Breast Reconstruction Post-Op Care Patient Q&A
Dr. Salzberg of the New York Group for Plastic Surgery often uses an a-cellular tissue matrix such as Alloderm or Strattice in his Direct-to-Implant, or “One-Step,” post-mastectomy breast reconstruction. This helps to:
- Avoid the use of tissue expanders, which stretch the pectoralis (chest) muscle to make a space for an eventual implant. Instead, the pectoralis muscle in combination with Alloderm or Strattice accommodates the permanent implant directly at the time of mastectomy (no painful expansions for months after surgery required.)
- Provide a supportive sling for the implant by maintaining the inframammary (under breast) fold to preserve natural breast shape, and act as an “internal bra” to support the implant.
- Here are frequently asked questions and answers for patients following breast reconstruction with implants and Alloderm or Strattice:
Breast Sensation and Appearance
Q: I feel like I have a tiny piece of plastic poking me underneath my breast along the incision—what is this?
A: This is most likely a small piece of suture material (stitch) that has worked its way to the surface of the skin before the body has had a chance to dissolve it. This is called a suture extrusion and should not be of concern; it will eventually dissolve with time.
Occasionally the skin around this exposed suture can get slightly irritated—red around the area with a very small amount of clear drainage. This is also not of concern and will resolve if the stitch is trimmed away from the area. This can be done in our office during one of your follow-up appointments. If you live far away, you can simply take a tweezer (wipe with alcohol first) and pull up on the end of the exposed stitch. Then trim the stitch with scissors at the skin level and place a small amount of bacitracin over the area, and cover with a Band-Aid for one day.
Q: Why do I get a pulling sensation when I engage my core, e.g., sit up straight from lying completely flat, open heavy doors, open bottles?
A: This pulling sensation is due to the fact that you’re engaging your pectoralis muscle, and should not be of concern. The implant will shift slightly around underneath the pectoralis muscle when the muscle is engaged or active, but this is totally normal with implant breast reconstruction. The sensation will feel less “weird” as you heal from surgery.
Q: Why do my nipples seem low or slightly wide?
A: Nipple position will change dramatically as the implant settles over the first 8—12 weeks after surgery. The implant will settle into the pocket; in doing so the nipple comes up and is more centrally located. Just be patient—it will look even better at 6 months after surgery!
Q: My breast skin or part of the breast skin (most commonly the lower pole) looks like the pores are really big or like the peel of an orange—is this normal?
A: Yes, this appearance of the breast skin is just tissue swelling. It will look like the skin has the appearance of an orange peel, and is actually called “peau d’orange.” It happens from swelling in the tissue just below the skin and almost makes your skin look like the pores are really big. Don’t worry—it will resolve with time. Doing gentle breast massage will help.
Pain or Discomfort
Q: I am having some back pain after my breast reconstruction—is this normal?
A: Back pain can be normal after breast surgery as you are sleeping in positions you are not accustomed to; you have favored your chest area (hunching over etc.), and your posture has been different in the initial healing phase because your pectoralis muscles are tighter than normal. Regaining your upper body range of motion and returning to your normal sleeping position will dramatically improve back pain.
Q: When can I take ibuprofen (NSAIDs)?
A: You may take NSAIDs (Aleve, ibuprofen, etc.) once you are 2 weeks out from surgery.
Q: Can I put a heating pad or ice pack on my breast?
A: NO. Heating pads or ice packs will not help with swelling or pain and can actually damage your skin. Your breast skin sensation has changed after a mastectomy and may not be able to sense when something is too hot or too cold. In both instances, this can burn your skin.
Q: My Steri-Strips haven’t fallen off and its been 2 weeks—should I pull them off?
A: You can gently remove your Steri-Strips if they have not fallen off by week 3 after surgery. You can do this while you are in the shower and they will gently peel off like a Band-Aid.
Q: When do I start wearing the silicone strips?
A: After the Steri-Strips have fallen off or been removed, and your scar is completely formed. Generally, this is around 3 weeks after surgery.
Bras and Breast Massage
Q: My bra is very tight and feels uncomfortable underneath my breasts; are you sure I should wear an underwire bra?
A: Bras can feel tight after surgery because you’re swollen and because your sensation is different. The nerves have been traumatized and thus can be oversensitive. If your bra is feeling too tight or making marks in your skin from being tight, take it off and let your skin breathe for a while. During this downtime, don’t engage in a lot of activity—watch a movie or do something relaxing. Try putting the bra back on after giving yourself this break.
If the bra still feels tight, you can try different bras other than those we’ve recommended. Cramming yourself into a bra that is uncomfortable is not ideal. We just want the bra to be comfortably supportive and not overly compressive, unlike a heavy sports bra. The bra should have a cup to provide a place and shape for the breasts to rest as you heal and the swelling goes down. Wearing a different bra than one we initially recommended does not mean that your reconstructive results will be compromised. You can always try to wear the more shaping supportive bra we have given you in a couple of weeks when your swelling and hypersensitivity have decreased.
Q: When do I start breast massage and how do I do it?
A: Breast massage is typically started 2 weeks after surgery. The purpose of massaging the breast skin is to help increase blood flow and reduce swelling. Simply use any type of lotion (refrain from heavy perfumed lotions), and make small circles with your fingers over the entire breast, including the incision. There should be very light pressure (the weight of a nickel) as you massage. Doing this 1-2 times daily will moisturize your skin and encourage the healing process.
Movement, Activities and Exercise
Q: Will I need physical therapy/When can I start physical therapy?
