DIEP FLAP INSTRUCTIONS

Pre Operative Instructions

If you have any questions concerning these Pre Operative Instructions, CONTACT US via email with your questions or call the office 713-441-6102.

Two or More Weeks Before Surgery

Scan of abdomen (and possible chest): Schedule scan of your abdomen (and possibly chest) to assess your blood vessels that we plan to use during your surgery.

FMLA and Short-Term Disability Paperwork: Please submit your FMLA or Short Term Disability paperwork to the office as soon as possible, as it may take up to 2 weeks to be finalized.

Pre-register for surgery: You will need to pre-register for your surgery with the hospital by contacting registration at 713-394-6805.

Pre-operative appointment: Make an appointment with the Anesthesia Pre-operative Assessment Center 3 weeks prior to your surgery by calling 713-441-6504, option 3. This is when you will have your pre-operative blood work and other testing that needs be performed prior to your procedure.

Pre-operative Labs: 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.

Mammogram: You will need to have an updated mammogram within the last 6 months.

Medications: Do not take any aspirin containing medication 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 located in your packet 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 or Anastrazole, you need to stop taking this medication 3 weeks before surgery. It is ok to continue your Femara (Letrozole)

Smoking: Nicotine 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 or use nicotine patches/gum for at least 8 weeks before and 6 weeks after surgery. This also applies to second hand smoke – avoid any room or car with cigarette smoke

Iron: Iron supplementation with a vitamin C supplement should be started as soon as possible prior to surgery. 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 1 product better than another. Taking iron supplements with food decreases such symptoms although all are better absorbed on an empty stomach. 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 but causes less gastric distress (eg. Fergon)
• Ferrous Fumarate: similar to ferrous gluconate (eg. Ferro-Sequels), contains stool softener.

Exercise: You may continue your exercise routine. You do not need to gain weight prior to your procedure.

Social Support: Set up your home support system. You will need help when you return home for the first 5-7 days. You will need friends and family to help you with household chores and errands during your recovery period for the first 3-4 weeks.

Recliner Chair: Please purchase or rent automatic lift recliner prior to surgery, as you will use this for the first 4-6 weeks post-operatively. More information regarding recommended automatic recliner chair is in your surgical packet.

Post operative garments: Please purchase recommended post-op garments: Solidea Compression Band and Loving Comfort Binder. You will be provided with a surgical bra from the hospital.

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 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 and it can purchased at most drugstores or grocery stores.

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

Medications: Your current medication list will be reviewed with anesthesia at your pre-operative evaluation appointment. Anesthesia will discuss with you which medications you should take the night before or morning of surgery, and which medications should not be taken. If you have any questions regarding this, please contact our office.

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.

Day of Surgery

Arrival at Hospital: 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. Please report to the Walter Tower – 6551 Bertner Avenue, 1st floor Registration Desk. You will be given your arrival time a few days prior to your surgery date. If you are running late, please notify them by calling 346-238-7840.

Prescriptions: Your prescriptions will be called into the Scurlock Walgreens Pharmacy at the hospital on the morning of your surgery.

Shopping List

Items that are useful to have at home and throughout your recovery

• You will need to purchase or rent a recliner chair for your post operative recovery. You will need this chair for the first 4-6 weeks of your recovery to protect your abdominal incision. Dr. Spiegel recommends you rent an automatic recliner. Please reference your surgical packet for more information regarding the recliner chair
• Hydrogen Peroxide
• Q-tips
• 4×4 gauze
• Bacitracin or Neosporin antibiotic ointment
• Post-operative garments – Loving Comfort Binder and Solidea Band
• Comfortable zip up or button shirt
• Comfortable loose fitting pants

Hospital Packing List

Items to bring with you the day of your surgery

• ID and insurance card
• Comfortable zip up or button shirt
• Comfortable loose fitting pants
• Pillow
• Slippers
• Robe
• Music player with head phones
• Book to read / iPad
• Toiletries
• Glasses

Post Operative Instructions

If you have any questions concerning your recovery, CONTACT US via email with your questions or call the office 713-441-6102.

