A GUIDE TO

BREAST SURGERY

Introduction
Faulkner Hospitals Breast Centre and Sagoff Imaging and Diagnostic Centre are nationally recognized for their efforts in the detection and treatment of breast disease. Our mission is to provide our patients with the best possible care with dignity and compassion. Toward this end, a team of Faulkner physicians, nurses, staff educators and administrative staff developed this guide on breast surgery. This guide is designed with patients and family in mind and should be used as a reference guide before, during and after breast surgery. You may not need the information contained in every section. For easy reference we have divided the book into several sections. The index will help you identify the pages of the sections you will need to review as outlined in your care plan. Please read those sections carefully and direct questions or concerns to your doctor or nurse practitioner. The first section, Faulkner Health Care Team, identifies the various providers that will be caring for you. The second section, Breast Health, explains the anatomy of the breast as well as a guide for completing self-breast exams. All patients should review both these sections. The third section, Types of Breast Surgery and their Risk and Complications, explains the various breast surgeries (in order) from basic to complex. In addition, it includes a description of the possible risks and complications associated with each procedure. As you review the information it is important for you to focus only on the procedure(s) (use the index to identify the proper pages) which you and your physician(s) have agreed upon in your care plan. This will help avoid confusion among the different procedures and may also help prevent unnecessary anxiety over procedures or tests that you may not require. The fourth section, Preparing for Surgery, outlines the necessary steps all patients must follow to be prepared for surgery. The fifth section, Same Day Surgery, should be reviewed by patients who will not stay overnight in the hospital and the next section, Hospital Stay, should be reviewed by patients who are admitted to the hospital. The seventh section, Arm Exercises after Axillary Lymph Node Dissection, Sentinel Lymph Node Biopsy and/ or Mastectomy, provides important arm exercise instructions for patients who have had an axillary node dissection and/or a mastectomy. The final three sections include information on frequently asked questions, a glossary of terms and a list of local and national resources. We hope this information will be useful to you and your family. Please keep this book to use as a guide during your treatment and recovery period from breast surgery.

The printing of this guide was made possible through the generosity of Carol Rabinovitz.

Table of Contents
A. Faulkner Health Care Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 B. Breast Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Anatomy of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Self Breast Exams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

C. Types of Breast Surgery and their Risks and Complications . . . . . . . . . . . 6

Breast Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Duct excision (including surgical ductogram) . . . . . . . . . . . . . . . . . . . . . . Partial Mastectomy (lumpectomy or wide excision or re-excision) . . . . . . . . . . . . Wire Localization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sentinel Lymph Node Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Axillary Lymph Node Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . Total Mastectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mastectomy with Axillary Node Dissection (or Modified Radical Mastectomy) . . . . . Mastectomy with Sentinel Lymph Node Biopsy . . . . . . . . . . . . . . . . . . . . . Breast Reconstruction (includes explanation of the various reconstruction procedures) Additional Support for Coping with Breast Cancer . . . . Pre Admission Testing (PAT) clinic appointment. . . . . . Pre-Operative (Pre-op) physical examination appointment Two weeks prior to surgery . . . . . . . . . . . . . . . . Seven (7) to ten (10) days before surgery . . . . . . . . . One week before surgery . . . . . . . . . . . . . . . . . The day before surgery . . . . . . . . . . . . . . . . . . The day of surgery . . . . . . . . . . . . . . . . . . . . Immediately following surgery . . . . . . . . . . . . . . Recovery process . . . . . . . . Dressing Care . . . . . . . . . . Signs and symptoms of infection: Pathology Results . . . . . . . . Post-operative exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 . 7 . 8 . 9 . 9 11 12 13 14 15 17 19 19 19 19 19 19 20 20 21 21 21 21 22 23 23 24 24 24 25 26 26

D. Preparing for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

E. Day Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

F. Hospital Stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Patient Care . . . . . . . . . . . . . . Pain Control . . . . . . . . . . . . . . Prevention of post-operative pneumonia Dressing Care . . . . . . . . . . . . . Drains and Drain management . . . . . Pathology Results . . . . . . . . . . . Recovery Process . . . . . . . . . . . Additional Post-op instructions: . . . . .

G. Arm exercises after an Axillary Lymph Node Dissection and/or a Mastectomy 27

Beginning Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Advanced Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

H. Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 I Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 J. Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

A. Faulkner Health Care Team

While a patient at Faulkner Hospital, you will have multidisciplinary team of providers monitor your care before, during and after your surgery. Breast Surgeon - The doctor who performs the surgery and who is responsible for your overall care. If you have breast reconstruction your plastic surgeon is also involved in your care. Since some surgeons operate at other hospitals as well as maintain offices outside of the Faulkner Hospital, they may not always be available at a given moment. However, the surgeon always has coverage available in his/her absence and has reviewed your care with the Physician Assistant and Residents. Anesthesiologist - The doctor who is responsible for your well being during the operation. The anesthesiologist works with a Nurse Anesthetist who will be present during the entire procedure. Radiologist - The doctor who reviews mammograms and other diagnostic images. The radiologist also performs core biopsies and wire-localizations. Pathologist - The doctor who dissects and examines the tissue in order to make a diagnosis. Physician Assistant (PA) - A licensed health care practitioner who works with your surgeon and the rest of the health care team to ensure that your care is the best possible we can provide. If you are admitted to the hospital, the PA will check on your progress and may perform a physical examination. Resident - A licensed medical doctor who works with your surgeon. Often, the residents have assisted in your surgery as well. The residents are available to address any medical issues you may have while in the hospital. Nurse - A licensed practitioner who coordinates your care with the members of the health care team. The nurse acts as your advocate to assure the planned treatments are progressing. The nurse also works closely with the nursing assistants to provide physical care. Nursing Assistant - The nursing assistant works under the direction of the nurse in providing physical care. Case Manager - A Registered Nurse with knowledge of health insurance, benefits, rehabilitation, skilled nursing facilities, and certified home care agencies. He/she will meet with you and your family to discuss your discharge plan. Your plan is based on your treatment and health care needs. Insurance benefits and your lifestyle will determine your individual discharge plan. With your consent, the nurse case manager will coordinate the necessary arrangements. Clinical Social Worker - A licensed professional trained to help with emotional issues facing you and your family. The social worker helps you cope during your recovery period and assists with family concerns. Nurse Practitioner - A licensed advance practice nurse who works with the surgeons in providing preopertive education, postoperative care and follow up.

B. Breast Health
Anatomy of the Breast

Pectoral Muscle The chest muscle extends from your breastbone to your shoulder and collarbone. It is located under your breast and contracts and expands to help move your arm. Lymph Nodes Help defend your body against infections. They are located under your arm and filter fluid from your breast and arm. Fat and Connective Tissue Supports and encases your entire breast. The more fibrous tissue, the firmer the breast.

Fatty Tissue Located throughout the breast. The more you have the softer the breast. Lobules Enlarge during pregnancy and produce milk for nursing. The mammary lobules are clustered throughout your breast and empty into the ducts. Ducts Carry milk from your mammary glands to your nipples during breastfeeding. The ducts are tube-shaped structures lined by a single layer of cells.

Nipple Located in the center of each breast. It is the outlet for ducts carrying milk. Areola Pigmented (or colored) circle of skin that surrounds each nipple.

Self Breast Exams Why perform self breast exams It is good for you to complete a monthly breast self-exam. Self-breast exams are easy to do and the more you do it, the better you will get to know how your breasts normally feel. Knowing how your breasts feel normally will help you notice any changes. Changes to look for include: lump or thickening in the breast, change in size or shape, dimpling of the skin, discharge from the nipple, retraction of the nipple, or redness or swelling of the breast. Women find most breast lumps themselves, but in fact, most lumps in the breast are not cancer. How to perform a breast self-exam 1. Lie down and put a pillow under your right shoulder. Place your right arm behind your head.

2. Use the finger pads of your three middle fingers on your left hand to feel for lumps or thickening. Your finger pads are the top third of each finger. Press firmly enough to know how your breast feels. If youre not sure how hard to press, ask your health care provider. Or try to copy the way your health care provider uses the finger pads during a breast exam. Learn what your breast feels like most of the time. A firm ridge in the lower curve in each breast is normal. 3. Move around the breast in a set way. You can choose either the circle (A), the up and down line (B), or the wedge (C). Do it the same way every time. It will help you to make sure that youve gone over the entire breast area, and to remember how your breast feels. When to perform a breast self-exam The best time to complete a breast self-exam is 5-10 days after your period starts, when your breasts are not tender or swollen. If you do not have regular periods or sometimes skip a month, do it on the same day every month, for instance the first day of the month.

