Michelle Grim PA-C on August 8th, 2013

 

Being Proactice About Lymphedema

Lymphedema is a frequent topic of conversation in many of our post-op visits after mastectomy and reconstruction.  It is true that your personal risk for lymphedema is increased by having breast surgery, but this risk may be exaggerated in educational resources online; your worry about lymphedema can then also be exacerbated by repeated mentions of it’s effects by friends or loved ones.  Navigating this topic, therefore, can be challenging.

As a practice, it is our goal to always provide our patients with the education they need to make informed decisions.  Below you will find a resource we created to address some basic questions regarding lymphedema.  As in any setting regarding your health, if you have additional questions, please reach out to us or ask your primary care doctor.

 

 

Being Proactive About Lymphedema

 

Breast cancer related lymphedema is a chronic swelling of the upper limb following breast and/or axillary lymph node surgery.  It has varying degrees of severity.  Lymphedema is uncommon in women who have had a mastectomy with a sentinel lymph node biopsy (SLNB) regardless of the number of sentinel nodes taken. However, risk increases if you have had an axillary lymph node dissection (ALND) and/or radiation to the breast and/or axilla (armpit).  Other factors that have been associated with increased risk for lymphedema after mastectomy include infection, obesity/overweight (BMI>25), increased age, and poor overall health status.  The more risk factors you have, the greater the risk for developing lymphedema.

 

Lymphedema cannot always be prevented, but if you are at higher risk for lymphedema, there are strategies that can be employed to reduce risk for lymphedema. The information below will introduce you to these general strategies.  For more specific information, or if you are at high risk for lymphedema, we recommend seeing a physical therapist who is certified in lymphedema care.  Please feel free to ask us for a referral should you need one.

 

Worry regarding lymphedema after breast surgery can, alone, be very devastating to quality of life.  Remember, your risk for lymphedema is relatively low if you have not had an axillary node dissection or radiation to the breast or axilla. If you are at relatively low risk but still have worry about lymphedema, please ask us or your medical doctor.

 

Skin Care Instructions

 

Preventing lymphedema is an extremely important aspect of lymphedema care in those patients with risk factors for lymphedema (especially those patients who have had ALND and/or radiation). The following strategies can be used to reduce your risk of developing lymphedema.  If you notice any limb swelling, please call your doctor.

 

These recommendations apply to your affected limb.

 

1.  DAILY SKIN CHECK

  1. Examine your arm and hand daily for cuts, burns, or bites; these are potential sources of infection.  Check all folds and in-between fingers.  Be sure to check any areas that are numb by looking at the area or feeling with your fingers.
  2. Treat skin openings with an antibiotic cream (such as Neosporin, Bacitracin, etc.) and band-aids to protect wounds from infection.
  3. Be aware of signs of infection which include redness, warmth, tenderness, pain, red streaks, or swelling.  Call your doctor immediately if you have these symptoms.
  4. Carefully inspect hands for hangnails and cracked or torn cuticles; if present, make sure to keep these areas clean by washing with soap and water.
  5. Lotion or cream use can help avoid cracks in your skin due to dryness.  Use lotions as needed to keep your skin moist.

 

2.  AVOID INFECTION

  1. Keep your arm, especially between fingers.  Dry well in all creases.
  2. Wash your garments and stockinet layer of bandages (if applicable) daily. Wash elastic bandages after no more than four wearings.
  3. Keep your cuticles moist with cream and push them back, without cutting them.
  4. Use gloves when doing dishes, loading dishwasher, cleaning house, gardening or when doing any other “dirty” work.  Turn gardening gloves inside out and wash them at the end of each gardening session.
  5. Always offer the other arm for injections or blood tests. Depending on your risk factors, recommendations for blood pressure measurements can differ; this should be discussed with your doctor. If you have had an axillary node dissection or radiation, try to avoid blood pressure measurements on that side.
  1. Use an electric shaver to remove hair in affected areas, as blade shavers may introduce infection.
  2. Use a thimble when sewing.

