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MUSC Health Plastic Surgery

Preparing for Surgery

Learn more information about your surgery:

 

Pre-Op

Starting now

Stop smoking. Smoking reduces circulation to the skin and impedes healing. Do not use any patches either, as these have nicotine in them, too. Remember that second-hand smoke is just as bad for you. Stay away from others who are smoking.

Two weeks before surgery

Do not take blood thinners. Stop taking any medications that contain aspirin, naproxen, or ibuprofen. In addition, stop taking Tamoxifen. Such drugs can increase bleeding during and after surgery. If you need a medication for pain before surgery, use medications containing acetaminophen. You should also limit your intake of vitamin E to less than 400mg a day, as it acts as a blood thinner.

The night before surgery

Shower the night before surgery and wash everywhere, paying extra attention to the surgical areas. Use the Chlorhexidine scrub provided to you.

Do NOT eat or drink anything after midnight. This includes water, gum and mints.

The day of surgery

Do NOT eat or drink ANYTHING. If you take daily medications, you may do so with a sip of water.

  • You may brush your teeth, but do not swallow the water.
  • Shower the morning of surgery and wash the surgical site with Chlorhexidine scrub. Dry off, but do not put anything else on your skin. That means not using perfume, moisturizer, deodorant or makeup.
  • Remove nail polish.
  • All body piercings (belly button, nipple, tongue, other) that are metal must be changed to plastic or removed entirely before the procedure. Please remove all other jewelry (necklaces, rings, wedding bands) as well. Also, do not wear anything in your hair that has metal on it.
  • Arrive at the surgery site two hours prior to your scheduled surgery. This allows time for registration as well as nursing and anesthesia evaluations.
  • Someone must accompany you to the holding area before your surgery. You must have a ride to and from the hospital (no taxis), and you cannot drive yourself home after surgery.

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Post-Op

Wound Care

Unless instructed differently by your physician, dressings should be left in place for 24 hours.

  • If you experience continued drainage from the operative site, you may replace the dressing with dry gauze to prevent leaking onto clothing.
  • You may shower 48 hours after your surgery. (No tub baths.)
    • Face away from the shower spray to prevent discomfort and pat dry.
    • If there is any tape on the incisions, it is OK for the tape to get wet. If the tape comes off on its own, you may leave it off.
    • Otherwise leave it on until you are seen in the office.
    • Getting the stitches wet in clean water will not harm them. Until permitted by your physician, you should avoid pool water, ocean water, bath water, etc. These are considered to be “dirty water.”
  • You may have a variable amount of swelling, bruising and/or discoloration at the operative site. This is expected and will resolve with time.
  • Wear the garments (example: bra) recommended by your surgeon. It is OK to take them off for short periods of time (example: to shower, to wash the garment).
  • Avoid heat application to the surgical site (ex: heating pad, hot compresses) until cleared by your surgeon.

Incisions

Most of the sutures are absorbable, but a few sutures may need to be removed approximately 1-2 weeks following the procedure.

  • Expect small amounts of drainage from the surgical site for a few days to weeks following your surgery, especially from the drain sites.
  • Because many areas are closed under tension, small areas may open along the incision sites following your surgery.
    • These open wounds ARE NOT closed with sutures once open.
    • Dressing changes will be needed in order to allow the wounds to heal and these wounds may take several weeks to heal following surgery.
      • If the opening is wide along the length of the incision (and not deep), wash the affected area with soap and water. Next, apply Vaseline or Neosporin and cover with gauze.
      • If the opening is deep, call the office for wound care/dressing instructions. Generally an office visit is not necessary and wound care  instructions can be given over the phone.
  • Do not wear any make up on or around the operative site until stitches are out and the wound is completely healed.

Medications

You may experience some adverse effects from the anesthetic medications that were used during your procedure. These effects will range from grogginess, to fatigue, to nausea, and may last for several days after the surgery. You also may have a sore throat from the breathing tube. Your prescriptions will help with these side effects.