Medications

• Antibiotic – To be continued until all drains are removed, or as otherwise specified by our office
• Aspirin– 81 mg (1 baby aspirin) once daily for 2 weeks after surgery
• Celebrex – anti-inflammatory, can be taken twice daily as needed for pain
  Gabapentin – nerve medication, can be taken three times daily as needed for pain
• Pain Medication – To be taken as needed for pain, as soon as you feel comfortable you may start weaning off of the pain medication and using Tylenol for pain. Remember this medication might make you feel groggy and constipated and cannot be mixed with alcohol
• Colace – Stool softener to be taken as needed for constipation
• Flexeril – Muscle relaxant to be taken as needed for back discomfort or muscle spasm
• Iron– continue same dose as taken before the surgery
• Zinc– supplement 50 mg daily, recommend for wound healing
• Selenium – supplement 200 mcg daily, recommended for wound healing

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.

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 5-6 times per day. If the drain requires emptying more than once per day, enter the DAILY TOTAL in the appropriate space on the Drain Output Record. Once your drain output is less than 25 cc total, per drain in 24 hours, that drain will be removed in clinic. 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.

How to care for your drains:

• secure drain with one hand at the insertion site to prevent pulling on the skin
• strip the drain 6-7 times daily; using an alcohol pad, run fingers all the way down the tubing to remove any clots of tissue that may clog the drain
• when emptying the drain, kink tubing to ensure no fluid backflows up towards the insertion site, then tip drain bulb and squeeze gently to remove all fluid
• once drain has been emptied, squeeze bulb to remove air and then place plug, this will allow the bulb to create a suction to remove fluid from the surgical area
• empty the drain 2-3 times daily (depending on how full it is)
• record total per drain on the drain output record in cc (1 cc = 1 mL)
• continue antibiotics as directed while drains are in place

Abdominal Precautions

After a DIEP or SIEA flap, you essentially are recovering from both breast reconstruction and a tummy tuck. It is very important to take the tension off of the abdominal incision to allow for proper healing and decrease the a risk of developing an abdominal wound. You are required to walk flexed at the hips for approximately 3-4 weeks. The time you are required to walk flex maybe longer depending upon the tension on your abdominal incision and this will be checked during you post operative appointment.

Sleep Position

We strongly recommend that you have a recliner to sleep in for the first 4 weeks. This allows your abdominal incision to heal without pulling, and prevents you from rolling on your side while you sleep. After transitioning back into the bed, you might find it more comfortable to sleep with your head elevated and 2 pillows under the knees to decrease the tension in your abdominal area. You should only sleep on your back, and avoid sleeping on the reconstructed breast flap(s) for at least 8 weeks.

Incision Care

Your incisions will have all absorbable sutures that are hidden underneath your skin. Your incisions will be sealed with Dermabond, a special incisional fibrin glue, or steri-strips. While the Dermabond or steri-strips are in place, you do not need to apply anything to your incisions. Sometimes you might feel a small knot come up through your incision area. Do not worry, this can sometimes happen and will be removed during your clinic visit. We will remove your Dermabond at your 4 week post-op appointment, at which time we will have you start taping your incisions for the next 4 weeks. The tape keeps your scar flat as it is trying to heal. Once you have completed the taping, we have a few options for scar therapy:

Umbilicus

Your new umbilicus will have some sutures around it. There might be some drainage and moisture in that area. After your shower, use a cotton Q-tip dipped in hydrogen peroxide to clean the incision and inside of the umbilicus. After cleaning, dry the umbilicus with a Q-tip and apply dry gauze to keep this area clean and dry.

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 will 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 decreases post-operative pain and decreases swelling. 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.

Showering

You will be able to shower on the third postoperative day in the hospital. Baths and swimming may be resumed 8 weeks after surgery, as long as all incisions are completely healed and there is no scabbing present.

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 higher than 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 2-3 months after surgery. This does not include abdominal crunch exercise, which can be resumed 6 months after surgery.

Driving

You may start driving after you have stopped all your pain medication and one week after all drains are removed. It is best to wait at least 2-3 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

Scar Therapy

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.

Silagen

Silagen is a silicone sheet made with the highest quality medical grade silicone. It creates a protective barrier over the scar, which increases hydration and provides an optimal environment to normalized collagen production. This will help flatten and soften your scar, and reduces redness, discoloration, itching and discomfort. You will start using Silagen approximately 8 weeks after surgery as long as there are no open areas or scabbing. You can place it on your incision(s) and wear it for 6-24 hours. Silagen can be washed and reused for 4-6 weeks. You will begin to see results in as little as 2-3 weeks.