 

3.   AVOID MUSCLE STRAIN

  1. Use your arm as normally as possible. Activities that require full range of motion of your arm are okay; there is no need to avoid using your arm in normal day to day activities.
  2. Discuss any questions regarding lifting restrictions with your therapist.  If you are low risk for lymphedema, lifting restrictions are often not needed.
  3. Begin any new exercise program slowly, increase gradually and monitor your arm carefully.  Be sure to warm up and cool down properly.  Swimming, walking, bicycling, dancing and yoga are suggested.  Aerobics classes may be acceptable.  Use of light weights with high repetition is acceptable.  Tennis, golf, and racquetball may be okay, but may increase swelling in some people; if you are high risk for lymphedema, discuss this with your therapist.  Contact sports are best avoided.
  4. Discuss your exercise preferences with your therapist for specific guidelines; your therapist may recommend measuring your limb on a regular basis to gain feedback about how your exercise program is affecting your lymphedema.

 

4.  AVOID SUNBURNS & BURNS

  1. Use a high SPF sunscreen on the arm at risk, and on the trunk quadrant, whenever in the            sun.
    1. Use extra long oven mitts to protect hands and forearms from cooking burns.
    2. Smokers should hold their cigarettes in the other hand.
    3. Practice taking covers off microwaved food with the other hand.
    4. Use caution with heated hair styling aids.

 

6.  AVOID CONSTRICTION

  1. Carry your purse on the other shoulder and lighten its load, if possible.
  2. After breast surgery, wear the lightest weight prosthesis you can manage.
  3. Wear a loose watchband, or wear your watch on the other arm.  Avoid tight jewelry.
  4. Underclothes should not bind at the chest or underarms.  Check bra size, especially if you gained weight from chemotherapy.
  5. Be sure clothes are loose at wrists.

 

7.  FLYING WITH LYMPHEDEMA

  1. Flying after breast surgery is okay.
  2. If you have lymphedema and have been prescribed a compression garment for treatment of your lymphedema you should wear that garment when flying.  There is no clear rationale for wearing a compression garment when flying if you do not have lymphedema.

 

 

 

1) Renting a medical electric recliner will help the first 1-2 weeks post tummy tuck. It will stand you all the way up and is much more comfortable than a bed. A lot of people simply use a million pillows to get comfortable, but for me a bed was difficult. Being short (around 5’1) it was very hard for me to get into the bed all together, let alone to find a comfortable position. I am so thankful that I had the electric recliner the first week and not sure what I would do without it. It cost me around $150 a week (plus delivery and pick up) to rent the recliner which was TOTALLY WORTH IT. If you are having your surgery in Chicago, the only place I found that would deliver to the city was:
Medical Equipment Inc.
1804 Glenview Road, Glenview IL 60025
(847) 724-8380 or (866) 668-5775

2) Stool Softeners! If your doctor doesn’t prescribe any, make sure you get them over the counter at your local pharmacy. The directions say to take 1-3 a day, so I would take one in the evening and one at night. I made the mistake of taking one on the 8th day post – op…around day 10 I had the worst pain in my life. The pain medications make you extremely constipated and I needed to use an enema, by far the worst experience of my life. I have never felt a pain like that, I was so worried that I might have popped stitches. I started taking 3 stool softeners a day (morning mid-day and evening) after that night, and it barely helped. I added prunes to my diet (around 7 per day) and my stools are finally feeling normal. Do not forget to take stool softeners – you WILL regret it if you forget.