  • Take all of your medications as directed on the labels.
  • If antibiotics are prescribed, take the entire prescription until finished.
  • Unless otherwise instructed by your surgeon, avoid all aspirin and non-steroidal products for 3-4 weeks after your surgery.
  • Allergic reactions to medications will manifest as itching or a rash. If this should occur, stop all medications immediately and contact the office.
  • Some patients have problems with constipation following surgery. If this occurs, try drinking prune juice or taking an over the counter laxative (ex: Colace).

Drains

Care for all of your drains according to the instructions given to you before discharge.

  • All output should be recorded on the enclosed sheet. This will help to determine when the drains are ready for removal.
    • The fluid needs to be recorded every 12 hours on the provided sheet.
    • Remove the drainage plug from the end of bulb, being careful not to touch the drainage spout. Drain into a measuring container. Fully squeeze bulb in your hand and reinsert drainage plug. Record drainage amount.
    • Once the drainage totals are less than 30 cc in a 24-hour period for two days, please call the office to schedule an appointment for drainage removal. (Do not forget to bring the record with you to your appointment.)
  • The site where the drain is attached may leak, and you may need to use a piece of gauze at the site to prevent the fluid from leaking onto your clothing.
  • If you have more than one drain, it is OK that they are draining different amounts from each other. Also, the drainage color may vary from one drain to the other.
  • Make sure that you have no tugging or pressure on the JP drain; this may pull it out of the incision. You can pin the bulb or tie the drain around your waist.
  • The drain should be level or below the incision in order to maintain suction.
  • If you think that your drain is “clogged” try “milking” or “stripping” it.
  • At some point, you may notice a white piece of plastic in your drainage bulb. This is nothing to worry about; your drain will still function appropriately.

Activity

Use common sense. If it feels like too much or hurts, then don’t do it.

  • Avoid strenuous activity or heavy lifting. Do not lift anything heavier than 10 pounds.
  • Sleep in any position that is comfortable.
  • We encourage moderate walking. More strenuous activity should be approved by your surgeon.
  • Do not drive until you have been off pain medication for 48 hours.

Possible Reason for Concern

  • Fever of 101.5 degrees or higher for 24 hours or more.
  • Significant increase in swelling, pain, drainage or redness of any surgical site.
  • Severe pain not responding to prescribed medication.
  • Other symptoms or problems you aren’t comfortable with after surgery.

In the event of an emergency, call 9-1-1 immediately!
Otherwise, please call our office at 843-792-4700 if you have any problems, questions or concerns. Someone is ALWAYS available 24/7.

You may talk to the following people if you call our office:

Residents
Josh Farrar, M.D.
Brian Kubiak, M.D.
Cindy McCord, M.D.

Physicians Assistants
Lauren Springs, PA-C
Jill Neumann, PA-C

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Anesthesia

MUSC has an outstanding anesthesia team whose members are focused on the best possible anesthesia care for your upcoming breast surgery. From the time you enter the MUSC system you will be identified as a Preferred Breast Care Patient. Our team will optimize your anesthetic preparation, anesthetic plan, and post-operative pain control strategy. Efforts will be made to have your preferences incorporated into the care plan, when appropriate, and your individual medical and emotional needs will be considered in a focused anesthetic experience. The most advanced technologies, supported by our MUSC world famous research facility, will be used to your advantage. In short, you will be receiving the most modern and personalized care available.

On the day of surgery, you will be asked to arrive two hours before your scheduled surgery time. Following registration you will be escorted to our preoperative holding area. There, you will be greeted by one of our excellent preoperative nurses who will prepare you for the operating room. You will also meet your anesthesia team. This team is comprised of a board certified anesthesiologist and either a certified registered nurse anesthetist or an anesthesiology resident. We will interview you to confirm your medical history so that we may tailor the anesthetic to your individual needs. Once in the Operating Room, you will receive medication through your IV and general anesthesia will be induced. Throughout the entire surgical period, we will continuously monitor and support your body, keeping you safe and comfortable, while providing optimum conditions for your surgical procedure. When your surgery is complete and you have awakened from anesthesia, we will transport you to the Post Anesthesia Care Unit. There, you will be monitored for pain, nausea, or any other issues until you are feeling comfortable and ready to go to your hospital room.

