Stitch Glitch Part 2 - When to Call the Doctor & Wound Care

Packing strip for wounds.

"If it starts getting red and expanding out, call me," my doctor said before I left his office on April 15.
A few days later, I had a red rectangle forming to the left of my stitch abscess. The wound (nicknamed "Primordial Ooze") was responding well to treatment and looking much better, but what was causing the redness? My skin is pretty sensitive, and I chalked it up to irritation from pulling off the tape when dressing the wound.  I had another appointment scheduled on April 29, so I thought I would just keep an eye on it.

By the following Tuesday (April 22), it wasn't better. In fact, it was a little larger. And redder. And some skin was peeling, and there was a little lump that was sort of purplish and sore. I did not have a fever, but the area did feel warm to the touch. The clinic opened at 9am and I called and got an appointment for 11:15. If it was nothing, I was sure my doctor would tell me, and after all the work he put into this surgery, I was pretty certain it was better to have him look at it now than to wait until things got worse.

"It's a good thing you came in," he said.  He examined my red  incision area, thought for a minute, and then moved to the counter and started opening drawers."You're not going to like this," he continued.

"You want to open it up," I replied.

This time he used a local anesthetic (thank you!). Sure enough, there was some infection, and a couple more pieces of stitch to remove. Apparently my body likes to push out the stitches. Thankfully, at five weeks, they are almost all dissolved, so this shouldn't be an ongoing problem. My doctor gave me a prescription for an oral antibiotic to clear up the infection.. He assures me everything will heal fine and these abscesses won't affect the appearance of my scar. I just need to be a little patient while everything heals. Patience is a thing cancer patients get to practice quite often, so I am not too concerned about it.

I went home to start wound care. Now instead of one stitch glitch, I have three! Primordial Ooze is mostly a superficial wound now. I have not named the other two, although Frick and Frack come to mind.

Gathering supplies for wound care...good scissors help!

Here is my daily wound care routine.

• Collect all of my supplies (gauze, iodized wound packing tape (Iodoform Packing Strip by Curad), Aquacel (similar to silver alginate), gauze, tape, scissors, and tweezers). It is easier if you have everything ready before you begin.
• Remove the dressing from yesterday and throw it away. Rub off as much sticky tape residue as I can from my stomach.
• My first wound, which is more healed, gets an application of Polysporin (Neosporin would work just fine also), then gets covered with a strip of Aquacel (or silver alginate).
• The new holes get a piece of iodized packing strip placed in them with the tweezers. Wounds heal from the inside out, so each day, a little less of the strip fits down into the hole. When the wounds are as healed as the other one, I will just use the Polysporin and Aquacel on them, too.
• Cover the whole thing with gauze and tape it in place. Done for another day!

Aquacel

I am keeping my appointment on the 29th, just to make sure everything is healing fine. 

When to call the doctor:

Fever

Redness, especially if it is increasing

Redness that is warm to the touch

Signs of infection like pus

If you have any other concern with a healing incision or wound.

May 27, 2014
Update:  At my appointment (May 13) , things were healing well. He trimmed tissue and probed around one wound one last time before sending me on my way. I went back two weeks later (May 13), and my doctor said "It is healed. Wait at least 8 weeks more" (before scheduling my last surgery). So, I am still healing, but back in the gym, walking, and trying to figure out what my new normal is. Life after cancer treatment is full of some odd ups and downs, and some unexpected emotions, but I am finding my way through it one step at a time.

More on my reconstructive journey:
Diep Decisions! Diep Flap Reconstruction
Diep Flap Surgery & Recovery - Week 1
Diep Flap Reconstruction Recovery - Week 2
Diep Flap Reconstruction Week 3 - Recovery Can Be Boring
Stitch Glitch! - Diep Flap Reconstruction Week 4

Stitch Glitch! - Diep Flap Reconstruction Week 4

Section of my tummy scar...healing nicely at 4 weeks!

