SGAP/IGAP Flap Instructions

Two or More Weeks before Surgery

Pre-operative Labs

Preoperative lab work must be obtained and reviewed prior to surgery. The lab work will need to be completed 3 weeks prior to surgery. You may also be requested to do a cardiac work-up before your surgery.

Medications

Do not take any medication containing aspirin, including cold formulas, for at least 2 weeks prior to surgery. Please let us know if you are taking or have been taking any herbal supplements or vitamin E. These will need to be discontinued also. Please refer to the Medication List for some frequently used medications that contain aspirin or an anti-inflammatory. These compounds have a tendency to decrease the average clotting capacity and increase bleeding during surgery. Tylenol may be used instead as it does not have these untoward effects. If you are on Tamoxifen, you need to stop taking this medication 3 weeks before surgery.

Smoking

Smoking compromises blood flow by causing spasm of blood vessels and significantly increases the risk of flap complications and wound healing problems. Therefore, DO NOT SMOKE for at least 8 weeks before and 6 weeks after surgery. This also applies to second hand smoke; therefore do not stay in the room with cigarette smokers.

Blood Donation

The amount of blood loss during the surgery varies, and only 30% of patients will require a blood transfusion. This of course is greater in patients undergoing restoration of both breasts. Therefore, we recommend that patients donate 1 to 2 units of blood prior to surgery. Preferably, the blood should be donated at least 2 weeks prior to surgery, and each unit is available for 35 days after donation.

Iron

Iron supplementation should be started as soon as possible prior to surgery especially when donating blood. Red cells contain a large portion of the body's iron stores. Therefore, supplementation should be started immediately and continued for at least 2 weeks after surgery. There are several iron supplements available without a prescription. All may cause some gastric distress or constipation, although individual reactions may differ. You may tolerate one product better than another. Taking iron supplements with food decreases such symptoms. All are better absorbed on an empty stomach, taken with orange or grapefruit juice or vitamin C. Avoid taking supplements with milk or calcium supplements, which decrease iron absorption. Some examples are:

• Ferrous Sulfate: usually the least expensive form, well absorbed, can cause gastric distress or constipation (e.g. Slow Fe, Feosol, Fer-In-Sol)
• Ferrous Gluconate: slightly more expensive and causes less gastric distress (eg. Fergon R)
• Ferrous Fumarate: similar to ferrous gluconate (eg. Ferro-Sequels), contains stool softener.

One Week before Surgery

Hibiclens™ Soap

Use Hibiclens™ (over-the-counter antibacterial skin cleanser) in the shower instead of soap for 3 days prior to surgery. Apply the minimum amount of Hibiclens™ necessary to cover the skin from shoulders to thighs and the buttocks and wash gently. Rinse again thoroughly (be careful not to get the product on your face, eyes, or ears). You do not need a prescription for this.

Notification of Illnesses

Notify our office promptly if cold, fever, or any illness appears before surgery. Call in any allergies, medications, or conditions you may have forgotten to tell us about.

Night before Surgery

Eating and Drinking

Do not eat or drink anything after midnight the night before surgery. This includes gum, candy and water. Failure to comply with these instructions may result in cancellation or delay of your operation. If you are diabetic and take insulin you will be instructed how to take your medication and discuss this with your anesthesiologist during the preoperative visit.

Arrival for Surgery

Please be punctual. If you are running late please call ahead, but be aware that not arriving on time may cause cancellation of your surgery. The pre-operative area is on the 3rd floor of Smith Tower, and the telephone number is 713-441-6047.

Post-Operative Instructions SGAP Flaps

Medications

There are 7 medications that you may be required to take after surgery:

1. Antibiotic - to be continued until the drains are removed
2. Pain Medication - remember this medication might make you feel groggy and constipated and cannot be mixed with alcohol
3. Aspirin - 325mg or 81mg (dosage will be discussed on discharge) every day for 2 weeks after surgery
4. Iron - same dose as taken before the surgery
5. Multi-vitamins daily
6. Zinc supplement 50mg daily
7. Colace - Stool softener 100mg daily (as needed)

Flap Monitoring

The flap(s) should always be warm and the same color as the donor site abdominal skin. Keep in mind that the breast mastectomy skin can be bruised and a different color from the flap skin. When you press gently with your finger, the flap should lighten and return to normal color within 2 to 3 seconds. If there is any change in the color, temperature, or pain notify the office immediately.

