at the same time.  Your plastic surgeon can help coordinate your specific reconstructive process around your chemotherapy treatments.

Radiation therapy is another treatment modality that may be ordered by a radiation oncologist.  Radiation works to kill cancer cells and shrink tumors.  Sometimes it is not known if patients will need radiation until after their mastectomy has been completed.  Radiation will affect your reconstruction process.  Depending on the type of reconstruction you undergo, your plastic surgeon may have to delay your reconstructive surgery to allow your tissue time to recover from the radiation or employ other techniques to allow for your reconstruction to be successful.  Radiation can alter the skin, tissue and muscle of the affected area, making it more challenging to work with compared to a non-radiated mastectomy site. 

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Procedures

When patients come in for a new patient consult, Dr. Burgess will review the various procedures she performs as well as discuss the other options available to patients.  She will help guide you towards the reconstructive surgery that most compliments your aesthetic goals, as well as maintain close communication with your other physicians.  Below is a summary of various types of reconstructive options.

Lumpectomy and Radiation

Depending on the tumor location and size, a lumpectomy may be an option for you.  A lumpectomy involves having a breast surgeon remove the tumor during a short day surgery.  Often times, patients undergoing this type of surgery require radiation to the affected breast.  In this scenario, patients typically do not need a plastic surgeon because the breast has been preserved and breast reconstruction is not necessary.

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Tissue Expanders

A mastectomy is a surgical procedure that removes breast tissue, including the breast cancer tumor(s) and questionable lymph nodes by a breast surgeon.  Mastectomy preserves the pectoralis (or chest) muscle and leaves behind a thin layer of tissue and skin. 

At the time of mastectomy, or at a later date, a tissue expander can be placed underneath the pectoralis muscle and patients usually spend one night in the hospital after a 1-3 hour surgery.  Drains are also placed to remove excess surgical fluid and blood.  The drains are removed in the office at subsequent visits, once the drainage volume has decreased to an acceptable level.  Patients normally have drains for one to two weeks.  (photo of Tissue Expander coming soon)

The tissue expander is a temporary implant that contains a port within its shell.  This port allows for adding more saline or salt water, once the mastectomy incision has healed, to expand or fill the tissue expander.  This process is known as expansion.  Your expansions normally start several weeks after surgery and usually occur every two weeks until you have reached your goal.  During a quick, in-office procedure, Dr. Burgess will use a very fine needle to place about 50mL of saline into the port of your tissue expander through a numb area on your chest skin.  The pectoralis muscle may feel tight and uncomfortable that evening.  Each patient has their own expansion schedule that can easily work around chemotherapy appointments, as well as their personal life.  The number of required expansions is very patient-specific.  Your final expanded volume depends on your individual goals for breast size, breast anatomy and how well you tolerate the overall process.
Once you have reached a volume that you and Dr. Burgess feel is acceptable, you will undergo a day surgery to remove the tissue expander and replace it with a silicone or saline implant.

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Implants

A saline breast implant is a medical device made up of a shell of silicone elastomer and filled with salt water or saline.  Saline is very similar to the fluid that occurs naturally in the body.  A saline breast implant has a special tube that allows the doctor to fill the implant at the time of surgery.  There are several types of saline implants.  Dr. Burgess will guide you in the decision-making process when selecting the implant that will best suit your frame and breast contours.
Saline implants have been used for decades and have a good safety profile.  Keep in mind that implants of any kind are not forever devices.  Although the leak rate is low, no one knows exactly how long your implants may last.   If your implant does leak, you may require a short day surgery to remove the implant and replace it in the future. 

The second type of implant commonly used for breast reconstruction is a silicone gel breast implant.  Silicone is a polymer, used in many household products, such as hand lotion and soaps.  The outer shell of the silicone implant is the same as the saline implant, but instead of being filled with salt water, it instead contains a silicone gel.  The silicone implant has a multi-layered barrier that helps prevent rupture.  Some people think that the silicone implant feels more natural as compared to the saline implant. 

Extensive studies have been completed with regard to the safety of silicone and saline implants.  Both implants are FDA approved and have been involved in clinical studies encompassing thousands of women since 1992.  Please visit mentorcorp.com to get specific details on these studies.
When choosing what type of implant to have, you should consider the pros and cons of both.  If you were to develop a leak the implant would simply go flat over hours to days if you have a saline implant.  The breast would look smaller and the salt water or saline from your implant would be absorbed by your body.  When a silicone implant ruptures, it can be known as a ‘silent leak’, because the silicone gel may leak over time.  The most accurate way to detect a silicone leak is by a breast MRI.  Therefore the current recommendation is to get a breast MRI 3 years after implant surgery and then every 2 years.  This should be done even if you are not experiencing any problems.  If a leak were detected in either type of implant, the goal would be to remove and replace the implant.  This is usually a day surgery and patients normally recover very quickly, as the pocket for their implant has already been created.

