Diep Flap Reconstruction Surgery & Recovery - Week 1

Well, I took the plunge and had reconstructive surgery on St. Patrick's Day. When my surgeon asked how I was doing that Monday morning, I said "I'm fine, but the more important question is how are YOU doing?" He replied "I'm GREAT," and I was happy to hear that!

My surgery took 4 hours and 10 minutes for a unilateral diep flap reconstruction (definitely the short end of the 4-8 hours my surgeon told me to expect!). There were two microsurgeons present (I did not meet the second surgeon). I remember talking to the anesthesiologist, who seemed very understanding about my concerns with nausea after surgery. As they wheeled me to the OR, the anesthesiologist told me I should be feeling light-headed. I was! The next thing I knew, I was in my room in the ICU and settling in for an evening of hourly flap checks. I was pretty groggy (and honestly don't remember much of Monday afternoon), but each time my nurse came in to check the circulation on the flap and I heard the reassuring "whoosh whoosh" of the vein and artery through the Doppler, I knew things were going well. And blessings on the anesthesiologist! I did not have any nausea or vomiting this time around! (Besides the typical IV anti-nausea medications, I also had a patch behind my ear).

My surgeon told me to expect a 3-4 day hospital stay. Surgery day is Day 0, so a 3-4 day stay meant going home Thursday or Friday. Here is a rundown of my week in the hospital:

Day 0:  The reason for ICU (my surgeon told me "You're not sick!")  is the higher level of nursing care. My nurse had 2 patients to care for, instead of 6 or 7. That made it easier to monitor my transferred flap tissue. I could not eat or drink anything those first 24 hours. I didn't feel like eating, actually, but my mouth was incredibly dry. My nurse did bring me a sponge on a stick in a cup of ice chips so that I could moisten my mouth. That helped, but I really wanted some water! In the ICU, I was hooked up to a PCA (pain pump, where I could give myself a boost of pain meds every so often), an IV, a catheter, oxygen, a wire in my transferred flap (along the vein connection) so they could monitor my circulation, and three drains (two in my abdomen, and one in my chest). The nurses would listen to the vein on the Doppler wire, and then take a sensor and hold it on an area marked with a stitch by my surgeon to hear the arterial flow. This is completely painless as there is no feeling in the transferred tissue. I dozed off and on throughout the night. My hospital bed was kept flexed to keep tension off my abdominal incision.

Day 1:
Tuesday morning I saw my surgeon, and by afternoon I was moved to a room on the floor and was out of ICU.  I was able to order lunch and have my first meal since Sunday evening. The nurses continued to monitor my flap and give me medications intravenously. On Tuesday, I also worked with a physical therapist on getting out of bed. The technique is to roll onto your side, let your legs swing down off the bed, and push yourself upright with your arm. It does hurt to do this, but once you are sitting, the pain goes away. I took a short stroll down the hospital hallway (hunched over a walker) and sat in a chair for awhile. I was allowed to eat anything on the hospital "room service" menu, and was encouraged to drink plenty of water. My surgeon came to check on me twice on Tuesday, and said the goals for Wednesday included unhooking me from as many things as possible (catheter, IV, etc.), and transferring me to oral medications. Sitting was not painful, and even walking wasn't too bad with the walker. My pain levels were probably between a 3 and a 6 on Tuesday (on a scale of 0 -10), depending on what I was doing. I was not using my PCA pump much, although the physical therapist made a great suggestion to use it prior to getting up for therapy. My husband slept on a crummy cot in my room Tuesday night. I felt so sorry for him, I did not ask him to stay on Wednesday! I don't think he got much sleep.

Day 2:
Wednesday was kind of boring, actually. My flap was doing well, my vital signs were good, and it was time to move forward. I took more walks in the hospital, spent more time in a chair, was given a couple of leg exercises, and was started on oral medications and taken off the IV. Removing a catheter is no big deal, either. You sit on the toilet while your CNA deflates the saline-filled balloon which holds the catheter in your bladder. Then, there is a gentle tug, and you are done! I read a bit on Wednesday, did some Sudoku puzzles, watched a little TV, visited with family, and slept some more. I saw my surgeon once on Wednesday. He informed me Thursday was mandatory shower day, and then I could see how I felt about going home.

Attractive TED stockings!