Breast exams are not a substitute for periodic examination by a qualified clinician.

C. Types of Breast Surgery and their Risks and Complications

There are three basic types of breast surgeries: biopsy, partial mastectomy and mastectomy. These surgeries may involve additional procedures such as a duct excision, wire localization, axillary lymph node dissection, sentinel lymph node biopsy and/or breast reconstruction. In reviewing this section please note that your surgery may include one or more of the additional procedures. Most breast surgeries and recovery are uncomplicated, however occasionally complications may occur. The risks and complications that are associated with the various breast surgery procedures follow the description of the procedure. Please review and do not hesitate to ask your surgeon for clarification. Breast Biopsy A breast biopsy is performed to remove an area of breast tissue for the purpose of diagnosis. The biopsy procedure usually takes about 45 minutes to one hour. Once the surgeon removes the tissue, the surgeon sends it to the pathology department for their review and diagnosis. Sometimes this procedure is done in conjunction with a wire localization (see page 9) to indicate the area to be removed or with a duct excision (see page 7). This surgery is considered same day surgery and there is no need to stay overnight in the hospital. This means that after the surgery, you will go to the Post Anesthesia Care Unit (PACU) until you are feeling well enough to go home. Please review the information on Day Surgery on page 21. Risks and complications include infection, local bleeding, scarring, bruising, hematoma (blood clot in the area of the surgery) and failure to remove the entire abnormal area. There may also be a change in the appearance of the breast.

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Duct excision (including surgical ductogram) A duct excision is a type of breast biopsy. Your surgeon will remove a portion of the milk duct to diagnose the cause of discharge from the duct onto the nipple. The radiologist will perform a ductogam at the Sagoff Centre (4th floor in Belkin House) before you come to the operating room, the day of the surgery. To perform the ductogram, the radiologist will insert a small, very narrow cannula (tube) into the duct (in the nipple) from which the discharge can be expressed. X-ray contrast material containing blue dye is injected through the cannula into the milk duct. A mammogram is then taken. The dye helps the surgeon identify the discharging duct during surgery. Sagoff staff will bring you to the Day Surgery department after the ductogram procedure is completed. In the operating room, the surgeon will make a skin incision to remove tissue. The wound is usually closed with self-absorbing sutures (stitches). The tissue is sent to the pathology department for processing, review and diagnosis by the pathologist. The duct excision surgery usually takes I to 2 hours. If the radiologist cannot express discharge the day of the procedure, that is, you have no nipple discharge, a ductogram usually cannot be performed. If this happens, the radiologist will confer with your surgeon and with you to discuss whether we will proeeed with surgery; if the surgery should be rescheduled; or if an office appointment should be scheduled with the surgeon. The surgery is considered same day surgery and there is no need to be admitted to the hospital. This means that after the surgery, you will go to the Post Anesthesia Care Unit (PACU) until you are feeling well enough to go home. Please review the section on Day Surgery on page 21. Risks and potential complications include but are not limited to: inability to breast feed; a change in the appearance of the breast and nipple; change in sensation in the nipple and/or surgical site; insufficient blood supply to the nipple; infection; local bleeding; scarring; bruising; hematoma (blood clot in the area of the surgery) and failure to remove or completely remove the abnormal area.

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Partial Mastectomy (lumpectomy or wide excision or re-excision) A partial mastectomy is performed to remove the abnormal tissue or lump and a margin of normal tissue surrounding the abnormal area. This may be referred to as breast conserving surgery. Once the surgeon removes the tissue, the surgeon sends it to the pathology department for their review and diagnosis. The surgery usually takes about one (1) to two (2) hours and there will be a 2-3 inch scar on your breast. The incision is closed with sutures that disolve. Sometimes this procedure is performed using a wire localization to indicate the area to be removed. If you are having a wire localization please see the explanation of the procedure on page 9. Sometimes this procedure also includes performing an axillary lymph node dissection or sentinel lymph node biopsy to remove lymph nodes from under the arm. Please see the explanation for these procedures on pages 9 or 11. This surgery is considered same day surgery and there is no need to be admitted to the hospital. This means that after the surgery, you will go to the Post Anesthesia Care Unit (PACU) until you are feeling well enough to go home. Please review the section on Day Surgery on page 21. Risks and complications include infection, local bleeding, scarring, bruising, hematoma (a collection of blood in the area of the surgery), seroma (fluid collection in the area of the surgery) and failure to remove the entire abnormal area. There may also be a change in the appearance of the breast as a result of the procedure.

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Wire Localization This procedure is performed immediately prior to a biopsy (page 9) or partial mastectomy (page 8) in help guide the surgeon to the mammographic abnormality that he/she cannot feel. Wire localization is a technique used to locate an abnormal area in the breast when the area cannot be palpated and/or when calcifications are seen on mammogram. The wire localization procedure makes it more likely that the area seen on the mammogram and the tissue removed in surgery correspond. In addition, this relatively painless procedure makes it possible for the surgeon to remove less breast tissue during surgery without increasing the risk of missing the mammographic abnormality. The wire localization is performed by a radiologist at the Sagoff Centre in the Belkin House on the fourth (4th) floor. To localize a mammographic abnormal area, the radiologist will position your breast in the mammography machine. The compression plate for this procedure is a special plate with an opening and a grid to mark your mammogram. The radiologist uses the grid markings to determine exactly where the area (tissue) to be removed is located. Sometimes the wire localization can be performed using ultrasound instead of mammography. For this, you will lie down on the ultrasound table and the radiologist will use the ultrasound sensor to find the area where the wire needs to be inserted.

Before starting the localization procedure the radiologist numbs your breast with a local anesthetic. Then he or she will insert a needle into the area where the abnormality is located. A few more mammographic pictures may be taken before a thin, flexible wire is passed through the needle and than the needle is removed. The final X-rays are taken to demonstrate that the wire is located in the correct area and to act as a guide for the surgeon. A bandage is taped over the soft wire and you can get dressed leaving your bra off. Once you are dressed you are accompanied back to the surgical area in the hospital for the surgery. Sentinel Lymph Node Biopsy This procedure is often performed in conjunction with a partial mastectomy or mastectomy. It may also be performed in conjunction with an axillary node dissection. The procedure identifies and removes sentinel lymph node(s) from under the arm. These are the first lymph nodes to receive drainage from the area of the tumor. There is often more than one sentinel lymph node. Your surgeon will use a blue dye, a radionuclide dye, or a combination of both to identify the sentinel lymph node. Once the surgeon has identified and removed the sentinel lymph node(s), he/she sends it to the pathologist for their review and diagnosis. The results will be given to you when you awaken This procedure does require that you perform post-operative

exercises, please see Arm Exercises on page 27. If a radionuclide dye is used, it will be injected into the breast in the area where the tumor is located or near the areola. This injection is done by a radiologist at the Sagoff Centre in Belkin House on the fourth (4th) floor. The radiologist uses either mammography or ultrasound to guide the injection, with a technique that is very similar to the technique described for wire localization. The injection of radionuclide is usually done at least 2 hours prior to your scheduled surgery. The amount of radiation exposure is less than a routine chest x-ray. After injection, you can get dressed leaving your bra off. Once you are dressed you will either be accompanied to the surgical area for your surgery or to Nuclear Medicine, where a scan is done to check the location of the sentinel lymph node. Once your scan is completed, you are escorted back to the surgical area for the surgery. If blue dye is used, it will be injected into your breast by your surgeon in the operating room. This is done immediately prior to the surgery. Risks and complications of sentinel lymph node biopsy include all the risks described for Axillary Node Dissection on page 11 and the instructions on page 27. In addition, if blue dye is used, you may notice a blue discoloration of your breast after surgery. This will fade in time. You may also notice a blue-green discoloration or your urine or other bodily fluids immediately after surgery. An axillary node dissection may be

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required at the time of surgery or at a later date. At the time of surgery, an axillary node dissection would be performed if the sentinel node(s) could not be identified or if the surgeon finds cancer in the axilla. It might also be required once the final pathology results are known if those results are positive for cancer in the sentinel node(s). Care of your arm

It is important to always watch out for and prevent infections on the affected arm. Avoid cuts, scratches, irritations and burns as much as possible by doing the following: use insect repellent and protective sunscreen wear gloves for washing dishes and using cleaners wear gloves for gardening wear padded gloves for reaching into a hot oven use an electric razor for underarm shaving and do not cut your cuticles In addition, avoid tight jewelry or clothing on the affected arm, carry your purse on the opposite shoulder, avoid blood draws, injections, IVs and blood pressures on the affected side.

