Immediate Breast Reconstruction
In theatre the breast surgeon removes the breast tissue, usually with the nipple and areola, through an opening around the nipple (skin-sparing mastectomy). In appropriate cases the nipple can also be spared in which case the incision is around the border of the areola. An island of skin attached to the flap from the abdomen will replace the nipple-areola when it is removed.
Delayed Breast Reconstruction
Delayed breast reconstruction gives a slightly different appearance as the skin on the flap is required to replace the skin that was removed during the mastectomy operation. The skin of the flap usually sits in the lower half of the breast with a scar across the breast and a second scar tucked into the fold under the breast.
Who is a Good Candidate?
Provided you are in good health with no significant medical problems the DIEP flap can be used for breast reconstruction in most ladies. You will need to have enough fat and laxity in your abdomen to provide tissue for reconstruction but if you have had a full-term pregnancy you will normally have sufficient tissue. Ladies who have previously had an abdominoplasty (tummy tuck) cannot have this type of reconstruction.
Who is not a Good Candidate?
Ladies with significant health issues or those with soft tissue disease will not be appropriate for microvascular reconstruction. In some cases the biology of your cancer makes it inappropriate to consider immediate breast reconstruction however, a delayed breast reconstruction can be discussed once you have completed treatment.
What to Expect at Consultation
At your initial consultation I will take a full medical history including all the details of your cancer diagnosis, treatments so far and any intended additional treatments. I will also ask about lifestyle and family support. I will examine you and assess your chest wall, breast size, and tissue to assess which reconstructive options are available to you. Depending on this assessment I may or may not be able to offer you a DIEP reconstruction. If this procedure is not suitable for you I will discuss what options are available to you.
If you are suitable for a DIEP reconstruction at this stage I will arrange a special CT scan to look at the blood vessels in your abdominal wall.
Following our consultation you will have further opportunities to discuss your options with your breast care nurse and make a decision. You will be able to discuss your proposed surgery helping you to understand and consider the options open to you and what support is available to you. Some patients, for whom the surgery is urgent, have only a short period of time in which to decide on what is the best procedure for them. Although I will explain everything to you it can be difficult to absorb all the relevant information at one visit therefore you may have more questions for your breast care nurse and of course we can always arrange a further consultation if you feel it is necessary.
I always see patients a second time before booking surgery to discuss the results of the CT scan and to give you an opportunity to ask any additional questions. At this stage I will also go through the consent process in the clinic.
Before Your Operation
Following your consultation and the decision for surgery you will be seen in the pre-operative assessment clinic. A team of nurses and anaesthetists will review your medical history and assess whether there are any clinical tests that need to be carried out to check your fitness for surgery.
It will assist if you stop taking any herbal remedies, homeopathic or complementary medicine not prescribed by your GP. Some of these tablets can cause excessive bleeding during surgery. They should be stopped at least 3 weeks before surgery but can be resumed when you are discharged. You must also tell me if you are taking aspirin, warfarin or other blood thinning medication. Smoking is detrimental to this type of surgery therefore you are advised to stop smoking prior to embarking on surgery.
You should expect to be in hospital for 3-5 days.
On the day of surgery I will draw some markings on you to be used as a guide for surgery. You will also see the anaethetist who will discuss the anaesthetic and post-operative pain management plan.
Items you should bring to hospital:
- Dressing Gown
- Post-op bra
Your bra will need to be supportive and without wires, ideally with a front fastening. If you need guidance this can be discussed with your breast care nurse. The bra is worn from the day of surgery, day and night for 6 weeks. This gives your reconstructed breast support.
Please do not bring in any jewellery and remove rings from the operated side because your hand is prone to swelling after the operation.
Also please note that flowers and plants are not permitted on the ward.
After Your Operation
After your operation you will be transferred to a ward area where you are closely observed. This area has a higher nursing staff ratio to enable close monitoring for the first 48 hours after your operation. The operation will take 4 to 10 hours depending on whether you are having one or two flaps. You will probably feel drowsy until the next day so it is advisable for your next of kin to telephone the ward before visiting.
When you wake up you will have a urinary catheter, a drain in each reconstructed breast and a drain in the abdominal donor site.
After your operation I encourage you to get out of bed as soon as possible. If you return to the ward early enough that may even be on the same day. This helps to open your airways up following the long anaesthetic. On the first day after the operation you will sit out of bed and do some short walks. We aim to remove the catheter later the same day.
You will have some tape dressings on the wounds and will put the bra on before getting out of bed to support the reconstruction. You will have a warming blanket (bair hugger) on for the first 24 hours after the operation. It is important to keep the area warm to maintain a good blood supply to the flap.
Your abdominal wound may feel tight following surgery. To improve comfort you can sit with you hips bent.