Day 3:
I was getting in and out of bed by myself to use the bathroom, and was feeling pretty good. For pain control, I was taking mostly ibuprofen and tylenol. The physical therapist told me she had signed off on me, so that was another milestone achieved. The shower was tiring, but I did it! I had my CNA make a necklace for me from some oxygen tubing to hang my drains on while I showered. She suggested pinning the drains to either a towel or washcloth around my neck, but when I suggested the necklace, she was happy to accommodate me. I had a shower chair, for which I was very grateful. It felt good to be clean. My hospital did not provide shampoo. My hair is still pretty short after chemo, and I used the mild liquid soap on it. Not ideal, but it worked pretty well, and it felt good to have clean hair. You might want to bring shampoo with you to the hospital. Getting back into the abdominal binder was a bit tricky, but overall I was happy to handle the shower myself.  My surgeon came by and I told him I was thinking of going home. He pulled the Doppler wire, and put everything in motion (did all the paperwork) for me to check out, but told me I could absolutely stay another day if I felt I needed to. I was glad I didn't have to leave before I was ready to, but to be honest, I really wanted a night of uninterrupted sleep!  After I saw my surgeon the third time on Thursday, I told him I was pretty sure I would be going home that day. I ended up leaving the hospital about 5 pm that Thursday.

Getting comfortable at home:
I don't own a recliner, so my surgeon suggested getting foam wedge pillows. I bought 2 prior to surgery, and used one under my back and head, and one under my knees. I put additional pillows on top of the wedges to get comfortable. My surgeon wants me sleeping in a "V" position on my back while my abdominal incision heals. It was a bit tricky getting in and out of a regular bed, but I was able to do it.  I am not using much pain medication. The most painful part so far has been my back, from walking hunched over. I had heard that was the hardest thing, and people were not kidding! Ouch!  There is also some discomfort at the drain sites and along my abdominal incision. I have occasional nerve pain from things being disturbed again in my chest, but am so grateful my poor pectoral muscle has been put back down where it belongs. The nerves are not nearly as aggravated as they were after the mastectomy. In many ways, I think this surgery is easier than my initial cancer surgery. Things are progressing nicely. I walk laps around my kitchen with my walker, and am trying to get more mobile. I also have some leg exercises from the physical therapist, and am still wearing my lovely white "TED" compression stockings, since I am laying around quite a bit.

Foam wedge pillows are nice to have for comfort at home.

Some Tips:
Do take a robe to the hospital. It was good to slip something on over my attractive hospital gown for those walking sessions.
Do take something to pass the time. I was glad to have puzzle books, music,  and a novel to distract me.
Do take advantage of the time in the hospital to rest as much as possible.
Do communicate what your needs are to your nursing team and your doctor.
Do prepare for your return home before you go to the hospital (I bought my wedge pillows, planned clothing I could get on over the abdominal binder and the drains, set things like tissues in easy reach of my bed, etc.  My surgeon mentioned having a different compression garment like Spanx, but not until Day 3 of my hospital stay! Ask your doctor what he/she recommends for you, so you can plan ahead! Do make arrangements for a walker and shower stool).
Do make your follow up appointment with your surgeon.
Do take pain medications as needed. I have not found this surgery to be particularly painful. Certain movements hurt, and I am sore, but it has been easy to manage the pain levels.
Do get plenty to drink, eat healthy, and move as much as you comfortably can. I am feeling sort of "full" and I think it is from abdominal swelling. My surgeon recommended I eat small amounts throughout the day, and also said I would probably need some naps while recovering at home.

I had FABULOUS medical care, and the best nursing team I could have imagined. I know I am forgetting a few people, but just want to give a shout out to my awesome surgeon Dr. Reuben; Dr. Richards, the anesthesiologist; Dr. Rinard, the other surgeon who assisted; my OR team (I was out before I got to the OR, so I didn't meet any of you!); my two physical therapists; Maria, who cleaned my room; and my nursing team: Stephanie, Jordan, Matt, Sarah, Mica, Cherysh, Emily...and 3 other wonderful men and women whose names I am sorry to say, I cannot remember. They were all competent, kind, caring, personable, hard working, and helpful throughout my hospital stay. I am so grateful to every one of them for the great care they gave me!

So, one week out, how am I feeling about surgery? I still can't believe I am on the other side, after waiting so long! My flap is soft and warm, and should heal up nicely. I know when my abdomen heals, I won't miss the fat they took to reconstruct the breast. The first week is over, I think I might be lucky and get a drain or two removed during my first follow-up visit, and I am well on my way to recovery. I can honestly say this has been easier than I thought it would be, and I have NO REGRETS about doing this surgery!