It is not unknown how long your implants will last.  Some silicone or saline implants may last decades, while others may rupture earlier.  In most cases, if you are on the younger side when you have your reconstruction process, (25-50 years of age), you will most likely need to have your implants replaced at sometime in your life. 

Deciding which implant fulfills your reconstructive goals and suits your lifestyle is a very personal decision.  Dr. Burgess normally allows for patients to pick which type of implant they prefer.  This is not a decision that has to be made right away.  Your permanent implant will not be placed until several months after your tissue expander placement surgery.  Therefore you do have time to decide which implant, silicone or saline, would work best for you.

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Fat Grafting

Fat Grafting is a technique in which your plastic surgeon is able to transfer unwanted fat from one area of the body to another, to add volume or to help correct a contour problem of the reconstructed breast. This is also known as autologous fat transfer. Fat grafting is a surgical procedure and Dr. Burgess may require general anesthesia or local anesthesia with light sedation. The unwanted fat is usually removed from the abdomen, back, or outer thighs using a gentle liposuction technique. The fatty cells are then carefully re-injected back into the area of the breast that requires more volume.

The advantages of fat grafting are that you are able to use your own tissue and the recovery is fairly minimal. This procedure is usually done to patients who have undergone mastectomy with reconstruction. Since it is your own tissue being re-injected, it may make the breast feel softer and more natural, especially in areas of previous radiation. In addition, many women are pleased that they were also able to have fat removed from an area of the body that they didn’t want it, such as the belly area.

The disadvantages to fat grafting are that a certain amount of the fat will resorb back into the body and you may need more than one fat grafting procedure to reach your desire of correction. Also, some of the reinjected fat may feel like a tiny lump, but these tend to soften with time. Dr. Burgess will assist you in your decision making process as to whether fat grafting is the best option for your breast restoration process.

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Acellular Dermal Matrix (ADMs)

Sometimes the natural anatomy of the pectoralis muscle may not be adequate coverage for the implant.  The muscle may have suffered loss or be of poor quality. For patients who have had radiation, utilizing their pectoralis muscle to support an implant can be challenging.  In these types of scenarios, an Acellular Dermal Matrix (ADM) may be employed.  An ADM is often a human cadaveric or porcine product that is utilized at the time of tissue expander placement.  The ADM is sewn into the pectoralis muscle, allowing for greater support in the lower breast pole, while supporting the tissue expander and eventually, the implant.  It can provide a natural shape or “hang” to the breast.  The ADMs also support cellular growth and healing, while providing stabilization of the implant.

AlloDerm® Regenerative Tissue Matrix

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TRAM (Transverse Rectus Abdominis Myocutaneous) Flap

Another option for some patients is another group of surgeries that involves using your own tissue. 
The TRAM is a major surgical procedure that involves using your own abdominal skin, fat and muscle to create and contour one or both breasts.  This surgery can be upwards of 6-12 hours of surgical time and a 2-4 day hospital stay.  The recovery from this surgery, as compared to the tissue expander procedure, is a greater length of time.  As with all reconstruction options, your surgeon will help guide you in choosing .  This surgery is best for women who have some excess abdominal fat.  Here, the Transverse Rectus Abdominis Muscle with fat and skin, is partially released and lifted up to form a new breast.  Since your surgeon is harvesting this tissue from your abdomen, you also will end up with a tummy tuck but the abdominal wall will be reconstructed as well, with a piece of mesh.  It is important to remember that this surgery will involve a scar across your lower abdomen and the breast area.  These scars are all easily hidden with most underwear or swimsuits.  Also, it is vital to avoid sun exposure to your abdomen for one year following surgery, since your skin may be sensitive to excess heat and could result in severe sunburn.

Since your new breasts are created from your own tissue, they may feel natural.  However, the skin sensation and coloring will be different since the skin and tissue came from a different area of the body.  Many women are however, pleased with their flatter abdomen as a result of the surgery.

It is important to keep in mind that only certain people are good candidates for the TRAM flap surgery.  Since it can involve an extended recovery, it is very important to be fairly healthy going into the procedure.  Smokers and those with prior abdominal surgeries, diabetes, chronic diseases, cardiac conditions, or on blood thinners may not be the best candidates. 

Recovery from this surgery is longer than with the tissue expander process.  Since your abdomen has been reconstructed, you must plan to be off work and avoiding any strenuous activity for about 8 weeks after surgery.  It is important to have someone that can assist you at home during your recovery.  Patients have multiple follow-up visits, to ensure that their healing process is on track.