3) For the first week post – op, having the following items will make your recovery much easier and more comfortable:
- Baby powder and lotion: you cannot shower for the first couple of days and you will sweat. I don’t use baby powder at all in my everyday life- but it did come in handy the first week post – op. Because you are indoors all day post op, your skin can get dry and crackly. I made the mistake of not using lotion and my skin did crack. When you are finally able to shower, make sure you lotion up afterwards!
-Back scratcher: I recommend a wooden one. It’s these types of little things that make the first week of recovery more comfortable.
-PJ gown that buttons down the front: I was more comfortable wearing nothing at all (except for my compression garment). But having something long to that doesn’t pull over your head is much more convenient.
-Cortozone cream: Since you can’t shower initially, you may get a rash (I did). The pain medication also can make you itchy.
-Neck Pillow: Sitting upright all day and night can make your neck sore and I found that having a neck pillow helps.
-Dry Shampoo: I honestly didn’t use this (I had my mother around who helped me wash my hair), but I heard a lot of people found it helpful since they could not shower.
-Neosporin and Q-tips: In the first couple weeks post op – you can have some seeping of fluids. I had a little spot that leaked on the left hand side. I didn’t want to touch it with my hands so I used q-tips.
-Lip Balm: I’m not sure if it was a side effect of the pain medication, but my lips were constantly dry.
-Grip, no slip socks: The one thing I didn’t want to imagine was slipping and falling on the floor. If you are going to walk anywhere where there isn’t carpeting, I recommend taking the precaution and wearing no-slip socks.

3) Pain medication: It is so important to stay on top of taking your pain medication post op. When I got back to the hotel (I traveled for my surgery), I took my pain medication and set my alarm for every 4 hours. I would make sure that I woke up in the middle of the night and never missed taking one. I think this is a main reason why I had such an easy recovery and barley felt any pain. When you miss taking your medication and wait until you feel pain or the pain is out of control, it takes a lot and is very difficult to get it back under control. If you are on top of taking your medication, you will have a much easier recovery. The pain medication does make you itch, constipated, and have crazy dreams. I also recommend asking your doctor for the prescription before surgery so you can get it filled and it will be ready post-op – can you imagine waiting in line for your pain medication at the pharmacy post op?

4) Hydration: I made sure that I drank a bottle of water every 2 hours after my surgery. It is so important to keep your muscles hydrated so they can heal. Being dehydrated can cause nausea and vomiting. I made the huge mistake of having one glass of wine with dinner the night before my surgery. Not only did it get me thirsty in the middle of the night (when you should not be eating or drinking anything before going under anesthesia), but after waking up from my surgery, I immediately threw up twice since I was so dehydrated. I personally am not going to drink for 2 months minimum after surgery – why risk it?

5) Laughing, Coughing and Sneezing: This can be very painful post tummy tuck. The best solution: grab a pillow (the harder the better, you don’t want anything too soft) or a folded towel and press it against your abdomen when you feel the urge coming. This will counteract the pressure and it won’t hurt. I always made sure there was something by me to grab if I needed to sneeze or cough.

6) Traveling for your surgery?: When booking your hotel room, make sure you request a handicap room. The only main difference is the bathroom. There are bars around the toilet for you to hold on to when using the bathroom (helpful) and it also comes with a handicap shower with a seat and removable shower head (very helpful). There is no way I would have been able to shower without it.

7) I weighed and measured myself immediately before going into surgery, and every day after as well. The only reason I did was to see what the fluid was doing in my body. Most people recommend not to weigh or measure yourself post – op because they don’t want you to get discouraged. You will weigh more and be larger for a while post – op, this is completely normal. I just preferred to know what the fluid was doing – if it was going down or going up. 2 days post-op , I was 8 pounds heavier. By day 8 post-op, I was the same weight as when I went in. At 3 weeks post up I weight 3 pounds less than when I went in for surgery, but I was 2-3 inches larger. At 3.5 weeks I gained 4 pounds and another 1-2 inches. The fluid will fluctuate, so keep that in mind.

8) New Injuries Post-Op: I guess it is common for old injuries to come up after having surgery. I didn’t have much pain from surgery, but after surgery I got a left frozen shoulder – this pain was unbearable. My doctor had to prescribe me heavier pain medication for my shoulder. I now have to start physical therapy. If you have had any previous injuries, it is not uncommon for them to become inflamed after any type of surgery.

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Michelle Grim PA-C on January 25th, 2013

Many of our patients express concern about what to expect after breast reconstruction.  In my discussions with patients prior to mastectomy and reconstruction, I always find it challenging to help patients anticipate what things will look like.  In practice, we find before and after pictures to be a useful tool to address this question, but breast reconstruction is definitely a process; this means that what you look like right after surgery is most likely not how your final reconstruction will look.  Regardless, most patients, in anticipation of the process they are about to experience, would like to know more about this intial post-op period.