The nursing staff will make regular observations including blood pressure, temperature, flap observations, drip monitoring and oxygen monitoring. The flap is closely observed during the first 48 hours to ensure that any problems with the blood flow are picked up early and dealt with in a timely fashion. If any problems with blood flow to the flap or other problems such as bleeding occur it would be necessary to return you to theatre to investigate the cause.
Do not be alarmed by the number of drips and drains you have when you first return from theatre, this is quite normal for this type of surgery.
This is used to give you fluids and keep you hydrated whilst in theatre and immediately afterwards when you are too drowsy to drink. It can also be used to give medication if required. Fluids are normally discontinued once you are drinking good volumes.
This will be inserted once you are asleep and allows you to pass urine without getting out of bed. As soon as you are up and about this will be removed.
Many women have anxiety about the catheter however it generally causes very little discomfort and is easy to remove.
You will have one drain at the site of the reconstructed breast and are likely to have one or two in the abdomen as well. These are removed before you are discharged.
You will have oxygen administered initially via a mask then through small tubes that sit in the nostrils. This is required until your oxygen levels are back to normal.
Compression boots and stockings
You will wear anti-thrombus stocking throughout you admission and for 6 weeks after discharge.
In addition to this you will have inflatable cuff on the calves during your operation and for 24 hours afterwards. These inflate and deflate in a cycle and gently massage the calves to help your circulation to continue to flow well whilst you are less mobile.
During your hospital stay our physiotherapists will see you on several occasions. The aims of physiotherapy following breast reconstruction are to prevent you developing breathing problems such as chest infections, to help get you mobile again, to help you regain strength and movement in your shoulder and arm and to advise you on returning to your normal daily activities.
Your physiotherapist will show you some exercises you can do for your lower body to prevent stiffness and aching in your joints. Moving your feet and ankles helps your circulation and relieves pressure on your heals.
On the first post-operative day you will be helped to sit out, stand up and walk short distances. As you start moving there will be a little soreness and pulling at the wounds but do not worry they will not split. You may find it difficult to stand up straight initially due to pressure on your donor site but this area becomes more comfortable over the next few days. You will increase this distance you walk every day and aim to do stairs on the day of discharge.
Following breast reconstruction there is a small risk you will develop a stiff shoulder. This is because the surgery is in close proximity to the shoulder joint and you will inevitably be a bit reluctant to move your arm. In immediate reconstruction you may also have had surgery to the axillary lymph nodes.
Your physiotherapist will advise and guide on which shoulder exercises to do and when. You should usually start these exercises the day after surgery. You will probably feel tightness, pulling and discomfort when you do the exercises. This is normal however if it is very painful please discuss this with your physiotherapist. What to Expect on Discharge
You will have all your dressings checked on the day of discharge, which is usually 3-5 days after surgery. At this stage you will still not be using the arm on the operated side for any lifting or carrying and you may still feel a little weak. You should have another adult at home with you for the first week after discharge. You will be seen again in the dressings clinic approximately one week following discharge.
It is normal to feel tired after major surgery so do not over exert yourself for the first few weeks at home. You may find simple tasks such as getting washed and dressed leave you feeling tired. Try to get plenty of rest and always balance periods of activity with periods of rest. Build up your stamina by going for a walk everyday, increasing the distance you walk each time. Continue to do the shoulder exercises that you have been given in hospital and begin any new exercises as directed. You should continue the exercises until twelve weeks after your operation.
Scar tissue is vital to the healing process however scars can tighten, limit movements and become uncomfortable. Massage helps to encourage the scar tissue to form in the correct lines and make a more functional rather than restrictive scar. Massage also makes the scar less sensitive and prevents adhesions.
To massage apply a small amount of simple un-perfumed moisturizing cream to the scar. Use the thumb or index finger to massage in small circular motion along the scar. Use a firm pressure and massage several times a day. Only start the massage once the wounds are fully healed (nurses will provide you with guidance on this).
Returning to Normal Activities
There are no strict rules for when you return to work, driving or sports and this will depend upon you as an individual, how you heal and the nature of your work or hobbies. I will give you guidance in the clinic, the following information gives you a generalized idea of what to expect.
Two weeks after your operation you can use the arm on the affected side for light activities eg lifting a full kettle or brushing your hair. Over the next 4 weeks you can build up the use of this arm by doing light household activities such as dusting and preparing light meals. At 6 weeks after the operation you should have returned to most normal daily activities such as carrying shopping and hovering. You will not however have normal energy levels until around 12 weeks post-op.
Return to Work
This will depend on the type of work you do. For office jobs or other non-physical work you can probably return at 6 weeks although you may find you tire easily and therefore it may be appropriate to negotiate reduced hours for the first couple of weeks. If your work is physical and involves heavy lifting you could return on light duties if possible at 8 weeks post-operatively but you should not do any heavy lifting until at least 12 weeks post-operatively. When you return to work you will need to gradually build up your strength so may benefit from a phased return.
Return to Driving
You should avoid driving for 4-6 weeks after surgery. You should not return to driving until you feel 100% alert and able to react in an emergency. You must have regained full shoulder movement before attempting to drive. You must always wear your seatbelt when in the car.