Non-prescription medications recommended for me at home:  Senna-S (stool softener/mild laxative), Ibuprofen (800 mg at meals), Tylenol (every 6 hours), 81 mg baby aspirin (once a day for 4 weeks). I did not take the Senna-S but used a different stool softener instead (similar to Colace).

My decision to have DIEP flap reconstruction

DIEP Decisions! - Diep Flap Reconstruction

When dealing with breast cancer, decisions are deeply personal and individual. I remember being shell-shocked and overwhelmed in the aftermath of my initial diagnosis, and I found myself sitting in the office of a plastic surgeon wondering what on earth I was doing there. How strange it was to be talking about appearances when I wasn't even sure the extent of my diagnosis or what treatments I would be facing.  Fortunately for me, my medical team knew more about this process than I did. My general surgeon sent me immediately to a plastic surgeon even though I was still reeling from the lumpectomy/mastectomy choice. And my plastic surgeon patiently explained what my best reconstructive options were, and then added those magic words that I really needed to hear..."but you don't have to make any decisions right now, and you don't have to do reconstruction at all, and you don't have to do it right away. You can wait a year, or five years, or more." He gave me a precious commodity in that moment...he gave me time.

Relieved, I agreed to his recommendation to have a tissue expander as a "place holder" put in immediately during my mastectomy. Immediate reconstruction was not an option for me, as I did not know if I needed radiation treatments until the pathology results came back after surgery. I had a "skin-sparing" mastectomy at the end of July 2012. Although I know some women are quite fearful of waking up without a breast, I was happy to wake up without cancer! The advantage of a skin-sparing mastectomy is that most of your own healthy skin is retained, and the scar is minimal. I was actually pretty impressed with how good my plastic surgeon made it look. However, I did not want to face more surgeries, and was pretty sure I would take the simplest route possible as far as reconstruction went.

When my general surgeon called with the pathology results, he let me know I was getting the "kitchen sink" as far as treatments went:  chemotherapy, radiation, and herceptin.  I continued to see my plastic surgeon while waiting to get my drains removed. In light of my upcoming radiation treatments, he recommended either a LAT flap reconstruction with an implant, or an autologous DIEP flap reconstruction. The LAT flap, he explained, was a smaller commitment up front (shorter surgery, quicker recovery time, etc.), but came with a longer term commitment as I would probably need regular implant replacements throughout my life. He said the life span of an implant is typically about 10-12 years, but after radiation I would have more issues with scarring, and that time might be shortened to as few as 7 years. (A LAT flap reconstruction uses your latissimus dorsi muscle to wrap the implant and protect it from scarring.) The DIEP flap, on the other hand, was a bigger commitment up front (longer surgery, longer recovery, etc.) but is considered a lifetime solution for breast reconstruction. My surgeon said he would not do any surgery until at least 6 months after radiation, again giving me plenty of time to make a decision.

During chemotherapy, I saw my plastic surgeon regularly (more frequently than my oncologist!) for "fills" of my tissue expander. He was great to work around the days when I felt worst during chemo, and always assured me we could slow the expansion rate if I so desired. He completed the expansions before my radiation treatments started. Why not do reconstruction before radiation? Radiation damages tissue. It damages skin, blood vessels, and more, and the effects continue for years. Two of my doctors called it "the gift that keeps on giving." My plastic surgeon said he was not going to put healthy tissue from either type of flap reconstruction in my chest only to have it radiated. Instead, he would wait until my body recovered from the immediate effects of the treatments. I wasn't ready to make a reconstruction choice anyway, so that was fine with me.

Chemotherapy changed my outlook. After chemo, I was certain of two things:  one, I hated my tissue expander and did not want an implant, and two, I could handle anything...nothing seemed scary anymore. I saw my plastic surgeon shortly after completing radiation treatments. My radiation oncologist said the effects on my skin were about average, and he was actually pretty pleased with how well my body had tolerated the treatments. My plastic surgeon, on the other hand, said "That skin is still quite pink!" I guess it is all a matter of perspective. We talked about reconstruction again, and he told me to see him about 2 months before I wanted reconstruction, and I went home to heal.

Meanwhile, being a slightly compulsive person, I began researching. I watched a condensed version of my surgery on "OR Live" (not for the squeamish!), and I actually found that to be greatly reassuring. Unlike my own delayed reconstruction, this one was an immediate reconstruction, but I still found watching the microsurgery procedure fascinating.