One of our patients recently chronicled this process, and has given us permission to share her pictures here.  We hope that you will find this helpful in anticipating what to expect as the process of reconstruction progresses for you.  Remember that all patients are different, and this is just one patient’s experience.  If you have any questions about what you see here, please feel free to email me at michelle@northwesternplastics.com

A Pictorial of Implant Reconstruction after Mastectomy

If you are planning to have immediate reconstruction with implants, expect that your initial reconstruction will be slightly smaller in size than your natural breasts.  Most patients with breast cancer will also have the nipple-areola complex removed which will leave a scar starting at the middle of your breast angling out towards your armpit (such as what is seen in this picture).  Incisions are generally covered by steri-strips after surgery.  These will remain on for usually around 10 days.  Bruising after surgery is normal.

This patient had bilateral non-nipple sparing mastectomy with immediate tissue expander reconstruction.

 

Once the steri-strips have been removed, you may see bunching along the incision.  This is normal and will resolve with time.  Some pink discoloration of the skin is also normal and is a sign of healing.  You may also notice a small scab along the incision.  We will monitor this at your follow up appointments.

Close up of right breast mastectomy incision one week post-op.

 

Most patient will be managing drains for 7-10 days after surgery.  When you are in the hospital, your nurse will teach you how to empty your drains, record the output, and strip them.  Once drains are under 30 ml/24 hours, we will remove them in the office.  Drains usually come out under the arm; most patients will have two per side.

Left: two drains as they appear under the arm. Right: securing drains after surgery, ace wrap for comfort.

 

Expansions usually begin 2-4 weeks after surgery once you are healed.  They can occur during chemotherapy, but not during radiation.  This patient had chemotherapy, but no radiation.  Her expansions were delayed slightly to allow her time to heal.  Delayed healing, as is shown in this picture, can occur after mastectomy due to inadequate blood supply to the skin.  If this happens, we will continue to watch the area.  We may remove the scab in the office and reclose the area with sutures if necessary.

At one month post-op, this patient still has a small scab on her left breast.

 

After healing is complete, expansions begin.  Once expansions and any other needed treatments are completed, we will proceed with your second stage surgery.  At this surgery, we will exchange to silicone or saline implants depending on your preference and will make small adjustments to improve symmetry and shape.  The second stage surgery is an outpatient surgery done under sedation that usually takes about 1.5 hours.  Most patients feel good enough after surgery to go back to their normal daily activities within a few days.

After exchange, you will notice your reconstruction feels much softer and appears more natural.  Between two and three months after exchange, we will proceed with nipple-areola complex reconstruction. Some patients elect not to have nipple reconstruction and just have tattoo.  This is sometimes also recommended if you have had radiation therapy and your skin is very tight on the radiated side.  Tattoo occurs in the office with Jeff.  After tattoo, we ask that you do not swim for 1-2 weeks; there are no other restrictions.

Tattoo planning will occur in the office during the tattoo session.  If you have particular desires for the appearance of your tattoo (such as color or size/shape), please come prepared with that information.  Pictures can be helpful if you’d like to bring pre-op pictures or other pictures that show your desired outcome.

Left: 3D tattoo planning; Right: one 3D tattoo completed. This patient did not have nipple reconstruction.

 

This patient completed her reconstruction, with the final procedure being her 3D nipple tattoo, approximately 5 months after her mastectomy and first stage reconstruction with tissue expanders.  As you can see, the appearance of the reconstruction significantly changed over time.  See below for her final pictures compared to her pre-op.

Left: before mastectomy; Right: completed implant reconstruction with 3D tattoo.

We hope this helps you!  If you have any questions about this process, feel free to check out our website and our frequently asked questions section.  And if you find you still have questions, please let us know!