A: The average patient will not require physical therapy following mastectomies and breast reconstruction. We encourage you to perform range of motion activities around 10 to 14 days after surgery. Exercises like walking your hands up the wall are beneficial to restore your range of motion to the pre-operative level. These should be done once or twice a day for 10—15 minute intervals.
If you find that you’re having difficulty getting full range of motion back in your upper body (common if you’ve had an axillary node dissection or a history of radiation), physical therapy can definitely help. You will need a referral from our office or from your breast surgeon to obtain an initial evaluation and treatment. You may begin a physical therapy (PT)/occupational therapy (OT) regimen at 3 weeks after surgery.
Q: When can I sleep on my side or stomach?
A: You may sleep on your side after your drains are removed. Alternate sides for a little bit at first so that all of your swelling doesn’t accumulate to one side. If you fall asleep on one side and wake up on the other, don’t worry. Just make yourself comfortable, and feel free to use pillows and blankets as needed. Sleeping on your stomach will be uncomfortable for a while and we do not recommend doing so until you are at least 3 months out from surgery. Most women say it takes 6 months before the stomach-sleeping position is doable.
Q: When can I start exercising?
A: From a medical standpoint you may begin exercising at 2 weeks after surgery. Go slow and pace yourself, as you are deconditioned; you just had surgery and haven’t worked out in a while. Additionally, you have had mild blood loss, which causes fatigue. When first beginning to exercise, it’s normal to feel a pulling sensation and tightness across your chest. The fatigue and tightness will improve as your body gets used to an exercise routine.
Initial exercise can include walking, running, using the elliptical machine without the arms; lower body weights; and or Pilates/Yoga that does not emphasize upper body strength maneuvers. If you would like to do upper body weights, biceps and triceps are generally okay. We do not want you to isolate your pectoralis (chest) muscles and thus activities like pushups, flies with free weights, swimming for exercise, and Pilates/Yoga positions where you’re holding your body weight up with your arms, are not advised until you are at least 12 weeks out from surgery.
At 12 weeks out from surgery you can begin to engage your upper body more. You can get back to pushups and other activities involving the pectoralis muscle. You will not be able to do these activities right off the bat as you did prior to surgery. There will be lots of movement with your pectoralis muscle and thus your implants will move a lot when you first engage in these activities. Pace yourself and gradually work up to the level you were performing at prior to surgery. Generally speaking, you will be able to get back to your previous pectoralis muscle strength level with time.
Q: When can I go swimming?
A: You may submerge yourself in water (swimming pool or ocean) when all of your incisions are closed and your drain hole scabs have fallen off to reveal formed scars; this is generally at 3 weeks after surgery. Hot tubs carry more bacteria than swimming pools or the ocean and are not recommended until 6 months after surgery.
Q: Can I go tanning or sun bathe?
A: Tanning beds are NEVER recommended by plastic surgeons! If you’re at the beach or in the sun, you will need to be careful because you can get sunburnt easily in the first year after surgery. Your breast area skin is hypersensitive, and sometimes it’s difficult to tell if you’re actually getting a sunburn due to changes in skin sensation that have not quite returned to normal. For this reason we ask that you wear sunscreen and get in the water periodically to cool off. You can also wear a shirt to protect your skin.
Q: When can I get a massage?
A: Some women may have back pain after breast surgery and would like to get a massage. This is okay to do, but it can be difficult or uncomfortable to lie on your stomach. Massages in an upright chair are probably the most comfortable during the initial 3 months after surgery. If you’d like to try a massage lying on your stomach, pad your sternum (chest bone) and your stomach to create a “hole” where your breasts can fall inside and not bear your weight when laying down…similar to how the masseuse accommodates pregnant woman.
Q: When is it okay to do household activities like laundry, sweeping or vacuuming?
A: You may do these activities 2 weeks after surgery with the exception of vacuuming. You should really wait 12 weeks before vacuuming, as vacuum cleaners are heavy and vacuuming requires a lot of pectoralis (chest) muscle work. You may do laundry at 2 weeks, but make sure to limit lifting heavy, such as large, full baskets or wet clothes. Wiping counters and sweeping are okay after 2 weeks, but don’t engage in this activity repetitively for long periods of time, i.e., wipe the counter once or twice but don’t clean the whole house in one setting!
Q: If I need it, when can I have a revision?
A: Revisions have been popular as we’ve developed new techniques to add contour to breast reconstruction, which will help improve symmetry and aesthetic appearance of the breasts. Very commonly we adjust implant size (you can go bigger if desired) and perform subcutaneous tissue transfer (fat grafting). We recommend waiting a minimum of 6 months after initial reconstruction surgery before pursuing any revision surgery, and revisions are most commonly done one year after initial breast reconstruction.
Q: What is subcutaneous tissue transfer (fat grafting)?
A: This involves using liposuction to remove a small amount of fat from an area of the body where you may feel you have excess. The fat is taken out using small cannulas (tubes) that preserve the fat cell and keep it healthy. The fat is re-injected through very tiny incisions (usually the ones you already have in the inframammary fold) into the tissue below the breast skin. Fat grafting can help correct contour irregularities and also add volume where you may be lacking tissue (most commonly in the upper pole of the breast where the mastectomy removed breast tissue and the implant couldn’t quite fill the tissue deficit.)
Recovery from the fat grafting procedure generally takes 3—5 days. You may have some mild bruising in areas where the fat has been taken and where it has been “grafted,” or inserted. We recommend you wear a compression garment (like SPANX) over the areas where we have taken the fat via liposuction for about 4 weeks.