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Axillary Lymph Node Dissection This procedure is often performed in conjunction with a partial mastectomy (page 8) or total mastectomy (page 12) in order to remove some of the lymph nodes from under the arm. The fatty tissue that is removed usually contains about six to twenty lymph nodes. This procedure usually takes an additional hour. Once the surgeon has removed the breast tissue and lymph nodes, he/she sends it to the pathologist for their review and diagnosis. If the axillary node dissection is performed in conjunction with a mastectomy you will be admitted to the Hospital, see page 23, otherwise you will go home the same day, see page 21. This procedure does require that you perform post-operative exercises, please see Arm Exercises on page 27. Risks and complications include: Injury to the intercostal brachial nerves: These nerves run through the middle of the lymph nodes and give sensation to a small area in the back of the armpit. Every effort is made to save these nerves. However, should they be cut or stretched during the procedure, the result would be an area of numbness along the armpit and the back portion of the upper arm. This may be temporary or permanent and will in no way affect function or use of the arm or hand. Please be careful when shaving your armpit. Collection of lymph fluid (Seroma): The fluid that traveled through the lymph nodes may accumulate in the space where the lymph nodes were removed until your body absorbs it. This is usually not significant and results in a small amount of swelling. If there is a larger amount of swelling and it is painful, aspiration of the fluid may make you more comfortable. Please contact your doctors office to make arrangements for you to have the fluid aspirated. Swollen arm (Lymphedema): This may occur because the lymph fluids from the arm must reroute and filter through the remaining axillary lymph nodes. Because only the lower lymph nodes are removed with this procedure, this complication happens much less often than it did with more radical types of surgery done in the past. Lymphedema occurs in a small number of patients, and symptoms can range from hand swelling alone to total arm swelling. Should you note any swelling of your hand or arm, please contact your surgeons office who will instruct you in the appropriate exercises and follow-up care. Intervention includes physical therpy, manual lymph drainage and garments. Early intervention is important, please review care of your arm page 10.

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Total Mastectomy A total mastectomy is the removal of the entire breast. The surgery usually takes 1-1/2 to three hours and there will be a 4-8 inch scar. Once the surgeon removes the tissue, he or she sends it to the pathology department for their review and diagnosis. Drains will be placed under the skin at the bottom of the incision to collect fluid during the first few post-operative days. See drain information page 25. After the procedure, you will go the Post Anesthesia Care Units (PACU) for observation until you feel well enough to be transported to your room. Patients are admitted to the hospital overnight. Please see page 23 for information on Hospital Stay Risks and complications include infection, local bleeding, scarring, bruising, hematoma (a blood clot in the area of the surgery), seroma (fluid collection in the area of the surgery). Delayed healing of the scar may occasionally occur due to decreased blood supply. This is more common in women who smoke or who have diabetes. If this happens a large scab will form and will gradually fall off as healing occurs. The incision will still heal normally. The mastectomy procedure does require that you perform postoperative exercises. Please see Arm Exercises on page 27.

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Mastectomy with Axillary Lymph Node Dissection (or Modified Radical Mastectomy) The surgery will take 2 to 4 hours including removing both the breast tissue and axillary lymph nodes. There will be a 4-8 inch scar. Once the surgeon removes the tissue, the surgeon sends it to the pathology department for their review and diagnosis. Drains will be placed under the skin at the bottom of the incision to collect fluid during the first few post-operative days. After the procedure, you will go the Post Anesthesia Care Units (PACU) for observation until you feel well enough to be transported to your room. Patients are admitted to the hospital overnight. Please see the information on Hospital Stay on page 23. Risks and complications include infection, local bleeding, scarring, bruising, hematoma (a blood clot in the area of the surgery), seroma (fluid collection in the area of the surgery). Delayed healing of the scar may occasionally occur due to decreased blood supply. This is more common in women who smoke or are diabetic. If this happens a large scab will form and will gradually fall off as healing occurs. The incision will still heal normally. To understand the risks and complications of an axillary lymph node dissection, please review the description on page 11. This procedure does require that you perform post-operative exercises. Please see Arm Exercises on page 27.

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Mastectomy with Sentinel Lymph Node Biopsy This procedure removes the entire breast and the sentinel lymph node(s). The surgery will take two to four hours and there will be a 4-8 inch scar. Once the surgeon removes the tissue, the surgeon sends it to the pathology department for their review and diagnosis. Drains will be placed under the skin at the bottom of the incision to collect fluid during the first few post-operative days. After the procedure, you will go to the Post Anesthesia Care Units (PACU) for observation until you feel well enough to be transported to your room. Patients admitted to the hospital overnight. Please see page 23 for information on Hospital Stay. Risks and complications include infection, local bleeding, scarring, bruising, hematoma (a blood clot in the area of the surgery), seroma (fluid collection in the area of the surgery). Delayed healing of the scar may occasionally occur due to decreased blood supply. This is more common in women who smoke or who have diabetes. If this happens a large scab will form and will gradually fall off as healing occurs. The incision will still heal normally. To understand the risks and complications of the Sentinel Lymph Node Biopsy, please review the information on page 9. The mastectomy procedure does require that you perform post-operative exercises. Please see Arm Exercises on page 27.

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Breast Reconstruction (includes explanation of the various reconstruction procedures) Breast reconstruction is intended to restore your breast shape. Reconstruction can be done at the same time as a mastectomy (immediate reconstruction) or months or years later (delayed reconstruction). There are several techniques a plastic surgeon can use for breast reconstruction. One is using artificial materials (expanders and implants), the second uses your own tissue, and the third uses a combination of both. Patients who have breast reconstruction are admitted to the hospital for approximately 3-5 days. Please see the section on Hospital Stay on page 23. Each type of reconstruction technique has risks and complications that are unique to that procedure. However, as for all surgeries the usual risks and complication include infection, local bleeding, scarring, bruising, hematoma (a blood clot in the area of the surgery) and seroma (fluid collection in the area of the surgery). Risks of smoking: Smoking causes the blood vessels to narrow. This lowers the supply of nutriebts and oxygen to the body. Smoking can slow down healing after surgery, making recovery time longer. A. Using artificial materials 1. Implant - Synthetic implants are tear drop shaped pouches that are inserted under the pectoralis muscle or skin at the time of the through the skin into a port leading to the expander. This is usually done on a weekly basis. After a saline injection, you may feel some discomfort for approximately 24 hours, that usually is relieved with Tylenol. As it is filled, it stretches the tissue overlying it just like your abdominal muscles and skin is stretched with pregnancy. The process of expansion takes 4-6 months. If you received chemotherapy, it may take 8-12 months. The tissue expander is placed at the time of the mastectomy. Once the expansion is complete, the expander is replaced by a permanent silicone filled implant. Nipple reconstruction is performed on an outpatient basis 3 months after the permanent implant surgery. The nipple will have no sensation. If you have an implant, you will need to take antibiotics before dental work and some gynecological procedures for the rest of your life. B. Using ones own tissue Using your own tissue involves transplanting ones own skin, fat and muscle taken from another part of the body to recreate the breast. The transplanted tissue is referred to as the flap. Once successfully transplanted, the living tissue may be sculptured to achieve the most appealing shape, size and contour while accurately restoring balance with the other breast and often with return of some sensation. There are different methods of transplanting

mastectomy to create the form of the breast. Most commonly these are silicone filled. Implants are often used in conjuction with another synthetic material called alloderm that can sometimes allow plastic surgeon to place your final implant at the time of your mastectomy. Silicone implants can also be used in conjunction with expanders in a two-step procedure as described below. Your plastic surgeon will discuss the best approach with you. The nipple will be reconstructed 3 months following the complete reconstruction on an outpatient basis. The nipple will have no sensation. 2. Expander - Artificial materials include the use of tissue expanders and saline implants. When reconstruction is done using a tissue expander, an empty plastic sac or tissue expander is placed under the muscle layer. The tissue expander is like a balloon and is gradually filled up or expanded by injecting a salt-water solution