I measured my abdominal scar. Guess how long it is?  If you said 23 - 1/4 inches, you are correct! Yes, my scar is nearly 2 feet long. Wow. That was a big incision.

I know I said week 3 was pretty boring, as far as recovery goes. Well, week 4 decided to add just a little bit of excitement. A piece of glue came off my incision on my abdomen and the incision was still a little sore there, and oozing a bit. I didn't think much of it, just put some gauze over it to protect my clothes and got on with the week. It got a little red, and kept oozing. There was a hole about as big as a pencil eraser. Throughout the week, it seemed to improve, and I was seeing my surgeon soon, so I just figured I would ask him about it. Monday morning (April 14) I went for a walk, and walked more normally than I have since surgery. It felt pretty good to be moving more easily. When I got home, the little opening had leaked more than before, and looked worse as well. I also had a reddened lump under my tummy incision nearby.

Some minor complications with an incision the size of my abdominal incision are not terribly uncommon. Tuesday morning (April 15) I went to see my surgeon and he took a look at it. All those stitches underneath my skin are in the process of dissolving (apparently they take about 6 weeks to disappear). Since I am at week 4, he said the stitches were breaking apart, and sometimes they can work their way near the surface. My body, in all likelihood, is reacting to a stitch and treating it as a foreign body, and thus, is not healing in that spot. He got gloves and a little packet of instruments and some gauze and told me he would remove the stitches that were causing the problem.

I couldn't really see what he was doing, as I was laying on the table at this point. I did raise my head once in awhile to check it out. I may not have been able to see everything, but I could sure feel it! He re-opened a little section of the incision, and probed around to find the stitches that were the culprits and remove them.

Me: "Ouch!"
Surgeon:  "Does that hurt?"
(Really??? You are cutting into a tender incision without any localized anesthetic!)
Me:  "Yes, a LOT."
Surgeon: "Sorry."

Don't get me wrong, my surgeon is incredibly gentle, but this did hurt. That Lamaze breathing from so many years ago still comes in handy!  I came home with iodized tape (for packing wounds) to put on the incision opening for 3-5 days, and then I will be putting Neosporin on it to keep it moist, covered with a piece of Aquacel (absorbent pad infused with silver to fight infection) while it heals. I also have an appointment in a couple of weeks to make sure it is healing well. The adventure continues!  Oh, and the doctor said, the reddened lump I was worried about was just skin irritation and some scar tissue forming underneath the incision. Scar tissue starts to peak, apparently, at 6 - 8 weeks. He said massaging the incision could help.

After 4 weeks, I am off baby aspirin and no longer have to sleep exclusively on my back. Since I am a side-sleeper, this makes me happy! I am wearing a compression garment during the day (I could probably write a whole post about my love/hate relationship with Spanx...but not today!) My doctor says I no longer have to wear the compression garment, but it does help with the swelling. He said I may want to wear one when being more active (going to the gym, hiking, etc.) over the next several months, as I will continue having the swelling for some time. He said in 6 months I will be mostly healed. But right now, I can increase my activity level and work on getting back to normal. Aside from my stitch glitch, things are progressing normally. Once the incision heals, I will probably meet with my surgeon in a couple of months to make a plan for phase 2, which will include any touch-ups to the new breast (NAC or nipple-areola complex), breast lift on my natural breast if I want it, any liposuction or fat grafting to improve symmetry, and any revisions to the abdominal incision. These touch ups are done on an outpatient basis with a 1-2 week recovery. Tattooing of the NAC complex takes place after phase 2 touch-ups have healed. I have heard that these revisions can take a good result to a great result. After all I have invested in this process, I think I am going for greatness!

Some people look at me like I am crazy to have gone through all of this, but let's put it in perspective. My cancer treatments and related procedures went from July 2012 - September 2013.  This reconstruction process with take up most of 2014. And then, I am done. No procedures down the road related to implants and their complications (capsular contracture, implant failure and replacement, etc.) If I am cured of cancer and live another 30-40 years or so, I say this is definitely worth it.  I am happy I am doing this. I am already pleased with the results.