Doppler

You will be discharged home with the Doppler in place, which is a tiny wire that will be removed at your first clinic visit. It will be covered with a transparent dressing which is waterproof. You may shower with this dressing, and in the event that it becomes wet, take off the dressing and cover with dry gauze.

Drains

You will also be discharged home with your drains in place. There are usually 2 drains in the abdominal area, and 2 in each operated breast. It is necessary to record total daily output for each drain. When the drain is near full, empty the contents into a measuring cup and record the amount in ml (equal to cc). You can also use the drain bulb itself that has markings to measure the output. Strip the drain tubing 3 times per day. If the drain requires emptying more than once per day, enter the DAILY TOTAL in the appropriate space on the Drain Record Sheet. Your drain(s) will be removed in clinic once output is less than 25cc total per drain. We use silastic drains, which reduce any discomfort during removal of the drain. The small opening that will remain in the skin will seal in 24-48 hrs. This opening may have a small amount of drainage, and can be covered with dry gauze until it seals closed.

Incision Care

Most of the incisions have absorbable sutures that are hidden underneath the skin. Sometimes, you might feel a small knot come up in the incision area. Do not worry, this can sometimes happen and will be removed during your clinic visit. Your incisions are sealed with special fibrin glue so you do not need to apply any ointment. After 2 weeks, the glue will start to peel and you can start taking it off in the shower. Also, you may resume your skin moisturizer 4 weeks after surgery.

Swelling

After surgery, your breast and abdominal area will feel swollen around the incisions, especially at the end of the day. This is normal and usually takes at least a month or more to resolve.

Surgical Garments

After the drains are removed, you may be fitted with a compression garment post-operatively to help with the swelling as you become more active. We have found that these garments provide support, and therefore decrease post-operative pain. The garment should be worn during the day for at least 4 weeks after surgery. You will also be fitted with a bra post-operatively in our office. This is a soft bra that does not cause compression issues on the reconstructed breast. These will need to be purchased through our office. A receipt will be given to you that you may submit to your insurance for any reimbursement. The compression garment is $55.00 and the bra is $30.00.

Showering

You will be able to shower on the third postoperative day in the hospital. Baths can be resumed 1 month after surgery, and swimming 8 weeks after surgery.

Activities

When you are discharged from the hospital, you will be able to take short walks and climb stairs. For 1 week after you return home, do not raise your arm on the operated side above your shoulder. You may perform light chores and start taking longer walks 3 weeks after surgery. Of course, no lifting anything heavier than 5 pounds for the first month. After 6 weeks, you may gradually resume your exercise regimen and you can return to full active status 2 months after surgery. This does not include abdominal crunch exercise, which can be resumed 6 months after surgery.

Sleep Position

You should only sleep on your back and not on your side, and avoid sleeping on the reconstructed breast flap(s) for at least 8 weeks.

Driving

You may start driving after you have stopped all your pain medication. It is best to wait at least 2 weeks after surgery, in order to feel confident when driving.

Work

You will be able to return back to a desk job, or light duty at 4 weeks after surgery. Be mindful that this should be gradual because you will feel tired more quickly and lack the normal reserve of energy.

Scars and Massage

After the incisions have completely healed, you can start applying pressure massage to the incisions to improve the appearance of the scars. Remember, that for the first 6 months, your scars will remain red, but with time they will turn lighter as they mature.

Smoking

ABSOLUTELY NO SMOKING for 6 weeks after surgery (this includes staying out of the room with smokers).

Emotional Support

The recovery period may be very difficult, when mood swings and emotions can be overwhelming. Contact our office for assistance in finding one of the many support groups available. We also have our own support group, the DREAMERS, which is comprised of patients who have undergone a similar breast reconstruction procedure. They are very helpful both before and after surgery for any patients who need extra support.

Mammograms

A routine mammogram does not need to be performed on the reconstructed breast. However, it can be performed if requested by your oncologist or other physician. You should still perform a self-breast exam on the reconstructed breast and keep note of any changes in the scar.