Delay in TRAM This should be part of TRAM page, since it is related to   this surgery.

Depending on the individual, sometimes another surgery may be required prior to the TRAM.  This procedure is known as a “Delay in TRAM”.  The Delay surgery is normally performed two weeks prior to the actual TRAM surgery and works to improve the blood supply to the flap.  During the delay procedure, blood vessels that supply the flap are divided from below.  This promotes blood vessels from above to become larger and more robust, reducing the risk of vascular insufficiency to the flap.  Dr. Burgess will determine whether you will require the Delay. 

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Latissimus Dorsi Flap

Another surgical option for some women is to reconstruct the breast using their own skin, tissue and muscle taken from the back and tunneling it to the breast area. This surgery is a favorable procedure for those that are not TRAM candidates or for those who have undergone radiation and need fresh tissue to the chest.  This is a major surgical procedure that can take 4-5 hours.  Most women require several weeks off of work and should not work out vigorously for 8 weeks.  Some patients require a tissue expander as well for additional volume, which is then replaced with a permanent implant once their expansion process is complete.  Patients can expect a scar on the mid-back/shoulder area.

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Microsurgical Flaps

The DIEP Flap is one type of breast reconstruction, that uses your own skin and fat to recreate the breast(s).  In this microsurgical procedure, blood vessels known as the deep inferior epigastric perforators, (DIEP) along with skin and fat are removed from the abdomen and relocated to the chest to create breasts.  This type of flap surgery leaves the abdominal muscles intact.  However, due to the complexity of this surgery there are few facilities that offer the DIEP technique.  There are also other types of microsurgical flaps and Dr. Burgess does not routinely perform them.

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Oncoplastics

Breast Reduction with Lumpectomy

Sometimes a breast reduction may be an option for larger breasted women who have been diagnosed with breast cancer.  The lump is removed at the same time as the breast reduction and often the unaffected breast is removed as well.  Many factors are considered, such as the specific cancer diagnosis, stage, tumor location, breast size, treatment modalities and personal goals. 

Following lumpectomy, a breast reduction will remove excess breast and fatty tissue in one or both breasts, making them smaller, lifted and more proportional to your body.  Your size, anatomy and tumor location will dictate what type of surgical approach your plastic surgeon may use.  Usually, women are left with a scar around the areola, a vertical incision from the areola to the base of the breast fold and sometimes an additional scar along the breast fold.

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Nipple reconstruction

Once your breast reconstruction is completed, you may consider undergoing nipple reconstruction.  This usually occurs 4-6 months after your permanent implant placement or muscle flap surgery, to allow your new breasts to heal and settle.  However, nipple reconstruction may be done much later, depending on patient preference.

Nipple reconstruction, also known as Nipple-Areolar Complex, (NAC), is a quick day surgery, which uses your own tissue on the breast to create a nipple.  The reconstructed nipple has projection, but no feeling or function.  The areola is created by bringing in skin from another area of the body, such as the lower abdomen and then covering the nipple areolar complex with a protective dressing for about 4-5 days.  Once this dressing is removed care must be taken to not injure them.  Patients should avoid vigorous exercise for about one month.  Most patients do not require much time off of work, usually only a few days if that, and find this surgery to be the easiest step in the whole reconstruction process.

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Surgery to the unaffected breast

Symmetry

Some women chose to only have a mastectomy to the affected or cancerous breast.  This is known as a one-sided or unilateral mastectomy.  To create symmetry between the reconstructed breast and the natural breast, patients often require surgery.  The type of surgery is patient specific.  Some smaller breasted women may require an augmentation, or implant to the natural breast, while some women may only need a breast lift.  Others still may need a breast reduction to the non-cancerous breast if they are naturally very large breasted.  Surgery to create symmetry is normally done at the time your permanent implant is placed to your reconstructed side, or after you have healed from your muscle flap surgery.  With unilateral reconstruction there is no firm time frame for surgery to create symmetry. 

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Mastopexy

A Mastopexy, or breast lift, removes a small amount of skin, breast tissue and fat, to lift and reposition the breast and nipple.  Similar to the breast reduction, a mastopexy can be done to provide symmetry to the unaffected breast.  This would be a possible option for a woman undergoing a one-sided mastectomy with reconstruction.  A breast lift may be done to better match the reconstructed breast with the natural breast.  Your plastic surgeon would guide you in deciding if a lift would be an option for you.  There are multiple techniques with regard to a breast lift.  Deciding which approach would provide you with the greatest symmetry and pleasing aesthetic result is a decision for your plastic surgeon.

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Alternatives

For those who are either not good candidates for surgery or choose not to reconstruct the breasts, there are alternatives.  Bra specialty shops work to fit women with special bras and prostheses that look very natural under clothing.  Depending on your health insurance, this may be a covered expense. 