Breast surgery has a very high incidence (60-80%) of postoperative nausea and vomiting (PONV). There are multiple risk factors that contribute to the likelihood of anesthesia-related nausea and vomiting such as a history of motion sickness and a previous experience of PONV. The anesthesia providers will assess for these risk factors and others to determine the best anesthetic approach to minimize the incidence of PONV.

Your recovery and care following surgery is equally important. Management of postoperative pain and nausea is an integral part of breast reconstruction surgery. At MUSC, we use a multimodal approach to control postoperative discomfort. This approach includes the administration of opiates, local anesthetics, non-steroidal anti-inflammatory (NSAID) medication, acetaminophen, and anti-nausea medications. These medications along with specialized anesthesia techniques used during surgery aim to minimize pain and nausea during your recovery period.

Postoperative Pain Management Treatment Options:

Medications

Several types of medications are available for the management of postoperative pain. Examples include:

  • Opiates, ex. Morphine, Dilaudid, Percocet, Lortab
  • Non-steroidal Anti-inflammatory Drugs (NSAIDs), ex. Toradol
  • Acetaminophen (Tylenol)

Intravenous opiates, such as Morphine or Dilaudid are typically administered through a patient-controlled device allowing you to self administer a predetermined amount of medication. These are changed to oral medications as your recovery progresses.

Thoracic Paravertebral Nerve Block

The thoracic paravertebral nerve block is a technique whereby a local anesthetic is injected in the vicinity of nerves emerging from the spinal column in the thoracic region. It results in anesthesia and analgesia to the chest wall area.

This particular nerve block is most commonly performed for patients undergoing breast (mastectomy and cosmetic breast surgery) and thoracic surgery. It can be administered to one or both sides of the body and the specific location and distribution of anesthesia and analgesia are a function of the level blocked and the amount of local anesthetic injected. Also, a catheter can also be inserted for continuous infusion of local anesthetic.

With paravertebral nerve blocks, the potential side effects of general anesthesia such as postoperative nausea and vomiting are avoided and patients often feel little or no pain. Any existing pain can be easily managed with medications. These nerve blocks do not result in loss of motor function and thus, do not impair a patient's ability to ambulate or care for herself following surgery. In addition, the injection of small amounts at several levels decreases the risk for local anesthetic toxicity.

Several local anesthetics can be used. However, the use of a long-acting local anesthetic provides the greatest benefit for pain relief. A commonly used local anesthetic, 0.5% Ropivacaine, has an onset time of 15-25 minutes and provides analgesia for 8-12 hours.

Continuous Wound Infusion

For patients whose surgery involves the abdomen, the surgeon may place a device, such as an On-Q pain pump, to administer a low dose local anesthetic continuously near the incision site. With this system, the infusion pump administers the medication through small catheters that are placed at the incision site by the surgeon near the end of surgery. When used to deliver local anesthetics to or around the surgical wound site, this type of device can significantly decrease postoperative pain and narcotic use and can be used for many days, even at home.

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Complications

There are risks associated with all surgeries. All patients must undergo a complete medical evaluation prior to surgery to identify any potential problems. It is important to note that most complications extend the recovery period but do not affect your final results.

Infection

In order to reduce the chances of post-operative infections, antibiotics are given during and after surgery. Most infections are mild and resolve without incident. If a serious infection develops, hospitalization with intravenous antibiotics and possible surgery may be required.

Loss of Sensation to the Skin

Nerves that supply skin sensation will be cut or damaged during surgery. In most instances, the nerves slowly recover over a period of one to two years.

