AUTOLOGOUS BREAST RECONSTRUCTION FOLLOWING MASTECTOMY
Written By Amanda N Rosso MS OTR/L CLT
Breasts are a very special part of the body. Breasts nurture and feed our children. They provide us with a sense of physical identity. The decision to remove Breasts through mastectomy is a traumatic process, and reconstruction is a personal choice for each individual. Reconstruction of Breasts historically involved various iterations of silicone and saline implants but has evolved to include many types of reconstruction including the usage of existing tissue from other parts of the patient's body. Autologous Reconstruction is a method of using skin, muscle and other tissue from one part of the body to rebuild a breast after a mastectomy has been performed.
The use of the body's own tissue can have both advantages and disadvantages. The medical history and present physical status are the two most important factors to consider when deciding whether or not autologous reconstruction is the best option. Not all women who have mastectomy are candidates for this type of reconstruction and some are only able to use implants for reconstruction. This will depend on the individual.
These are the most common forms of Breast Reconstruction using body tissue of the patient.
FREE TRAM FLAP
LATISSIMUS DORSI FLAP
DIEP FLAP/SIEA FLAP
FREE TRAM FLAP
Transverse Rectus Abdominis Musculotaneous Flap Surgery aka TRAM FLAP is the process in which a skin, a portion of the muscle belly, fatty tissues and blood vessels are disconnected from the abdominal region and reattached to the chest wall following Mastectomy. The navel is usually repositioned during this surgery which tends to be between 3-6 hours in duration. This procedure is generally associated with longer hospitalization times to insure blood-flow or vascularity of the region. Post-surgical drains are attached at the time of surgery and remained attached until the physician removes them at follow up visit. Patient's initial concerns will be managing edema and scars. Patients are usually instructed to wear post-surgical trunk binders as well as chest compression to assist with managing edema and promoting healing. Modalities such as scar massage, taping, silicone strips and lymphatic drainage are important in the first few weeks after surgery. Patients will have physical limitations and precautions for several weeks following this procedure but should be encouraged to keep active. Once surgical scars are properly healed, patients can then begin the process of strengthening the upper body and newly repositioned core muscles.
LATISSIMUS DORSI FLAP
This procedure is sometimes used in conjunction with a breast implant if needed. Latissimus Dorsi is a large muscle of the back and begins just below the shoulder blade. During this procedure, a pad of skin, fatty tissues, a portion of the muscle and blood vessels are placed beneath or above the pectoralis major (chest area) . Latissimus Dorsi Flap reconstruction is considered due to the size and location of the muscle, and it is an option when the tissue of other areas has been compromised due to radiation therapy. “LAT FLAP” can sometimes temporarily affect shoulder and trunk movements and patients should be prepared to manage a possible weakness within those areas. This is an especially important consideration for those who have pre-existing orthopedic issues within the area. As with the aforementioned, the patient's initial concerns will be managing edema and scars. Modalities such as scar massage, kinesio taping, silicone strips and lymphatic drainage are important in the first few weeks after surgery. Patients will have physical limitations and precautions for several weeks following this procedure but Range of Motion should be encouraged within safe limits. Once surgical scars are properly healed, patients can then begin the process of strengthening the trunk. Repositioning of such a large muscle can disrupt the center of gravity of our body. Exercise is very important in creating balance in the muscles of the back area.
DIEP FLAP/SIEA FLAP
Deep inferior epigastric perforator Flap or Superficial Inferior epigastric flap is a procedure in which fatty tissue, blood vessels and skin are used to reconstruct the breast. The muscle belly is spared during this 6-9 hour procedure and the results are similar to a tummy tuck resulting in reconstructed breasts. As with the aforementioned, the patient's initial concerns will be managing edema and scars. Modalities such as scar massage, kinesio taping, silicone strips and lymphatic drainage are important in the first few weeks after surgery. Post-surgical drains are usually placed along multiple surgical drain sites and often limit trunk and upper body movement. Once they are removed, and tissue is sufficiently healed, patients should begin gentle exercise. Patients often experience tightness in abdominal region. Patients in therapy should expect to spend time to strengthen the upper extremities and core muscles once limitations and precautions are lifted by physician.
HOW CAN CANCER-RELATED OCCUPATIONAL THERAPY HELP?
Cancer is a journey and through it there are many stages. Some of them will be more difficult to move through, but through every step of the process, there is an opportunity to meet the moment with strength and positivity. A Cancer Diagnosis will force you to re-evaluate every aspect of your life, self-care habits, your relationships, your goals and where you stand within many aspects of your life. Occupational Therapy can be very helpful both before and after surgery.
WHY IS PRE-SURGICAL THERAPY SESSION HELPFUL?
Patients are able to establish a relationship with a member of rehabilitation team
Therapist offers in patient education and preventive care information
Patient is able to ask questions and get a picture into current status
Lymphedema Education and Compression Garment Fitting
Collaborate on Physical Activity/Exercise Plan to fit patient with progressions
Patient less likely to experience post-surgical rehabilitation issues
Post-Surgical Therapy is a delicate process that requires determination and careful attention. The body experiences the trauma of surgery under sedation. Sedation alters the body's ability to consciously feel the activation of the parasympathetic nervous system response to the physical disruptions. Once the body awakens, it is in a state of recovery and repair and driving towards finding balance (think homeostasis) and addressing the following:
POST-SURGICAL THERAPY
The repositioning of tissue leads to a disruption in the center of gravity of the body. This can affect movement, posture, breathing, and flexibility of trunk and upper body.
numbness and sensation impairment
Wound/Scar Management
Compression Garment Education and Fitting
Yoga and Meditation Techniques
Patient education and training in Self Care
Strength and Flexibility
Patients benefit tremendously from seeing an Occupational/Physical Therapist who specializes in Cancer/Oncology and Lymphedema prior to having their surgery. Occupational Therapists should have a Full "CLT" Complete Decongestive Therapy Certification from a school of Lymphatic Study. Check out the National Lymphedema Network www.lymphnet.org for a directory of Certified Lymphedema Therapists.
For more information about Cancer Related Rehabilitation topics or treatment visit:
References:
winicour, jodi. (n.d.). Breast Cancer Rehabilitation. Breast Cancer Rehabilitation . Retrieved 2022, from www.klosetraining.com.