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Recovery

Tissue Expanders recovery

Patients who undergo tissue expander surgery normally have several surgeries to complete their reconstruction.  During the first stage of reconstruction, when the tissue expander is placed, most patients take a minimum of several weeks off of work.  This surgery does require the placement of drains and the majority of women prefer to have their drains out prior to returning to work.  Dr. Burgess provides prescription pain medications, a muscle relaxer, antibiotics and other medications to aid in you recovery.  It is important to avoid lifting anything heavier than a gallon of milk or vigorous exercise for 4-6 weeks following this surgery.  As you begin your in-office expansions, you may exercise lightly, but it is important not to push yourself too far, as you can delay healing.

When your incisions have begun healing from your tissue expander placement surgery, (normally about 2 weeks after your surgery), you may begin your expansions.  The number of expansions you require will depend on your frame, the quality of your skin and tissue, as well as your goals for reconstruction.  Following your expansion, your chest may feel tighter and more uncomfortable.  Dr. Burgess prescribes pain medication to assist you during this time.  Many patients are able to return to work during the expansion period.  Once the final volume has been obtained, patients undergo a second surgery to remove the tissue expander and replace it with their final silicone or saline implant.  This is a day surgery and patients normally go home after surgery.  We still require patients to avoid heavy lifting or vigorous exercise for at least 4-6 weeks after surgery.

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Breast Reduction recovery

Breast reduction patients normally spend one night in the hospital and then go home with someone who is able to assist them with medications and personal care.  Patients can shower the second day after surgery, even with their drains in place.  Drains are usually in for about one week, depending on the patient.  Dr. Burgess provides prescription pain medication, antibiotics and other medications to assist in the recovery period.
It is important to avoid strenuous activity or heavy lifting for a minimum of one month and most women take about 2-3 weeks off of work.  Because patients still have breast tissue following a breast reduction, it is crucial to still do breast exams and breast cancer screening.  Usually a new baseline mammogram is done 6 months to one year after your surgery.  Final results for a breast reduction can up to one year, as patients can be swollen and retain fluid in their breasts.

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TRAM flap recovery

Women who are candidates for a TRAM Flap should anticipate a longer recovery than those having other types of reconstruction.  Dr. Burgess requires women undergoing a TRAM to avoid strenuous activity for 8 weeks following surgery, but patients are encouraged to be up and walking.  Patients have between 4-6 drains that may be present for several weeks and may wear an abdominal garment for about a month.  The garment provides support during the healing process, as well as compression to decrease swelling to the operative area.  Dr. Burgess does provide prescription pain medication, a muscle relaxant, antibiotics and other medications to assist you through the post operative period.  Patients may experience some abdominal muscle weakness and some of the weakness will improve with time.

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Latissimus flap recovery

The Latissimus flap surgery involves moving the Latissimus muscle from the back and tunneling it forward to create a breast.  Occasionally a tissue expander may be required to supplement the volume of the new breast. During this time patients should avoid heavy lifting or vigorous exercise that could compromise their muscle flap for 6-8 weeks.  Walking is a great way to transition back from surgery.  Avoiding lifting or pulling anything heavier than a gallon of milk is important as the new breast and back incisions heal.  Normally patients have several drains that can be in for a couple of weeks.  Patients may shower two days following this surgery, even while the drains are still intact.  If a tissue expander was needed, the expansion process will begin several weeks after the initial surgery.  Plan for at least several weeks off of work following the Latissimus surgery and if an implant is needed, additional time off work would be needed when the tissue expander is removed and replaced with your permanent implant.

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Nipple Reconstruction recovery

Nipple reconstruction is normally the last surgery in the reconstructive process.  It is also usually the easiest surgery for patients, as the area can be numb and the pain can be minimal.  The recovery process involves wearing a nipple protector or bolster for 4-5 days to safeguard the new nipple and areola.  We ask that you avoid getting the bolster wet.  When patients return to clinic several days later, the bolster is easily removed and they are instructed on how to care for the new nipple.  It is important to avoid lifting any heavy objects against your chest and to avoid strenuous exercise for at least 4 weeks.  We have patients apply ointment to protect and lubricate the area during the initial healing phase.  As the nipple and areola heal, the scars actually work to your advantage in helping to disguise mastectomy scars.  Some patients go on to tattoo the areola.

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Copyright © 2009-2010, Elisa A. Burgess, M.D., F.A.C.S.. All rights reserved.

Board certified plastic surgeon Dr. Elisa A. Burgess specializes in Lake Oswego face lift as well as eyelid surgery (blepharoplasty), liposuction, tummy tuck and breast augmentation. She serves the entire northwest Portland / Vancouver metro area and beyond.