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your own tissue and your bodys size and medical history help determine which method is best for you. 1. TRAM Flap -

on pain control of constipation. This surgery can take an additional 3-4 hours after the mastectomy. Drains are placed to collect fluid post-operatively. Nipple reconstruction is performed on an outpatient basis 3 months after the surgery. The nipple will have no sensation. Risks and complications include poor blood flow to the TRAM flap and therefore tissue may partially or entirely die. Patients who are smokers, have diabetes, prior abdominal surgery or are obese may be at a higher risk for complications.If this happens, the dead tissue may need to be removed surgically. The incision will still heal normally. This technique may also cause abdominal wall weakness that can lead to an abdominal bulge or hernia. You may experience unusual sensations in the abdomen or breast areas, including numbness. This may last from several weeks to several months or may be permanent. 2. Latissimus Flap This procedure involves the transfer of one of the large muscles of the back (the latissimus dorsi) to restore

skin and the volume to the breast. The muscle is detached from its normal position and brought around to the front. Despite the transfer of this muscle, shoulder function is not affected. This technique is good to reconstruct a small breast, but often more tissue is needed and a saline implant is inserted under the flap as well to add volume. There will be a straight scar on the back. The front will have an oval shaped incision where the skin and muscle from the back are attached to the skin of the chest. This procedure can take an additional 3-4 hours after the mastectomy. Drains are placed to collect fluid post-operatively. Nipple reconstruction is performed on an outpatient basis 3 months after the surgery. The nipple will have no sensation. Please see page 23 for discussion on pain control and patient controlled analgesis. Please see page 21 for discussion on pain control of constipation. Risks and complications include poor blood flow to the flap and therefore tissue may partially or entirely die. If this happens, the dead tissue may need to be removed surgically. Seromas (fluid collections) in the back wound are quite common. These occasionally require drainage in the office. You may experience unusual sensations in the back or breast areas including numbness. This may last for several weeks or months or even permanently.

The TRAM flap tissue is harvested from the abdomen using a similar incision to that used for a tummy tuck procedure. The muscle can be detached from its normal position and brought up to the chest area to reconstruct a new breast. There will be a straightline incision across your lower abdomen. The chest will have an oval shaped incision where the skin and muscle from the abdomen are attached to the skin of the chest. The TRAM flap is not suitable for patients who have too much or too little abdominal fat. Your plastc surgen will further explain this procedure to you as well as determine whether you are an appropriate candidate. Please see page 23 for discussion on pain control and patient controlled analgesia. Please see page 21 for discussion

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D. Preparing for Surgery

It is important to have all your questions answered before surgery in order to feel confident about the choices and plan you have made with your surgeon. Women are anxious prior to surgery. In the days before the surgery, be sure to do some nice things for yourself, eat well, and do whatever you can to feel as relaxed as possible. Make sure your work responsibilities are covered in your absence, so you can concentrate fully on your recovery. Women living alone find it helpful to have some meals prepared ahead of time at home and groceries bought, so that they wont have to prepare much when they get home. If friends ask how they can be helpful, have someone suggest to them that they send over some prepared meals. Additional Support for Coping with Breast Cancer The following will explain the steps you may need to take in order to prepare for surgery. Social Work Services One of the most stressful times in the breast cancer experience is at the point of diagnosis. For most women the diagnosis of breast cancer comes as a surprise without advance notice or warning. Most women do not have a family history of breast cancer and do not have a ready-made team of clinicians to treat their breast cancer. Women typically feel physically well, which makes it hard to believe that anything is actually wrong. In the absence of complete medical information its common to have ones mind wander toward worst case scenarios. During this time of enormous anxiety, women need to integrate information about a complicated disease, and make complex decisions about their own care. Family and friends mean well, but are often themselves distraught by news of the diagnosis and dont always know the right thing to say. Breast cancer causes distress in many areas of ones life. Women worry about how they will be able to continue working, or caring for their children. Women worry about side effects from breast cancer treatment. Women worry about their mortality. At the Faulkner Breast Centre, we are concerned not only with your physical recovery from breast cancer, but also with your emotional health during breast cancer treatment. We have, as part of our professional team, a clinical social worker specializing in counseling women with breast cancer. The counseling is designed to provide you with additional support for coping with the myriad of stresses caused by the diagnosis as well as reduce your risk for anxiety or depression. Some of the topics covered in counseling can include: deciding between treatment options helping ones children cope with the diagnosis and treatment managing work responsibilities during breast cancer treatment maximizing ones support system interaction of breast cancer treatment with other personal or family stressors psychological impact of stopping hormone replacement therapy referrals to community resources and supports making connections to other women who have completed breast cancer treatment how breast cancer treatment will interact with a history of depression or anxiety why did this happen to me; what does this diagnosis mean in my life? Most women begin to feel less anxiety once some of their particular issues of concern have been addressed, and once the full details of their diagnosis are known and a treatment plan is underway. For more information, or to schedule an individual or family appointment please call Janet Rustow, LICSW at (617)983-7967. Helping Your Children Cope with Your Breast Cancer Diagnosis and Treatment When diagnosed with breast cancer, a mothers most immediate concern is often how to help her children cope with the experience. While parents generally want to protect their children from difficult and painful situations, their children may actually be imagining something far worse than the reality of the breast cancer diagnosis. Children rely on their parents for information and for ways of coping with difficult situations. The following suggestions are designed

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to give parents a basic guideline to begin thinking about how best to help their children. Tell Your Children Early on About Your Breast Cancer Many children have already picked up that something is wrong by the increase of telephone calls and the anxiety that is present in the home. Childrens fantasies are often worse than the reality. Set the example with them, early on, that you will give them honest information, answer their questions, and listen to their concerns. We recommend that children hear the information from their parents and that you use the word cancer. Wait until a time when you are able to focus on your childs needs. It is fine to take a few days to allow yourself to begin to digest the news, before you share it with your children. Assure Your Child That You are Taking Active Steps to Treat Your Breast Cancer Children often feel helpless in their ability to help in a time of crisis and need reassurance that you are working with doctors who have helpful treatments for your breast cancer. Let them know what needs to happen. Children should be told about the treatments you will be having, how it will impact the family routine, and who will be available to them when you are busy with your treatments. Encourage them to ask questions. Answer them truthfully. If you dont know the answer, assure them you will find out and get back to them. All mothers fear their child asking whether they are going to die from the cancer. Assure them

that the doctors are hopeful about the treatments they are offering. The doctors will let you know if the treatments are not working, in which case, you will let your child know. How Children React Children will typically react to their mothers breast cancer with fear, curiosity, sadness and anger. Young children will be most concerned with how the illness will effect them. Even though they cannot fully comprehend the meaning of the illness, they should be told about it, with age-appropriate language. Young children are very dependent upon their parents for their emotional wellbeing. Try to arrange for their dad, or favorite baby sitter information or grandparent to spend extra time with them. Try to keep routines as normal as possible. Since children of this age engage in magical thinking, it is important to assure them that they did not cause your cancer, and that cancer is not contagious. If your child wants to help you, let them, in age-appropriate ways. Drawing pictures for you is a great way for young children to express emotions. Older children are typically concerned about themselves and their own world. Discuss with them in more detail how your illness and treatments will impact their life. Arrange for favorite other people to accompany them to activities in your absence. Adolescents are keenly worried about body image and may be embarrassed or worried about various side effects of your treatment. Seek out their specific concerns and

address them. For example, you may need to assure them that you wont arrive at their school without a wig or scarf in place while on chemotherapy Notify Key People in Your Childs Life About Your Breast Cancer It is wise to let your childs babysitter, teacher or guidance counselor know about your illness. They can watch for signs of anxiety or depression in your child. Let your child know that you have discussed your illness with the babysitter, teacher or counselor. This will provide your child with someone during the day that they can talk to about what is happening in the family. Most children who were coping well before their mother was diagnosed with breast cancer do not require professional help to cope with their mothers illness. Do watch for the following signs and seek professional help if you notice any of them lasting for more than a couple of weeks: sleep or eating disturbance, inability to concentrate, sudden changes in school performance or attendance. We hope these guidelines are helpful. They are meant only as general suggestions. You know your child best, and are in the best position to convey the information in a way most helpful to your child. For more specific information, or to discuss your particular concerns, please call our clinical social worker, Janet Rustow, LICSW at (617) 983-7967. Pre Admission Testing (PAT)

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clinic appointment / At the same time your surgeons office staff schedules the surgery, a vist to PAT (Pre Admission Testing) will be scheduled. This is a separate appointment from your pre operative physical by your primary care physican. During this time, you will meet with a member of the anesthesiology staff who will evaluate you and answer any questions you have concerning anesthesia. You will also meet with a day surgery registered nurse who will explain specifically what to expect during your hospital stay. Pre-Operative (Pre-op) physical

Please discontinue Vitamin E and any herbal supplements. Please discontinue any diet drugs (notify your physician) Please do not take aspirin for 10 to 14 days prior to your scheduled surgery. If you take aspirin daily, please notify us and check with your doctor before stopping. Seven (7) to ten (10) days before surgery Do not take any non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin, Advil, Aleve, Naprosyn, Relafen, etc) for 7 to 10 days prior to surgery. Tylenol is

etc.) after midnight on the night before your operation. Remove nail polish Remove all jewelry including rings Remove contact lenses Leave valuables (checkbook, credit cards, etc.) at home Arrange to have someone drive you home once your are ready to be discharged. Arrange for someone to be at home with you during the first 24 hours after surgery You may brush your teeth the morning of surgery If you are instructed to take some of your medication on the

Be sure to inform the anesthesiology staff of any medication you are taking and whether you smoke and your previous anesthesia experience.