Return to Sport
Provided you have healed you can return to sports at 4 - 6 weeks but you should start with less vigorous activities and gradually build up your level of activity. You will be unfit and will need to build slowly. You should not participate in contact sports or raquet sports until 3 months after your surgery.
What to Expect After Discharge
We know that this may be a difficult time for you. It often helps to talk to family and friends about how you are feeing. All of the team are here to offer support. If you feel that you need some additional support after discharge your breast care nurse will be your first point of contact. If it is felt necessary you will be offered the opportunity to meet one of our psychotherapy and counseling team for additional support. You are also welcome to request this if you feel in need of additional support.
You will be given a dressing clinic appointment approximately one week after you go home. At this appointment a nurse will clean the wounds, re-dress them if required and organise additional appointments if required.
I will see you 6 weeks after your operation and check the reconstructed breast and make sure all is going well.
If you have had an immediate reconstruction you will be seen by the Breast Surgeon 2-3 weeks after surgery to discuss your results and additional treatments that you may be offered. You may be referred to see an oncologist to discuss radiotherapy or chemotherapy.
Potential Risks and Complications of DIEP reconstruction
Like all Microsurgical breast reconstructions, the DIEP flap requires a specially trained and skilled Plastic Surgeon with Microsurgical expertise and a specialist theatre team and anaethetist. In the vast majority of cases, Microsurgery is a success. There is a 1-2% risk of failure of the flap. Remember that the procedure involves reconnecting a 2 mm diameter artery and vein under the microscope and there is a small chance of a clot forming at the site of this join. If the flap circulation becomes blocked for some reason, the flap could fail and require removal. This is most likely in the first 24 – 48 hours, which is why we monitor you most closely during this period. Around 5% of patients may require return to theatre to have the vessels inspected and possible re-joined.
Potential complications also include those related to having a general anaesthetic such as cardiac or respiratory compromise, blood clots in the leg (DVT) or the lung (PE).
In addition to the risk of flap loss other early complications include bleeding or haematoma that may require return to theatre, infection, delayed wound healing, seroma (a collection of tissue fluid) and post-operative pain.
You will feel swollen and bruised for the first few weeks in both the breast and the abdomen, this settles down over a period of a few weeks. You will experience numbness at both sites which will recover slowly over many months but is unlikely to fully recover. The scars will be red/pink initially but should fade over time. In rare cases patients develop abnormal thickened scars, which may require additional treatment.
Occasionally some areas of the flap do not quite have enough blood supply and small areas of fat become necrotic forming a firm hard lump in the reconstructed breast. This usually settles with time but can take 1-2 years. In very rare cases fat necrosis requires excision.
It is not unusual for the DIEP flap to feel quite firm for a number of weeks post-operatively. This usually softens over the first few months to ultimately feel like a normal soft breast.
In the long-term there may be a degree of asymmetry requiring “touch-up” surgery or contralateral symmetrising surgery (see following section). In a few cases there may be a mild contour defect in the abdomen which is usually amenable to correction at the same time as additional procedures.
The entire process of breast reconstruction may take many months and you will often require additional procedures to achieve the final result. Other procedures that may be offered to you are;
Nipple-Areolar Reconstruction & Tattoo
Nipple reconstruction is typically offered at least 3 months after your breast reconstruction. It is a local anaesthetic, day-case procedure that takes around 30 minutes. It involves lifting an area of skin on the flap and suturing it to create a prominence. It does not give any colour to the nipple / areola and to achieve this you will require a tattoo.
Nipple tattooing can be done once the scars in the area are mature (no longer pink). It is a simple outpatient procedure that takes around 40 minutes. A coloured semi-permanent pigment is applied using a small needle. The area is then covered with a dressing and you will be advised when to remove it. It can fade with time and may need a top-up from time to time.
Lipofilling / Autofat Injection
This involves taking fat from other areas of the body (by liposuction) and injecting it into the reconstructed breast to fill out any contours / dips in the reconstructed breast or to give additional volume. Usually 50% of the fat is absorbed so the procedure may need repeating.
Occasionally to reconstruction is too large or has fullness in one area. You may be offered liposuction to correct this.
Excess Skin (Dog Ear) Excision
Occasionally at the end of a scar excess skin can form a prominence that has the appearance of a dog’s ear. Often these settle with time but if appropriate they can be removed under local anaesthetic.
After reconstruction there may be a difference in the size of the breasts as the natural breast is larger. If this is the case it can be reduced to match the reconstructed side. This is usually a day-case procedure but you may require one night in hospital.
"I am absolutely delighted with the result of my reconstruction. I am a very lucky lady to have had you as my surgeon."
- AG DIEP Breast Reconstruction
"Thank you so much for all your support, kindness and amazing skills. You have been truly wonderful."
- AK DIEP Breast Reconstruction