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Michelle Grim PA-C on January 18th, 2013

As a physician assistant who takes care of many women recovering from mastectomy and reconstruction, I have a pretty good understanding of what occurs during the post-operative period. Northwestern Specialists in Plastic Surgery puts a huge emphasis on education as a practice, and being a part of this practice, I’ve learned so much about how to educate women, help them understand realistic expectations, and help them feel they are receiving the information they need to be comfortable with their reconstruction process. But, in all of that educating, I must say, I can’t give a first person account of this process.  I personally have not had to experience breast cancer.  The best that we’ve found we can do is give a summary account of what is most common and the range of experiences.

The more time I spend helping women through this challenging journey, the more I realize it is just that, a journey.  No two women are exactly the same, and no two surgeries are exactly the same.  For that reason, although we constantly strive to help women through their breast reconstruction experience, we also realize there’s still a gap we’d love to help fill.

One of our patients recently mentioned that the sensations she had after surgery were unexpected.  She wished she had known she would feel some particular sensations in her breasts after reconstruction, and felt she would have been more at ease had she known about them ahead of time.  As a practice, we constantly work on figuring out ways to communicate this exact type of information.  In the end, however, we realize that what we end up educating our patients about are the most common experiences.

In an effort to continue to improve our ability to help our patients, this list below will present some of the initial, first person, patient reported sensations/experiences we have collected from our patients.  We thought it might be helpful to provide a first person account of the feelings that have been experienced by our patients.  Some will no doubt find this useful, both to look at and to contribute to.

We would love to use this space to share more and more. We hope that many will add to this list.  Please share your experiences with other women about to embark on their individual journey with breast cancer and reconstruction.  If you’d like to contribute, please email additional descriptors to me at michelle@northwesternplastics.com.  We would like this list to be as complete as possible, and only you, women who have actually been through this process, can make it complete.

 

Feelings the you have had after breast reconstruction:

  • pressure
  • heat
  • spasms
  • armpit numbness
  • porcupine feeling under my arms
  • the feeling of plastic inside my body when I move
  • the feeling of wearing a tight bra even when I’m not wearing anything
  • the feeling of wearing a metal bra
  • tighter at night or when I wake up
  • itching
  • burning
  • my breasts feel bumpy
  • my breasts look flatter in the front
  • tightness that extends down my arm toward my elbow
  • tingling
  • cold

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If I used Botox for a number of years, do I stop needing it? Does my face “remember” it? 1 answer on Quora

If I used Botox for a number of years, do I stop needing it? Does my face “remember” it?

Clark Schierle, MD, PhD on March 1st, 2011

What is a “retouch” after liposuction?” 1 answer on Quora

What is a “retouch” after liposuction?”

Liposuction is as much art as science. In an effort to avoid any complications such as dimpling, rippling, excessive removal in any one area and to try and achieve a smooth, refined result, your surgeon may choose to be more conservative. Depending on the amount of fat to be removed, some swelling may begin to set in during the surgery which can obscure the final result. Every effort is made to plan the areas to be treated preoperatively with skin markings, planned volumes to be removed, etc… However, even with the best planning and execution, there may be areas that do not respond completely as expected. If the majority of the result is pretty good and there are a few small areas that require additional liposuction, this can often be performed in the office under local anesthesia. Limited volumes can be removed safely in this manner, typically waiting several months to ensure that all swelling has resolved and the result is truly final. As always, be sure your physician is board certified to ensure they adhere to the highest standards of care.

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Clark Schierle, MD, PhD on February 18th, 2011

What is the link between lymphoma and breast implants? 1 answer on Quora

What is the link between lymphoma and breast implants?

Although there does appear to be a real link between Anaplastic Large Cell Lymphoma (ALCL) and breast implants, the risk as we currently understand it is extremely low. With 34 documented cases in an estimated 5 to 10 million women with breast implants, the risk is similar to being struck by lightning. No surgery is without risk so it is important to take this new information in context.

Saline and silicone breast implants are the most studied medical devices in history. With breast augmentation becoming the most common cosmetic plastic surgery procedure in the United States it’s important that we understand the risks as thoroughly as possible. That’s what this new FDA announcement is all about: gathering more information so this new, very small risk can be better understood.