If you have any questions about your medications and surgery, you may call anesthesia at Faulkner Hospital at 617-983-7179. examination appointment A pre-op physical exam must be completed before surgery to ensure that you have no health --problems that may put you at risk for surgery and anesthesia. Should you have health problems, both your Primary Care Physician (PCP) and surgeon will coordinate a treatment plan to minimize your surgical risk. The pre-op physical exam can be completed by your PCP or at the Faulkner Hospital. The office staff at your surgeons office who books the surgery will help you plan for the pre-op. Two weeks prior to surgery Please consult with your doctor to determine the best plan for you. okay to take. One week before surgery Please discontinue Plavix after checking with your physician. The day before surgery On the last business day before your surgery you must contact the Day Surgery Unit at (617) 983-7179 between 9 a.m. - 3 p.m. to confirm your time of arrival. Do not eat or drink (including water, ice, vitamins, hard candy, gum,

morning of your surgery, please take with just a sip of water Bring your asthma inhalers with you If you have diabetes, do not take insulin or diabetic pills The hospital staff will make every effort to safeguard your possessions while you are a patient. Our focus is on the important essentials for daily living such as eyeglasses, dentures, and hearing aids.

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The day of surgery On the day of surgery, go directly to the Day Surgery PreOp unit on the first floor. Plan to arrive at the designated time. After checking in at Day Surgery, you will remain in the waiting room where your family and friends can join you. If you are scheduled for a wire-localization or sentinel lymph node biopsy, the nurse will direct you to the Sagoff Centre in the Belkin House on the fourth (4th) floor. Once the radiologist has placed the wire, you will return to the day surgery unit. The nurse will ask you to change your clothes and she/he will meet with you to prepare you for surgery. At this time, the nurse will answer any questions or address any concerns you may have. Next, the nurse will escort you to the anesthesia holding area where a member of the anesthesia team will place an intravenous (I.V.) line in your arm. Your surgeon will also visit you briefly. You may bring along a book or portable cassette/

cd player with headphones to help pass the time. A nurse anesthetist will then take you by stretcher to the Operating Room. During your operation, a nurse anesthetist continuously monitors your heart rhythm, blood pressure, breathing and oxygen saturation (effectiveness of oxygen delivery to the tissues of the body). Immediately following surgery After surgery, the staff will transport you to the Post Anesthesia Care Unit (PACU or Recovery Room), where you will remain until you are fully awake. Your vital signs (blood pressure and heart rate) will be monitored and the following medical devices may be used: Oxygen mask Heart Monitor Automatic blood pressure cuff Small device on your finger to monitor blood oxygen levels Recovery time varies by individual, but the average stay in the PACU is typically between 1 and 2 hours.

With a breast biopsy or partial mastectomy, you may have a bandage on your chest, which you can remove 24 hours after surgery, or you may have a clear dressing which will wear off in a couple weeks. Do not try to remove it. Under the bandage there are multiple steri-strips (narrow, one inch long adhesive strips) across the incision. These strips will fall off on their own about 7-10 days after surgery. The nursing staff will give you instructions on how to care for the incision at home. It may help to place a pillow under seat belt for the ride home. Only patients who had a mastectomy, with or without breast reconstruction, will be admitted to the hospital. Please see the information on Hospital Stay, on page 23. All other patients go home as soon as they feel ready to go. Please see Day Surgery section on page 21. This section will explain what you can expect once you are home.

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E. Day Surgery
This section will explain what you can expect once you are home. Recovery process You will receive pain medication in the PACU. Your surgeon will give you a prescription for pain medication for at home, especially the first night. You may experience pain or discomfort in the area of the incision as well as tiredness from the general anesthesia. The tiredness may last a few days. Constipation can occur from anesthesea or pain medicine containing a narcotic. Do not avoid pain medication because of risk of constipation. Constipation can be prevented / minimized by: adequate fluid intake early ambulation as tolerated use of stool softner or laxative while taking pain medication containing narcotics. Recovering from surgery is an emotional process as well as a physical one. Not only will you be tired from the anesthesia, you will need time to catch up emotionally with all that has happened physically. Dont rush yourself. You may wish to begin preparing yourself for the next phase of treatment by reading or by talking to other women who have been through the experience. Dressing Care The surgeon will cover your incision with a dressing, or a clear liquid bandaid sometimes with an elastic (ace) bandage wrapped around it. You will be discharged with the dressing in place, please note the following (the nurse will review all of this with you before you go home): Remove the dressing 24 hours after surgery, you may then shower Gently wash the incision area and pat dry If the incision is covered with strips of tape (steri strips) they should remain in place until they loosen on their own (may take as long as 7 to 10 days.) or are removed by your surgeon Signs and symptoms of infection: Please contact your doctors office if you note the following: Elevated temperature Increased redness around the incision Foul smelling drainage from incision For patients who also had an axillary node dissection or sentinel lymph node biopsy, have a simliar bandage as your breast incision. Please follow the same guidelines for incision care and infection monitoring as for the breast incision. It is not unusual to have decreased sensation or numbness in the armpit and along the back portion of your upper arm. This may last for weeks or months and in some instances may be permanent. You may also experience a feeling of pulling under your arm and have some restriction in the use of your arm initially after surgery. Pathology Results The pathology report outlines the results of the examination of the breast tissue and/or lymph nodes. Your surgeon will follow up with you by phone to inform you of the pathology results as soon as they are available. At that time the surgeon will review the results with you as well as discuss any further consults you may need. Important components of the pathology report include: whether the margins or edges of the tissue are clean (free of cancer cells) or dirty (have cancer cells present) - dirty margins usually indicate the need for a re-excision to remove the remaining cancer cells whether estrogen-receptors

DO wear a bra at all times for support after a partial mastectomy (or re-excision) for 48 hours or more and then while you are awake for at least three weeks

You may use an ice pack for relief of moderate pain or swelling. Apply to incision intermittently (Twenty minutes on / twenty minutes off.)

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Please review the information on Arm Exercises on page 27. are present - if estrogen receptors are present it indicates that the breast cancer is sensitive to hormones and may respond to hormonal treatment. if you had an axillary node dissection, whether there are any breast cancer cells in the lymph nodes - if the lymph nodes contain tumor cells further treatment may be indicated, such as chemotherapy or hormone therapy Post-operative exam You will need to make a postoperative appointment with your surgeon for a post-operative check. Your surgeon will inform you about scheduling this appointment.

