Lower Transverse Rectus Abdominis Muscle
Flap and Abdominal Wall Closure
This method, when appropriate, allows the breast to be reconstructed without a silicone or saline prosthesis. This method uses the skin and subcutaneous fat from the infraumbilical area to form the new breast mound.
GETTING READY FOR SURGERY
TWO WEEKS BEFORE SURGERY you should stop taking ASPIRIN, or any aspirin-family drugs like Ibuprofen or Naproxen. Take plain Tylenol instead. This will reduce your risk of bleeding during surgery, and bruising afterward. Other herbs and medications that interfere with blood clotting include arnica, garlic and Vitamin E. Avoid them all for 2 weeks before surgery.
The office will call in prescriptions to your pharmacy of choice for the medications you will take before and after surgery. Mephyton 5mg is a form of vitamin K that is well absorbed orally. It is an essential cofactor for 4 of your clotting factors, and we ask you to take it for 5 days before surgery to minimize bleeding during surgery and bruising afterward. Celebrex 200mg is a strong non-narcotic pain reliever. We ask you to take it before and after surgery to minimize the amount of narcotic pain reliever you require. This will get you clear-headed and back to driving 2 days earlier than you would be able to if you weren't taking it. Soma 350mg is a muscle relaxer to help your abdominal muscles relax to accomodate the tightening sutures that are placed during surgery. Vicodin is a narcotic pain reliever to take for moderate to severe pain that you may have in spite of the Celebrex and Soma. Prilosec OTC reduces your stomach's acid production to minimize the risk of aspiration if you should experience nausea after surgery. It is not a prescription drug, so you won't get a prescription for it, but you should buy a small box of 10 tablets while you are at the pharmacy to get your other medicines.
5 DAYS BEFORE SURGERY
1. Stop smoking. Smoking causes narrowing of blood vessels in the abdominal skin. The abdominal skin usually receives circulation from two directions--vertically from the abdominal wall, and horizontally from surrounding skin. After this operation, the skin has to survive on just the horizontal blood supply from surrounding skin. This makes it quite sensitive to the vasoconstriction caused by smoking. A variable amount of lower abdominal skin may die during the first week after surgery if you smoke. For this reason, you must not smoke for at least five days before your operation and at least three weeks afterward. Smoking cessation does not reduce the risk of skin loss to as low as it is in nonsmokers, but it does improve it significantly.
2. Stop consuming alcoholic beverages. Alcohol interferes with your liver's ability to utilize vitamin K to synthesize 4 of your body's 12 clotting factors. The resulting deficiency causes extra bleeding during surgery and extra bruising afterward.
3. Take vitamin K to help your liver restore normal levels of clotting factors. Mephyton 5mg is a form of vitamin K that is well absorbed orally. We will give you a prescription for it at the time of your preoperative consultation.
THE DAY BEFORE SURGERY a nurse from the hospital will call you to tell you what time you should come to the hospital. She will review your preoperative instructions with you:
Before supper, take 2 Prilosec OTC tablets and 2 Celebrex tablets. The Prilosec OTC will reduce your stomach acid production, thereby reducing your risk of nausea after surgery. The Celebrex is a non-narcotic pain reliever that will help reduce your requirement for narcotic pain relievers after surgery.
At bedtime, drink 2 16-oz. glasses of water. This will assure that you will be well hydrated on the morning of surgery, so it will be easy to find a vein for starting your IV.
Do not eat or drink after midnight the night before surgery.
THE DAY OF SURGERY First thing when you awaken, take 2 Prilosec OTC tablets and 2 Celebrex tablets with a sip of water. At this time, you should also take any medications you take on a daily basis, such as birth control pills, blood pressure medication, etc. Take a shower with antibacterial soap, such as Dial or Safeguard. This will reduce the bacterial colonization of your skin and make the surgical skin disinfectant in the operating room more effective.Wear comfortable clothes with buttons or zippers, easy to put on and take off without requiring you to stretch or bend. DO NOT wear any makeup, jewelry, deodorant or nail polish. Have a friend or relative drive you to the hospital.
You will be asked to arrive at the hospital 90 minutes before your surgery start time. You will meet your anesthesiologist, and the plastic surgery OR nursing team. Dr. Seaberg will see you in the preop holding area before surgery, to review your procedure with you and mark your incisions. You will then be taken to the operating room. Your surgery will take about 3 hours to perform.
After your operation, a sturdy elastic support will surround your abdomen. Three or four wound drain tubes will carry away any fluid accumulation beneath your incision, so healing will not be delayed. You will not be allowed to take a shower while you have your drains in, which means sponge bathing. You will also have big bulky dressings over your breasts, which you will leave alone until your follow up appoitnment 5 or 6 days later. You will be observed in the recovery room until you are fully alert and ready to go home. At the time you leave the hospital, you will be given a follow-up appointment to see me in the office 5 or 6 days after surgery, to check the output of the drains and remove them, as well as sutures, if they are ready.
Your friend or relative will drive you home. YOU WILL NOT BE ABLE TO DRIVE YOURSELF HOME AFTER SURGERY! The first night after surgery you will need someone to pamper you at home. You will feel tired due to the medications you received during surgery, and you will not feel like doing very much for yourself.