After a time out for a broken ankle, a surgery to repair it, and physical therapy,  I saw my plastic surgeon again. He did another fill on my tissue expander.  Radiated skin, he explained, may look healthy, but it is not. By stressing the skin with another fill, he gave it a chance to heal and start responding more normally. I was surprised to see how my post-radiation skin reacted to this expansion. It became slightly pink again in the radiated field, and it was very itchy. After about a week, things calmed down and went back to normal, but now I could literally see what my plastic surgeon was talking about.

He ordered a CT scan for me, and I went and had the scan with contrast at a local hospital. This would allow him to see the blood vessels in my chest and abdomen. A DIEP flap reconstruction takes fat and skin from your abdomen, and transfers it to your chest. Blood vessels from the flap are attached to blood vessels in the chest during microsurgery. It is a delicate procedure, and adds to the length of surgery time.  At my pre-surgical consult, he showed me the results of my scan, identifying blood vessels that were the best candidates. He said once in surgery, they would confirm which blood vessels to use by a visual inspection as well as by using the CT scan.

Some things to remember when choosing a surgeon for your DIEP flap reconstruction:

Plastic surgeons have to undergo further training in microsurgery in order to do a DIEP flap. It is recommended that any surgeon you choose has performed many (100-200) flap procedures. It is also recommended that you have a scan of your blood vessels prior to surgery, and that two surgeons perform the surgery.  Do get recommendations from your medical team. Do look at before and after pictures of their work.

My surgeon has coordinated to do my surgery with another microsurgeon he has worked with many times before. I asked him who would be doing what during my surgery. He said he would work on my abdominal flap and blood vessels supplying that tissue, while the other surgeon would remove the tissue expander (yay!) and access the blood vessels in my chest. Then both surgeons would work together under the microscope to connect my flap to the blood supply in my chest. After the connections are made, my surgeon will shape the transferred flap, while the other surgeon closes my abdomen. If your surgeon does not work with another surgeon, does not regularly do DIEP flap surgeries, or says he will give you either a DIEP flap OR a TRAM flap, you might want to get another opinion.

While this is a major surgery, the success rate is extremely high. Most surgeons boast at least a 97% success rate. Although my surgeon reminds me that if the flap fails, it is a 100% failure for me, he does have a very high success rate. When making a decision about a DIEP flap, I think it is wise to research your doctor, ask a lot of questions, familiarize yourself with all your options, and consider what is best for you. Good luck with the decision making process! I am convinced this is the right choice for me, and now that I am a year removed from radiation, I am glad I had time to not only make the decision, but also time to work on getting physically stronger after all my cancer treatments. I think the better shape I am in going into this surgery, the better my recovery will be. Do eat right and continue to exercise right up until the day of surgery. I will let you know how it all goes!

My planned hospital stay will be as follows:

Monday - surgery

Monday night - ICU to monitor the flap

Tuesday afternoon/evening - move to a room in the hospital. On Tuesday I should also be able to begin eating, and I believe they will also get me up out of bed, either to walk, or sit in a chair.

It is a planned 3-4 day hospital stay. I will be able to shower and eat normally while still in the hospital. 

I will have 3 drains (two abdominal drains, and one in the chest).

I am not planning on taking anything to the hospital the morning of surgery except my glasses. When I am moved to a room, I will make sure my husband brings me a lightweight robe, a book, chapstick, my mp3 player, my phone, and maybe slippers. I will also pack loose clothes and slip-on shoes for the ride home later that week. My surgeon said he will have me wear an abdominal binder after surgery for the first few weeks.  I am lucky to have several surgeons and a couple of different hospitals where this procedure is performed within a few miles of my home, so I don't have to worry about traveling to have this done. As more surgeons begin doing DIEP flap reconstruction, hopefully you will have options close to home as well.

Also, in case it isn't obvious, know that your surgeon will take before and after photos of you, and your surgeon will also draw on you prior to your surgery. When you wake up from your surgery, you will likely be connected to an IV, oxygen, drains, compression "stockings" on your legs, and a catheter. The general risks of surgery and anesthesia still apply for a DIEP flap reconstruction. However, I am grateful this option is available, and have heard it said that this is the "gold standard" for breast reconstruction.

FOR INFO ON MY SURGERY AND RECOVERY:
Diep Flap Surgery and Hospital Stay

Good information about DIEP flap surgery can be found at the links below:
Diep Sisters (has a list of surgeons in the U.S and Canada...good place to start if you don't have a referral from your general surgeon)
Breastcancer.org
Diep Flap - Johns Hopkins
Diep Flap in Utah

Diep flap blogs:
Gingerbread Guts
Diep Flap Surgery for Dummies