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F. Hospital Stay
This section is for patients who are admitted to the hospital and explains the services and care patients receive while in the hospital. The rooms are located on the 7th floor and all are private. Visiting hours are from 12 pm to 8 pm daily. Family may visit but rest is important and it is wise not to overexert oneself. Patients who had a mastectomy stay overnight in the hospital. Patients who also had breast reconstruction will stay in the hospital for 3-5 days. If you had a TRAM Flap reconstruction you will have an abdominal incision as well as the breast incision. With a Latissimus Flap reconstruction you will have an incision on your back to the side of the scapula as well as the breast incision. Patient Care Your surgeon will stop by and check on you daily. If you had breast reconstruction your plastic surgeon will also come in to check on you. In addition to the surgeon monitoring your care, a team of residents, physician assistants and floor nurses will do the same. We encourage you to ask questions you may have for the health care team. You will feel drowsy for a few hours after arriving in your room. Your incision will be bandaged and you will have one or more drains in place as well as oxygen and Venodyne Boots. Venodyne Boots are special compression wraps which are applied to your legs to help maintain good circulation to avoid blood clots from forming in your legs. These gently squeeze and release your legs in the calf, knee and thigh areas. They will be removed once you are out of bed and walking. You may also have a Foley catheter in place and an IV for fluids. A nurse or nursing assistant will help you get out of bed for the first time and activity is increased gradually. Once the Foley catheter is removed, a nurse or assistant will help you go to the bathroom. Moving helps to increase your strength and is good for your circulation. Once your bowel functions have returned you are ready to eat. You will start with clear liquids and advance to regular food, as you are able to tolerate this. This usually occurs over one to two days following surgery. For patients who had TRAM Flap reconstruction, bowel function takes longer to return. For patients who had breast reconstruction the nurse will visit frequently to check the skin flap for adequate blood flow by checking the skins color and temperature. Your room temperature will be kept warm to facilitate optimal blood flow. For patients who did not have breast reconstruction, your doctor will order a consult for you to be fitted for a prosthesis and special bra. In the initial post-op period, you will receive a temporary form. When your incision has healed, you can then be fitted with the permanent prosthesis and surgical bras. Pain Control When you first awaken, you may have some discomfort over your chest and under your arm if you also had lymph node surgery. Many women describe the pain as moderate although you may feel more or less discomfort depending on your procedure and your individual sensitivity to pain (everyone is different.) Various methods of pain control are available. You may receive injections of pain medicine or a Patient Controlled Analgesia (PCA) pump. The pump administers intravenous medication that you control. The nurse will instruct you on how to use the pump to administer a dose by pushing a button. Use of this device allows a steady level of pain medication to remain in the bloodstream. You cannot overdose! The pump has been preset to deliver only certain amounts of medication; you cannot receive more than is programmed. Do not feel the need to tolerate pain! You must have adequate pain control, particularly early in the postoperative period, in order to actively participate in the recuperative process. See constipation information page 21. Eventually, your pain medication will be changed to the oral form (pills) in

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anticipation of your discharge from the hospital. Prevention of post-operative pneumonia Pain control after surgery is important not only for your comfort but also to ensure you maintain adequate breathing and to allow you to actively participate in your physical therapy. As is the case after any type of surgery, deep breathing, coughing and using an incentive spirometer are important for preventing post-operative pneumonia. Being out of bed and walking, as you are able, are also preventive measures for pneumonia. The nurse will show you how to use an incentive spirometer and help you practice the breathing exercises. The spirometer is a clear plastic tube with a ball inside and the tube is attached to a mouthpiece. As you take a deep breath IN, the plastic ball should rise to the top. This ensures you are taking deep breaths to prevent respiratory congestion and fever. Dressing Care The surgeon will cover your incision with a dressing, or liquid bandaid, or with an elastic (ace) bandage wrapped around it. The surgeon or physician assistant will remove the

dressing on the first or second day after surgery. Your incision may be covered with strips of tape (steristrips) or xeroform gauze. The steri strips should remain in place until they are removed by your surgeon or until they loosen on their own. (May take as long as 7 to 10 days.) Drains and Drain management You will have one or more drains (also called Jackson-Pratt or JP drain) placed during surgery to help drain fluid and blood from around the surgical site. Drainage and/or bleeding into the drain is normal and expected for the first several days after surgery. The nurses will check your drains and empty them. Each shift the nurse will document the amount of fluid in the drain(s). If the drain(s) is/are ready to come out before you are discharged from the hospital, the surgeon or physician assistant will remove them. Should you go home with drains in place please follow these instructions (the nurse will review them with you before you leave the hospital): Keep the incision dry until your drain is removed. Pin the tab on the bulb to your clothing to prevent pulling or

put drain bulb in camisole pocket. Strip or milk the J.P. tube to release any clotty threads that may accumulate along the inside of the JP drains. This will help keep the tube from clogging. Keep track of the amount of fluid in the drain. Once the fluid is less than 30 ccs over 24 hrs per drain, call your surgeons office to schedule an appointment to have the drain removed. It is advisable to take a pain pill one hour before the drain is removed. To empty the drain: - wash your hands, wear gloves - open the top of the bulb and empty contents into refuse container - compress sides of bulb and close top - measure fluid and record under appropriate drain number Do not put anything into drain bulb - only empty it. Empty twice daily. In order to make the monitoring process easier; the nurse will give you a form to take home, so you can write down the fluid measures. See example.

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If your drain loses suction open the top, compress the sides of the bulb and replace the top. Call your doctors office to schedule appointment for drain removal when amount is less than 3Occ or mls in 24 hours per drain. You need to empty your drains twice a day. How to record your output:

Date Drain #4 1/1 1/1 1/1 1/1

Time

EXAMPLE Drain #1 Drain #2

Drain #3

8 AM 10 15 20 30 2 PM 15 8 16 7 10 PM 8 5 6 10 24 HR TOTAL____________________________________________________________ 33 28 42 47 TIME DRAIN #1 DRAIN #2 DRAIN #3 DRAIN #4

DATE

For patients who had breast reconstruction, please call your plastic surgeon to have the drain removed. If you have a dressing over the drain site, it will need to be changed daily. Wash your hands after carefully removing the existing dressing. Place the new dressing over the drain site. If you have someone to help you, have him or her apply the tape while you hold the dressing in place. Use only a small strip of paper tape. Avoid placing the tape on the incision. If you are doing this alone, tear

the piece of tape first, then hold the dressing with one hand over your drain site and apply the tape with your other hand. Once your drain has been removed you will only need a dressing over the site for one day in case of any drainage from the drain site. Shower 24 hours after last drain is removed. Signs and symptoms of infection: Please contact your doctors office if you note the following:

Elevated temperature Increased redness around the incision or drain site Foul smelling drainage from incision or drain site Pathology Results A pathology report is a report on the examination of the breast tissue and/or lymph nodes. The surgeon will follow up with you to inform you of the pathology results as soon as they are available. This may be while you are still in the hospital or by telephone. At that time the surgeon will review the results with

DO NOT shower, shave underarms, use deodorant, or powder on this area until the drain is removed, unless otherwise instructed by your surgeon.

DO resume the above activities after the drain is removed as instructed by your surgeon.

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you as well as discuss any further consults you may need. You will then schedule a follow up vist with the breast surgeon. Important components of the pathology report include: whether the margins or edges of the tissue removed are free of cancer cells or have cancer cells present. whether estrogen-receptors are present - if estrogen receptors are present it indicates that the breast cancer is sensitive to hormones and may respond to hormonal treatment if you also had an axillary lymph node dissection or sentinel lymph node biopsy, whether there are any breast cancer cells in the lymph nodes Recovery Process It is important to take frequent rests during the day and not to overdo it. It can take several weeks to get back to your previous level of activity. Recovering from surgery is an emotional process as well as a physical one. Not only will you be tired from the anesthesia, you will need time to catch up emotionally with all that has happened

physically. Dont rush yourself. You might wish to begin preparing yourself for the next phase of treatment by reading or talking to other women who have been through the experience. For lumpectomies or lymph node surgery, there is a chance of blood or fluid collecting under the skin (seroma) that can cause swelling and discomfort. To ease the discomfort, apply ice to the area. Call the surgeons office if the area continues to swell and cause pain. It may need to be aspirated (remove fluid with a needle and syringe) at the doctors office. This is not painful since the area is usually still numb. If the fluid re-accumulates, the aspiration may be repeated. Vigorous movement or activity of the affected arm may increase the chance of developing a seroma or worsen an existing one. Additional Post Operative Instructions: Mastectomy with reconstruction: You will need a postoperative appointment with your plastic surgeon and your breast surgeon.

Do not sleep on your stomach or on the operative side. Your plastic surgeon will instruct you about wearing a bra. Do Not lift any thing heavier than 5-10 lbs for 6-8 weeks. Mastectomy without reconstruction: You will need a postoperative appointment with your surgeon. Prosthesis - you may wear a camisole with insert following your surgery. After your drains are removed you may wear a soft bra with insert. In one month you may be fitted for a permanent prosthesis. A representative from a supply company may visit you in the hospital and provide you with a camisole. A list of prosthesis providers is also on page 43, these products are covered by your insurance. Your stiches will dissolve. Do Not lift any thing heavier than 5-10 lbs for 4 weeks.

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G. Arm exercises after an Axillary Lymph Node Dissection and/or a Mastectomy

The following are general Range of Motion exercises to help you increase your arm motion. Please check with your doctor before attempting. Do the exercises slowly. Aim for gentle stretching. Remember not to hold your breath while exercising. You might want to exercise after your muscles are relaxed from a warm shower, or 45 minutes after pain medication. Try to do each exercise 5-10 times, 2-3 times per day Beginning Exercises A series - WEEK 1 If you had an axillary node dissection, start 2 days after surgery. If you had a mastectomy, start 1 day after the drains are removed. If you had breast reconstruction, check with the plastic surgeon.