WHEN YOU ARRIVE HOME, make yourself comfortable. Relax for the remainder of the afternoon and evening. Feel free to move around, but avoid heavy exertion. You will still feel slightly drowsy (we plan your medicines accordingly) and will sleep intermittently. Start with liquids if you are hungry, and if your stomach feels fine, progress to other food, as you desire. If you are at all nauseated, be assured that the nausea will be gone in 6-8 hours. During this time, do not eat solid foods; just drink a small amount of clear liquids. You received medicine to prevent nausea during your surgery, but if it persists, call me.
OFFICE PHONE 573-443-5500
HOSPITAL OPERATOR (ask her to beep me) 573-815-8000
Celebrex is intended to be your primary postoperative pain reliever. Take Celebrex twice a day with food (dry cereal, or crackers, or a glass of milk, if you don't feel like a meal).You are to take carisoprodol (Soma) 350 mg routinely four times a day (at mealtimes and at bedtime) for 10 days. The carisoprodol is a skeletal muscle relaxant, and helps your abdominal muscles adjust to being pulled tight by your surgery. The other medication prescribed is Vicodin, a synthetic narcotic pain reliever. Take Vicodin one or two at a time, every 4 hours, if needed to control pain. Most people take two Vicodin at a time, every 4 hours, for the first 12 to 24 hours after surgery. One to two days after surgery they start cutting back to one every four hours, and by the third to fourth days are taking it only at bedtime.
You will have an anti-nausea patch on the skin behind your right ear. You should leave this in place for 48 hours after surgery. On the second day after surgery you should remove the patch and wash the skin beneath the patch to remove any medicine residue. You should then wash your hands to remove any medicine residue from your hands.
FIRST DAY AFTER SURGERY
Your wound drains will collect wound fluid from the space between your abdominal muscles and abdominal skin. The wound fluid is usually some shade of red the first day or two after surgery. This is normal. Record the amounts collected. Empty the collection bulbs as often as needed to keep them collapsed. You will be given a separate instruction sheet with good drawings to remind you how to do this. It is normal to feel groggy and stiff and sore. Your abdomen will feel very tight. This is partly due to the tightening sutures that were placed in the abdominal muscles and partly due to swelling. It will gradually feel less tight and more normal with each additional day of recovery. Take your pain pills as often as you need them. Get up and move around a little every four hours or so. Mostly, rest in bed with your hips and knees flexed, and let other people wait on you. Wear your abdominal binder. You may adjust the tension on the binder as often as you need to, for comfort. Walk stoop-shouldered and bent at the waist, to keep tension off your sutures.
SECOND DAY AFTER SURGERY
You should feel less groggy now, but will probably still be quite sore. Keep taking your pain pills as often as needed. Your appetite may return this day, or it may not. If not, that is probably a side effect of your pain pills. Try to eat a little, even if you don't feel like it. Keep your wound drain bulbs collapsed. Move around a little more. Drink lots of liquids. Wear you abdominal binder. Continue to walk stooped over when you walk.
THIRD DAY AFTER SURGERY
You may realize that you are constipated. This is a common side effect of pain medication. If so, drink some prune or apple juice, or take some Milk of Magnesia. You should have less pain this day, and fewer requirements for pain pills. Your appetite should start to return. You should be up and around more. Spend more time up in a chair than you spend in bed. Empty your drain bulbs as often as needed to keep them collapsed. Keep wearing your abdominal binder. Continue to walk stooped over when your walk.
FIFTH OR SIXTH DAY AFTER SURGERY
Come to the office so we can check your wound drains and external sutures, and remove them if they are ready. After your sutures are removed, your incisions will be covered with Steri-strips. Wetting the Steri-strips briefly during a daily shower will not hurt them. Try to leave the Steri-strips in place for at least one week; two weeks is better. For as long as they stay on, they are helping to produce a finer, less noticeable scar. Continue wearing your abdominal binder (except when you are in the shower or the binder is in the laundry) for a full two weeks after surgery. After you return home, you may take a shower, if you like. If you do this, leave your new drain-site dressing on during the shower. After you get dried off, change the drain-site dressing. You can start standing up straight, if it is comfortable to do so.
SECOND WEEK AFTER SURGERY
You should have a reduced requirement for pain medications, now that your sutures are out. Try to get by on Tylenol or Ibuprofen. If you need the pain pills to get you through unavoidable activity (childcare, for example), or to get to sleep at night, that is pretty typical. Increase your activity. Take some walks outside the house, weather permitting. You will still become tired after minimal exertion and will probably take lots of afternoon naps.
WEEKS 3-8 AFTER SURGERY
For the first three weeks you are at home, you should keep your elastic abdominal support in place at all times, except when bathing. You can resume normal baths or showers after your drains are removed. Leave your Steri-strips in place for as long as they remain adherent to skin. If the ends curl up, trim the curls and leave the central portion in place. You should expect to be easily tired for two weeks following your operation. During the third week you will feel steadily stronger. By the end of the third week, you should be able to resume full activity, including work and sexual relations, with little if any discomfort. You will continue to gain strength and stamina for a full 8 weeks following surgery.