After care, Surgery edition

What to expect after surgery?

I can only speak from a surgeon's perspective of patients recounting their experiences to me, as I have never myself been a patient going through these procedures. I encourage everyone to find someone who has been through the procedures to gain their insight. BUT also remember everyones experiences are different, take all opinions with a grain of salt, your experience may be vastly different. I hope below can give some insight as to what to expect.

Lets start with reviewing the breast surgery options: a partial mastectomy (aka "lumpectomy") or a mastectomy. Below are general ideas and not hard and fast rules. Each surgeon should explain this related to their experience, at their hospital, with each individual patient's needs.

Procedure time:

• Partial mastectomy: likely ~1-2 hours

• Mastectomy: likely 1-2 hours per side (if both breasts likely a total of 3-4 hours) for removal of the breast, if reconstruction is done at the same time it depends on the type of reconstruction. Expander/implant based reconstruction tends to add another 1-2 hours of surgery. Self-tissue flaps can add another 4-8 hours of surgery.

• Lymph node surgery : likely adds 30 min- 1 hour of surgery.

Procedure anesthesia

• Partial mastectomy/mastectomy: generally, you are asleep for both of these procedures. The surgeon and anesthesia team may have you breathing on your own in a "twilight sedation" or fully under "general anesthesia" where you have a breathing tube helping you breathe inhaled sleeping medications. You will need someone to drive you home from the surgery or the hospital stay.

Procedure recovery:

• Partial mastectomy: usually outpatient surgery, meaning you come in and go home the same day. Anticipate 1-3 days acute gentle recovery, 2-6 weeks overall recovery. Most people feel back to their baseline with some incisional tenderness by day 3,4,5. No heavy lifting > 10 lbs , for 2-4 weeks

• Mastectomy: some patients can go home same day, but others are recommended to spend overnight stay in the hospital and are discharged the next morning. Anticipate 3-5 days acute gentle recovery , 4-8 weeks of overall recovery. Most people feel back to their baseline with some incisional tenderness by day 5,6,7. Usually you go home with drains after mastectomies. These generally stay under the incision for 1-2 weeks and are removed in the office by the surgeon. No heavy lifting > 10 lbs , for 2-4 weeks

Procedure pain expectations:

• Partial Mastectomy: Generally, people tend to have the most pain day 2 after surgery, and 90% of people's pain is controlled with oral over the counter medication like Tylenol/acetaminophen and Motrin/Ibuprofen. I have found that narcotics are rarely required with good local anesthetic. The most tender incision people tend to report is the underarm incision for lymph node surgery.

• Mastectomy: when the breast tissue is removed, the chest wall tends to lose sensation from the nerves being cut beneath it, this tends to dampen the pain signals after mastectomy. I have most patients telling me they had less pain than they expected. I generally recommend nerve blocks prior to starting surgery to help with post operative pain. Again most patients do well with over the counter pain medications,  like Tylenol/acetaminophen and Motrin/Ibuprofen. Some patients need stronger pain meds for 1-5 days after surgery. If reconstruction is done at the same time as the mastectomy sometimes the plastic surgeons will also add in muscle relaxers and stronger narcotic based pain medications.

Things to note or ask the surgeon:

• Where will the incision(s) be and what will they look like? will they be "hidden" meaning in a skin fold or around the areola and if not, why not.

• Ask if they have a portfolio of before and after to see real patients results.

• When is showering allowed? Generally, it is advisable to avoid bathing/submerging incisions until they are fully healed generally 2-4 weeks after surgery. Typically, showering is okay 24-48 hours after surgery. We want things to stay clean while they heal. I tend to recommend letting the water hit on the back and its okay for water and soap to run down over incisions, and then to pat the area of the incision dry, avoid rubbing. Some surgeries and surgeons do not allow showering and recommend sponge bath or "bird bath", ask the surgeon their recommendations.

• When to resume home medications? Sometimes we recommend holding medications such as blood thinners prior to surgery to limit bleeding risks. Generally, we recommend resuming 24-48 hours after surgery, this should be clarified by the surgeon.

• When to come for a post operative check? Generally, we want to check the incision initially 7-14 days after surgery to ensure proper healing and discuss the final pathology results as they return.

• When is driving allowed? Generally, 2-7 days after surgery pending which type of procedure and if pain is well controlled without narcotic pain medications.

• If you have lymph node surgery with blue dye: your urine WILL be blue, but don't worry, it goes away in 24-48 hours as the medication processes through your body.

Possible risks/complications for surgeries:

• Bleeding (i.e. bruising or hematoma - a collection of blood like a blood clot)

• Infection

• Fluid build up in the breast (seroma) or in the breast skin (edema)

• Injury to surrounding tissues/structures (nerves, lymphatic channels, blood vessels)

• Lymphedema (build up of lymphatic fluid) of the arm/hand, generally if lymph node surgery is done with the breast surgery

• Change or loss of sensation to area around the incision, underarm or chest wall

• Loss of blood supply to nipple/areola in certain surgeries, could result in nipple/areola death, loss of skin, loss of sensation.

• Change in breast appearance, loss of volume, dimpling, sunken in area.

• Thickening (keloid), stretching (hypertrophy) , discoloration of the scar.

• Limitations in arm/chest wall muscle motions , possibly requiring physical therapy to help restore function.

• Post mastectomy phantom breast pain syndrome, if the breast is removed, there can be phantom sensations as if the breast is still there. Sensations like burning, pain, aching, itching, etc.

• Emotional and psychological affects of removing the breasts such as body dysmorphia, i.e not recognizing ones body.

These are generalizations and specific details for each patient should be discussed with the operating surgeon!

I hope these points help ease some anxieties related to surgery!

As always, more to come, and thank you for being here!

~Dr. Collins