Standing firmly with feet slightly apart, rotate trunk while swinging arm behind.

Elbow bent at right angle and held against trunk, slide arm on table surface in an inward arc.

Seated with elbow bent and held against side, slide arm in an arc, outward with table surface for support.

Holding arms with hands under elbows, move side to side as if rocking a baby.

B Series - Week 2 Advanced Exercises Add these exercises as follows: For axillary node dissection, 1 week after surgery. For mastectomy 1 week after drains are removed.

Graphics source: Visual Health Information

Lift arm out to side, elbow straight, palm downward. Do not shrug shoulders or hit trunk.

With elbow straight use fingers to crawl up a wall or door frame as far as possible

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Advanced Exercises Do the exerises slowly. Aim for gentle stretching. Remember not to hold your breathe while exercising. Try to do each exercise 5-10 times, 2-3 times a day. Call your surgeons office if you have any questions or concerns about the exercises, or your progress. For axillary node dissection, start 2 days after surgery and you have mastered the beginning exercises. For mastectomy, start 2 weeks after the drains are removed and you mastered the beginning exercises. WEEK 3

Bring arm across front to opposite side.

Gently pull on elbow with opposite hand until a stretch is felt in the shoulder.

Maintaining erect posture, draw shoulders back while bringing elbows back and inward. Return to starting position.

Raise arm to point to ceiling, keeping elbows straight With fingers clasped

behind head, pull elbows back while pinching shoulder blades together. Stand straight with arms

relaxed at sides. Roll shoulders continuously in backward direction. This exercise can also be done one shoulder at a time. With elbow straight use

fingers to crawl up a wall or door frame as far as possible

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Important Dos and Donts for patients who had an axillary lymph node surgery.
Information following axillary lymph node surgery: 1. Start exercises as instructed; do not exceed exercise times and amounts. Your surgeon will instruct you on weight limitations. 2. You may use an electric razor on the affected side one week after surgery. 3. Do not use powder or deodorant for one week following surgery. When showering, use soap and water. Dry gently. 4. Maintain arm precaution (see page 10) indefinitely. 5. Use moisturizer on hands. 6. Call your surgeon/NP with any questions or concerns you may have. 7. Call immediately if you notice swelling or redness on the affected arm. Note that you may experience swelling of the hand or arm (please see risk and complications for axillary lymph node dissection on page 11). This may occur immediately after surgery, or years later. If you note any swelling of your hand or arm, contact your surgeon and you will receive appropriate instructions. It is important to watch out for and prevent infections on the affected arm. You should avoid cuts, scratches, irritations and burns as much as possible by doing the following; use insect repellent and protective sunscreen, wear gloves for washing dishes and using cleaners, wear gloves for gardening, wear padded gloves for reaching into a hot oven, use an electric razor for underarm shaving, and do not cut your cuticles. Keep your skin soft and free of cracks with a moisturizing lotion. In addition, avoid tight jewelry or clothing on the affected arm, carry your purse on the opposite shoulder, avoid blood draws, injections, IVs and blood pressures on the affected side.

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F. Frequently Asked Questions

1. How long is the recovery period after surgery? Approximately 2 days for a biopsy or duct excision, 2 weeks for partial mastectomy and sentinel lymph node biopsy, 2-3 weeks for partial mastectomy and axillary node dissection and 3-4 weeks for mastectomy. Mastectomy with breast reconstruction can have a 4-6 week recovery period. If complications occur, recovery may be longer. 2.Do you have a drain in after a partial mastectomy? If you have a drain, how long does it stay in? Usually a drain is not placed for a partial mastectomy. Some surgeons place drains after axillary dissections. Mastectomy with or without breast reconstruction will always have drains. Over the course of several postoperative days, the amount of drainage will decrease and the drains can be removed. If the drain is not ready to be removed, you will go home with the drain. You will be taught how to take care of the drain and measure the drainage. A visiting nurse will visit you daily to check on you. The drain will be removed at the surgeons office. 3. Are there stitches to be removed? Most surgeons use absorbable stitches on the inside and these do not need to be removed. On the outside you will see liquid bandaid or steri-strips across the incision. Steristrips are small pieces of white adhesive tape which stay in place for 7-10 days, when they usually fall off. Your surgeon may remove them at your postop visit. 4. Will I experience pain after the surgery? You may experience postoperative pain at the incision area (breast, chest, abdomen or back) and/or your upper arm or under the arm. If you are in the hospital, you will receive pain medicine intravenously or by injection initially, and then orally with pain pills, once you are able to tolerate a diet. If you have day surgery, your surgeon will give you a prescription for a pain pill. 5. Is the surgery day surgery or do I stay in the hospital? If I stay in the hospital, how long do I stay? Biopsy, duct excision, partial mastectomy and axillary lymph node dissections or sentinel lymph node biopsy are day surgery and you will be discharged from the recovery room once you are fully awake and recovered from the effects of anesthesia. If you have a mastectomy, you will be in the hospital approximately 1 day. If you also have breast reconstruction, you will be in the hospital for 3-5 days. 6. Where will the incision(s) be? Incisions will be made on your breast for a partial mastectomy, under your arm for an axillary lymph node dissection, on your chest for mastectomy and additional incisions on your abdomen or back for breast reconstruction. 7. When can I take a shower? Following a partial mastectomy and/or axillary lymph node dissection or sentinel lymph node biopsy, you can shower approximately 24 hours after the surgery when the bandage is removed. If you have had a mastectomy with or without breast reconstruction, you cannot shower until after the last J.P. drain has been removed. 8. Can you travel by plane if you have an implant? Yes, it is safe to fly with an implant. 9. When can I resume sexual activity? The general rule is that you may resume sex when you feel able and your wound has healed. If you have had reconstruction, avoid activities that will make you sweaty, red in the face or out of breath for the first few weeks after surgery. It is

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important for you to remember that your sensation in the reconstructed breast will be decreased or absent. Check with your individual surgeon for further information. 10. How soon can I start driving again? For same day surgery patients you can drive again 24 hours

after the procedure if you are not taking prescription pain medication and are able to move your arm easily. For mastectomy patients you can drive again 24 hours after discharge from the hospital if you are not taking prescription pain medication and are able to move your arm easily.

It is best to drive only short distances at first and gradually increase your driving time over a few days. If you had breast reconstruction, please check with the plastic surgeon before driving.

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I. Glossary
Adjuvant therapy (AD-ju-vant): Treatment given in addition to the primary treatment. Areola (a-REE-oe-la)): The area of dark-colored skin that surrounds the nipple. Aspiration (asp-er-AY-shun): Removal of fluid from a lump, often a cyst or post operative fluid (a seroma), with a needle. Atypical hyperplasia (hyper-PLAY-zha): A benign (non-cancerous) condition in which breast tissue has certain abnormal features. This condition increases the risk of breast cancer. Axilla (ak-SIL-a): The underarm (armpit). Benign (bee-NINE): Not cancerous; does not invade nearby tissue or spread to other parts of the body. Biopsy (BY-op-see): The removal of a sample of tissue, which is then examined under a microscope to check for cancer cells. Excisional biopsy is surgery to remove an entire lump. Incisional biopsy, is when the surgeon removes part of the tumor. Removal of tissue with a needle is called a needle biopsy. Bone Scan: A nuclear medicine scan to assess whether the breast cancer has spread (metastasized) to the bones Cancer: A term for more than 100 diseases in which abnormal cells divide without control. Carcinoma (kar-sin-OE-ma): Cancer that begins in the lining or covering of an organ. Carcinoma in situ (kar-sinOE-ma in SY-too): Cancer that involves only the tissue in which it began; it has not invaded other tissues. Chemotherapy (kee-moeTHER-a-pee): Sometimes chemotherapy is used in addition to surgery and radiation therapy. Chemo therapy involves using drugs to destroy cancer cells by stopping them from growing or multiplying at one or more points in the cells life cycle. Chemotherapy may often consist of more than one drug. How often and for how long you will get chemotherapy depends on the kind of cancer you have. Depending on the type of cancer you have the chemotherapy may be administered intravenously, by mouth or into the muscle. If you are a candidate for chemotherapy, your surgeon will refer you to a medical oncologist for a discussion of the different types of chemotherapy. Clinical trials: Research studies that involve patients. Each study is designed to answer scientific questions and to find better ways to prevent or treat cancer. Your decision about participating in a clinical trial does not affect your care. Core Biopsy: Removal of a portion of the breast lump or abnormality seen on mammogram or ultrasound using local anesthesia and a special core biopsy instrument Cyst (sist): A closed sac or capsule filled with fluid. Duct: A tube in the breast through which milk passes from the lobules to the nipple. Cancer that begins in a duct is called ductal carcinoma. Ductal carcinoma in situ: involves only the ducts and has not spread to other tissue. Estrogen (ES-troe-jin): A female hormone. Estrogen Receptor: A binding site on tumor cells for estrogen. This can be measured in breast cancer cells Estrogen receptor test: A test to measure the amount of certain proteins, called hormone receptors, in breast cancer tissue. Hormones can attach to these proteins. Hematoma (hem-a-to-ma): collection of bloody fluid which may accumulate in areas where tissue was removed.