For more on my Diep flap experience:
Diep Decisions! Diep Flap Reconstruction
Diep Flap Surgery & Recovery - Week 1
Diep Flap Reconstruction Recovery - Week 2
Diep Flap Reconstruction Week 3 - Recovery Can Be Boring

Diep Flap Reconstruction - Week 3 - Recovery Can Be Boring

Even animals get bored....

I saw my surgeon again on April 1. He removed the 4 stitches and glue glob from my belly button. He also said I could start peeling off the surgical glue from my other incisions when it hangs loose.

Medically, here is a list of where things stand as I head into week 3:
Two more weeks of baby aspirin every day.
Two more weeks of the abdominal binder, although I can start taking it off at night if that is more comfortable.
Two more weeks of sleeping on my back. (My surgeon says after four weeks the transferred flap will have grown its own network of blood vessels, and will not be as fragile any more.) The body is pretty amazing!
Four more weeks until I can participate in vigorous activity.
No lifting more than about 10 pounds, no strenuous housework. Light housekeeping is okay.
Gentle stretches and motions with my right arm are okay.
Walking, walking, walking is good. Just nothing too vigorous.
Still avoiding caffeine (caffeine restricts blood vessels). I confess when my friend brought over amazing chocolate-marshmallow cookies, I indulged! So far, my flap is alive and doesn't seem to have suffered any ill effects, and those cookies were to die for!
I am still not quite standing up straight, but I am getting close.

I will follow up with my surgeon in two weeks, and then probably after a couple of months. The earliest touch-ups can be done would be 8 weeks after surgery. I think that will be too soon for me.  There isn't any rush. My doctor says the flap will shrink a little, as it doesn't have as robust a blood supply as it had when it was attached to my stomach. He says everything needs time to settle before we do any procedures to improve symmetry, create a nipple, make any corrections on the tummy incision, etc. Revision surgery is done on an outpatient basis, and the recovery is relatively short. I am almost done! When I think back to when I first met my surgeon in 2012, this day seemed very far away. Knowing I have made it--actually made it to reconstruction and took the plunge with a DIEP flap-- really makes me smile! I am also grateful to have worked with an amazing surgeon through this whole process.

Mentally, week 3 seems harder than week 1 and week 2. Those weeks I was pre-occupied with just getting through the surgery and the initial stages of recovery. Now I feel pretty good, but I am getting pretty tired of convalescing.  I am not in a lot of pain, but have twinges of soreness in my stomach and I have some random nerves that fire off occasionally in my newly created breast. This nerve pain is always weird, as my breast area is numb. However, this happened after the mastectomy, and I am assuming tampering with the pectoral muscle and removing scar tissue from the area has re-irritated those damaged nerves. I am still moving pretty carefully. I know I should tackle a few of those things I never have time to do (draw, cross stitch, etc.) and use my down time wisely, but I feel scattered and can't seem to concentrate very long on anything. I am reading a lot, but am bouncing from book to book (I am currently reading two non-fiction books, one novel, and listening to another novel on audio book). I wish I were standing up straight so walking around the neighborhood would be easier, and I am really, really sick of sleeping in the same position all night long on my back, and am finding it hard to get comfortable. Now that I am partially healed and the drains are out, I just have to wait patiently for my body to finish the healing process. And waiting patiently isn't my favorite thing. I know it is only for a few more weeks, and I also know I really want to protect my abdomen and flap after all I have gone through. It is important I take this time to heal, but it is sort of a boring process! I am not yet to the point where I miss doing housework...but I may get there...just maybe. I am very grateful that things have gone so smoothly, and that I am healing just like I am supposed to, so I really shouldn't complain.

But I might complain...just a little.

My Diep Flap journey:
Diep Decisions! Diep Flap Reconstruction
Diep Flap Surgery & Recovery - Week 1
Diep Flap Reconstruction Recovery - Week 2

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