Flap Loss/Total Flap Failure

Reasons for flap failure include:

  • inadequate flap blood vessel anatomy (due to prior surgery or inherent anatomy)
  • inadequate recipient vessels in the chest (due to prior surgery, inherent, or radiation)
  • a blood clot
  • a small kink in the vessels due to positioning of the flap
  • injury to the flap blood vessels at the time of surgery


Fat Necrosis

Fat necrosis occurs when the blood supply in that region of the flap is not strong enough to keep the tissue healthy. As a result, small areas of the reconstructed breast can become firm, and you may develop contour irregularities in your breast. While fat necrosis does not inhibit you from completing your normal activities, it may be bothersome to you and can be fixed with an additional surgery.

Mammographic Changes

Approximately six months after completing your breast reconstruction, you will need to have an MRI (magnetic resonance imaging test). This MRI will allow your physicians to have “baseline” films of your new breasts in order to allow them to more accurately track changes in your breasts in the future.

Scars

Many patients believe that plastic surgeons can perform surgery with little to no scarring. While we have techniques that help minimize scarring, you still will have evidence of surgical incisions.  Most scar formation is determined by your genetic predisposition to scarring. Your own history of scarring will give you an indication of what types of scars you can expect. Steroid injections, silicone-based creams and silicone sheets may be needed to reduce the appearance of scars. Occasionally further surgery is necessary to correct unsightly scarring. Scars take at least a year to become fully matured.

Incomplete Resolution of Lymphedema Following Lymph Node Transfer

Vascularized lymph node transfer is a fairly new technique that is associated with an improvement in lymphedema symptoms in many surgical patients including decreased circumference of the arm or leg, and decreased tightness or heaviness. But a complete “cure” of lymphedema is uncommon.

Systemic Complications

As with any other surgical procedure, you may experience an unexpected medical emergency related to your underlying medical condition such as a heart attack, stroke, heart rhythm problem, pneumonia, or kidney problem.  If severe enough, these problems could result in death.

Deep Vein Thrombosis (DVT), Pulmonary Embolus, Fat Pulmonary Embolus

Blood clots can form during or shortly after any surgery. A blood clot that develops in your leg is called a deep vein thrombosis (DVT). If it dislodges, it can migrate to your lung and is called a pulmonary embolus (PE). A PE typically makes you feel short of breath, and you may experience chest pain and a quickened heart rate. It also can lead to death. We have several standards in place such as SCD boots and anticoagulation therapies in order to minimize the potential for developing these complications. If fat is inadvertently injected into a vein during fat grafting, it can travel to the lung, and if large enough, this event could be fatal.

Seroma and Hematoma

Seromas (fluid collection) and hematomas (blood collections) may form. While your body can reabsorb small amounts of fluid, it may not be able to reabsorb it all. Larger fluid collections may require needle aspiration, or even a surgical drainage procedure.

Skin Infections

Skin infections present as redness, tenderness and swelling. In addition, some patients experience fevers and drainage. Simple wound infections can be treated with antibiotics while a more serious abscess may require surgical drainage.

Capsular Contracture

The body’s natural response to a foreign object, such as a breast implant, is to form a lining or “capsule” around it. Sometimes this capsule tightens and squeezes the implant causing pain and distorting the aesthetic appearance (capsular contracture). This can happen at any time after surgery but usually happens within the first few months. The cause of capsular contracture is unknown. The correction of capsular contracture might require the surgical removal/release of the capsule, or the removal/possible replacement of the breast implant.

Wound Healing Problems

Often your wounds are closed under a lot of tension. As a result, sometimes incisions open. While this will delay your recovery process, it will not affect your final result. Most of the time, these wounds will heal on their own with proper wound care and do not require additional surgery. You may need to be taught wound care techniques, such as wet-to-dry dressings, or need the use of negative pressure therapy (wound VAC). You also may need the aid of a home health care nurse.

No Guarantee of Bra Cup Size

Depending upon where you shop, the type of bra you prefer and how you wear your bra, your bra cup size may vary.  Due to these differences, we are unable to guarantee an exact bra cup size after your reconstruction.

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Patient Story

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