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Her-2: A tumor marker that can be measured in breast cancer cells. Hormones: Chemicals produced by glands in the body. Hormones control the actions of certain cells or organs. Hormone therapy: Treatment of cancer by removing, blocking, or adding hormones. Jackson-Pratt (J.P.) Drain : A device which drains and collects fluid from the incisional area. Lobe: A part of the breast; each breast contains 15-20 lobes. Lobular carcinoma in situ: involves only the lobules of the breast and has not spread to other tissues. Lobule (LOB-yool): A subdivision of the lobes of the breast. Cancer that begins in a lobule is called lobular carcinoma. Local therapy: Treatment that affects cells in the tumor and the area close to it. (i.e. the breast and adjoining lymph nodes) Lumpectomy (lump-EK-toemee): Surgery to remove only the cancerous breast lump; and margin of normal tissue , usually followed by radiation therapy. Also referred to as partial mastectomy. Lymph (limf): The almost colorless fluid that travels through the lymphatic system and carries cells that help fight infection and disease.

Lymph nodes: Small, beanshaped organs located along the channels of the lymphatic system. Bacteria pr cancer cells that enter the lymphatic system may be found in the nodes. Also called lymph glands. Lymphatic system (lim-FATik): The tissue and organs (including the bone marrow, spleen, thymus, and lymph nodes) that produce and store cells that fight infection and disease. The channels that carry lymph also are part of this system. Lymphedema (lim-fa-DEE-ma): Swelling of the hand and arm caused by extra fluid that may collect in tissue when underarm lymph nodes are removed or blocked. Malignant (ma-LIG-nant): Cancerous; can spread to other parts of the body. Mammogram (MAM-o-gram): An x-ray of the breast. Mammography (mam-OG-rafee): The use of x-rays to create a picture of the breast. Mastectomy (mas-TEK-tomee): Surgery to remove the breast. Modified Radical (MRM) Mastectomy includes removal of lymph nodes. Total Mastectomy does not include removal of lymph nodes. Menopause: The time of a woman's life when menstrual periods stop; also called "changing of life." Metastasis (meh-TAS-tasis): The spread of cancer

from one part of the body to another. Cells in the metastatic (secondary) tumor are like those in the original (primary) tumor. Microcalcifications (MYkrow-kal-si-fi-KA-shunz): Tiny deposits of calcium in the breast that cannot be felt but can be detected on a mammogram. A cluster of these very small slecks of calcium may indicate that cancer is present. Milking & Stripping: technique for releasing clotty threads that may accumulate along the inside of the J.P. Drain. MRI: A type of breast imaging that is done with the use of a large magnet. No radiation is used. PACU: Past Anesthesia Care Unit, the unit you are transported to right after your surgery. Palpation (pal-PAY-shun): A simple technique in which a doctor presses on the surface of the body to feel the organs or tissues underneath. Partial Mastectomy: Partial mastectomy is surgery to remove the abnormal tissue or lump and a margin of normal tissue surrounding the abnormal area; is also referred to as lumpectomy. Pathologist (path-OL-o-jist): A doctor who identifies disease by studying cells and tissues under a microscope.

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Progesterone (proe-JES-terown): A female hormone. Prognosis (prog-NOE-sis): The probable outcome or course of a disease; the chance of recovery. Prosthesis (pros-THEE-sis): An artificial replacement of a part of the body. A breast prosthesis is a breast form worn under clothing. Radiation therapy (ray-deeAY-shun): Sometimes radiation therapy is used in addition to surgery. Radiation therapy consists of X-ray treatments to the tumor containing area in the breast. The X-rays can kill the tumor cells or keep them from growing and dividing. The treatments involve positioning you in a radiation therapy machine to receive the treatments. Small tattoos are placed on your skin to allow exact positioning of the X-rays. The treatments are given on an outpatient basis 5 times a week for 6.5 weeks, 5 weeks are for total breast irradiation and 1.5 weeks of a boost (extra dose) to the tumor area. Remission: Disappearance of the signs and symptoms of cancer. When this happens, the disease is said to be in

remission. A remission can be temporary or permanent. Risk factor: Something that increases a persons chance of developing a disease. Sentinel Lymph Node: First lymph node or nodes to receive drainage from the area of the tumor Seroma: collection of bodily fluid which may accumulate postoperatively in area where tissue was removed. Stage: The extent of the cancer. The stage of breast cancer depends on the size of the cancer and whether it has spread from its original site to lymph nodes and/or distant sites. Staging: Staging is a term used to describe those tests we do on all patients with a new diagnosis of breast cancer to determine if there are any obvious signs of spread (metastasis). The tests commonly used include a chest x-ray, liver function tests and tumor makers (a blood test), and a bone scan. (You may eat and drink as you usually do before and after these tests.)

Systemic therapy (sis-TEM-ik): Treatment that reaches and affects cells all over the body. Tissue (TISH-oo): A group or layer of cells that performs a specific function. Tumor: An abnormal mass of tissue. Ultrasonography (ul-tra-sonOG-ra-fee): A test in which sound waves are bounced off tissues and the echoes are converted into a picture (sonogram). These pictures are shown on a monitor like a TV screen. Tissues of different densities look different in the picture because they reflect sound waves differently. A sonogram can show whether a breast lump is a fluid-filled cyst or a solid mass. Wire-Localization: A technique to localize a breast abnormality that cannot be felt. The procedure involves placing a wire into the breast under local anesthesia before the surgical procedure. The localization can be done under guidance of either mammography or ultrasound. X-ray: Radiation is used in low doses to diagnose diseases and in high doses to treat cancer.

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J. Resources
Service Category
Counselling

Local Resources
Faulkner Breast Centre social worker Janet Rustow, LICSW 1153 Centre Street, Boston, MA 02130 617-983-7967 Zakim Center for Integrative Therapies 617-632-3322

National Resources
Cancer Care Inc. 1-800-813-Hope www.youngsurvival.org www.cancercare.org www.lotsahelpinghands.com Look Good, Feel Better 1-800-395-LOOK National Coalition for Cancer Survivors 1-877-NCLS-YWS www.cansearch.org

Peer support

Genetic Counseling

Dana Farber Cancer Institute High Risk Clinic 617-632-2170 New England Medical Center Division of Genetics 617-636-5461

Lymphedema Support

Greater Boston Lymphedema Network Meetings on 3rd Wednesday of the month 781-894-2309 New England Medical Fitting 988 Middle Street Weymouth, MA 02188 1-800-341-1512 Friends Boutique - DFCI 44 Binney Street Boston, MA 02115 617-632-6178

National Lymphedema Network 1-800-541-3259 www.lymphnet.org

Breast Prosthesis

Internet Sources
Internet Massachusetts Breast Cancer Coalition 1-800-649-MBCC American Cancer Society MA www.ma.cancer.org Breast Cancer Network of Strength 312-986-8338 www.networkofstrength.org Young Survival Coalition 646-257-3000 www.youngsurvival.org www.breastcancer.org American Cancer Society (ACS) 1-800-227-2345 www.cancer.org National Alliance of Breast Cancer Organizations (NABCO) 1-888-806-2266 www.nabco.org National Breast Cancer Coalition 1-202-296-7477 www.natlbcc.org National Cancer Institute 1-800-4-CANCER www.cancernet.nci.nih.gov www.nci.nih.gov Center for Cancer Suppport and Education 781-648-0312 www.centerforcancer.org Susan G Komen Breast Cancer Foundation 1-800-462-9273 www.komen.org Oncology Nursing Society www.ons.org Onco.Link www.onco.link.upenn.edu Lance Armstrong Foundation www.livestrong.com Lotsa Helping Hands www.lotsahelpinghands.com CaringBridge 651-452-7940 www.caringbridge.org

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www.FaulknerHospital.org Faulkner Hospital 1153 Centre Street Boston, MA 02130