If you currently have breast implants in place, whether for cosmetic or reconstructive purposes, you should be aware of any changes in the way your implants look or feel and bring this to the attention of your physician. Most of the reported cases of ALCL have found lymphoma cells in a fluid collection around the implant (see figure to the right). If you have been diagnosed with ALCL in the setting of breast implants, this information should be reported to the FDA by your physician.

It’s important to understand that this information is still preliminary. For instance one of the patients reported developed ALCL within one year after her implant surgery, casting some doubt as to whether there was truly enough time for the implants to have been the cause of the ALCL in this case. Another two patients also had disease in other lymph tissues at the time of diagnosis, raising the possibility that the lymphoma did not develop in the breast but rather may have spread to the breast from other primary locations. This ambiguity in the data is just the reason why we need more information.

Northwestern Plastic Surgery Associates has established a website with the latest information on this evolving topic. Visit us at Chicago breast implant updates.

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Clark Schierle, MD, PhD on February 18th, 2011

Breast Cancer Awareness: What should everyone know about breast cancer? 4 answers on Quora

What should everyone know about breast cancer?

Women should know their options for reconstruction to restore the look and feel of their breasts after surgery to treat breast cancer. The Federal Women’s Health and Cancer Rights Act of 1998 mandates all health insurance to cover any reconstruction after breast cancer, including cosmetic procedures to an unaffected breast for symmetry. Our website provides more information and resources for women wanting to learn more about breast reconstruction after breast cancer surgery. http://northwesternplastics.com/

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Clark Schierle, MD, PhD on February 18th, 2011

What is the most effective scar-fading treatment? 2 answers on Quora

What is the most effective scar-fading treatment?

There are many scar remedies on the market and even more home-made treatments which are aimed at improving scars. Having done extensive scientific research on scarring at the Wound Healing Research Laboratory, I can definitively say that as of this time, there is now treatment which can truly make a scar disappear. There is good laboratory and clinical evidence for the effectiveness of massage and silicone gel products in improving bad scarring.

Massage works to stimulate the body to remodel, soften, and flatten raised or thickened scars. It is most effective when initiated two to three weeks after the initial injury. Thirty minutes a day is recommended. I tell patients to massage whenever they’re stopped at a red light or when the commercials come on if they are watching TV.

Silicone gel appears to modulate the hydration state of the epidermal layer and cause molecular signals which improve the maturation of underlying scar tissue being created by fibroblasts. Again, it is most effective when initiated two to three weeks after the initial injury. Gels should be applied twice daily, while sheets should be worn for twelve hours a day (either while sleeping or during the day, not both).

More drastic treatments such as radiation, steroid injections, and immune suppressing medications can be used in certain severe scarring conditions such as keloid scars, where the scar overgrows the boundaries of the original injury. Other treatments, including Vitamin E, cocoa butter, etc… can help with the hydration state of the scar and improve some aspects such as decreasing redness, but have not been shown in rigorous scientific studies to be of much benefit. That being said, if a patient or their family wants to try them, I don’t discourage them. They may help, and as long as they don’t hurt, I am not against trying alternative remedies.

Both silicone and massage will make a bad scar better, but nothing can make it disappear entirely. Scars which are over a year old are typically mature and will not respond significantly to additional treatment. Surgery may be indicated to revise the scar at this point. For more information, seek out a board certified plastic surgeon or dermatologist in your area to customize your treatment for you.

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Clark Schierle, MD, PhD on February 18th, 2011

Can you get plastic surgery to remove dark eyebags? 4 answers on Quora

Can you get plastic surgery to remove dark eyebags?

Treatment of the lower eyelid is a very hot topic of plastic surgery interest and research. There are many anatomic features of aging that can lead to a less than ideal aesthetic appearance in this area. These include excess skin, thin skin, excess fat, or inadequate volume in the tear trough, lid-cheek junction, nasojugal groove, or orbito-malar regions. A careful examination by a board certified plastic surgeon in your area will assess these problems and help decide if the best treatment involves skin care, injectable treatments, or surgery.

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