Neocutis BioCream

Neocutis BioCream is a cream that is a blend of human growth factors, interleukins and other cytokines to help reduce the appearance of your scars, improve skin texture and help replenish moisture to your skin. You can use BioCream in conjunction with Silagen. You would start using it approximately 8 weeks after surgery as long as there are no open areas or scabbing. The cream is massaged once to twice daily on the incision. You will start to notice results in as little as 2 weeks. For best results, you will continue using for at least 2 months.

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 Pink Sisters, 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 monthly self-breast exams on the reconstructed breast and keep note of any changes in the scar.

Physical Therapy

Some patients will be referred to Physical Therapy to assist in their post-operative recovery. There are multiple reasons as to why you may be referred to physical therapy, some of which include range of motion of your arm(s), lymphedema after removal of your lymph node(s), or post-operative swelling at your surgical site. Need for physical therapy would be evaluated during your appointment with Dr. Spiegel.

Week by Week Guide

1st Day After Surgery:

The first day after surgery is for resting and the main goal will be to work on deep breathing

• You will get out of bed to a recliner chair twice today
• Work on incentive spirometer, or targeted deep breathing
• You will have a foley catheter that will remain in place today
• You will be given IV fluids and antibiotics. You will also have a pain button for pain medication to be given to you through your IV
• Diet – regular diet with restriction of no coffee or caffeine
• Restrictions: You must walk flexed at the hips. Arm range of motion restricted to 45 degrees. No lifting/pushing/pulling with your arms

2nd Day After Surgery:

The nurses will start preparing you to take care of yourself at home

• Shower with the help of the nurses. You will shower with the water to your back. It is ok to shower with your drains.
• Walk in the hallways with assistance of the nurses
• Sit to recliner chair again
• Foley catheter will be removed and IV fluids will be decreased
• Transition to oral pain medication and antibiotics
• Restrictions: You must walk flexed at the hips. Arm range of motion restricted to 45 degrees. No lifting/pushing/pulling with your arms

3rd – 4th Day After Surgery:

The 3rd-4th day after surgery the nurses will be getting your ready for discharge home

• Increase walking in the hallways
• Shower with assistance
• The nurses will go over drain care instructions and teach you how to strip your drains
• Discharge from the hospital – you will be given prescriptions for all post op medications
• Restrictions: You must walk flexed at the hips. Arm range of motion restricted to 45 degrees. No lifting/pushing/pulling with your arms

1 Week Post Op Appointment:

• Bring drain log to appointment
• Possible removal of drain(s)
• Able to increase arm range of motion to 90 degrees
• Continue zinc and selenium
• Continue surgical bra
• Restrictions: You must walk flexed at the hips. No lifting/pushing/pulling with your arms. No household chores

2 Week Post Op Appointment

• Bring drain log to appointment
• Possible removal of drain(s)
• Able to extend arms above head (180 degrees)
• If abdominal drains removed, start wearing compression garments: Solidea band and Loving Comfort Binder
• Ok to start driving one week after final drains are removed, if completely off pain medication
• Restrictions: You must walk flexed at the hips. No lifting/pushing/pulling with your arms. No household chores

4 Week Post Op Appointment

• Remove dermabond and abdominal prenio
• Start taping incisions for the next 4 weeks
• Transition from surgical bra to supportive bra
• Continue compression garment
• Ok to start to transition from recliner to bed with pillows propping up both your back and your legs, if approved by the office (based on abdominal tension)
• Ok to no longer walk flexed, if approved by the office (based on abdominal tension)
• Return back to desk job or light duty
• Restrictions: No lifting/pushing/pulling greater than 5-7 lbs with your arms

6 Week Post Op Appointment

• No appointment necessary
• Ok to transition to sleeping flat in your bed, unless otherwise instructed
• Ok to slowly start resuming normal activities, unless otherwise instructed
• Ok to resume intimacy
• You may discontinue your compression garment, unless otherwise instructed

8 Week Post Op Appointment

• No appointment necessary
• Start scar therapy treatments
• Ok to submerge in water, as long as all incisions are completely healed and you do not have any scabbing present

3 Month Symmetry Appointment

• Symmetry consultation with Dr. Spiegel to discuss breast size and shape and any questions/concerns/preferences
• Timing of the second stage of reconstruction will be discussed. You must wait a minimum of 3-4 months from the time of your initial procedure before proceeding with your second procedure to allow your body adequate time to heal
• When thinking of timing of the second procedure, it is best to be at a stable weight, or have achieved your goal weight and maintained this weight for at least 2 months