Most women understand that their recovery after a breast reconstruction will not be immediate. But what does that really mean? Are we talking weeks? Months?
I spend a great deal of time NOT talking about the details of breast reconstruction operations with my patients. Whilst I am not talking about the operation, I am talking about what they should expect after the operation. Unfortunately, I think it is this period, after the operation ends, that really matters the most to patients. This it the period that patients truly experience, with all the difficulties, frustrations and challenges. This is the period that can shape a patient’s opinion of her surgery, and it can enormously influence how a patient feels about her reconstructed breast.
Dr Andrea Pusic is a Plastic Surgeon from The Memorial Sloan Kettering Centre in New York. She is the co-creator of the Breast-Q, perhaps the most widely used outcomes measure with regards to breast surgery and breast reconstruction. In a recent publication in the Journal of Plastic, Reconstructive & Aesthetic Surgery, she has attempted to describe, as objectively as possible, the true post-operative experience for patients.
So, what should women expect?
During discussions of breast reconstruction, women will often ask “when will I be back to normal / go back to work / be able to go on holiday / be able to play with my kids?”. Your surgeon will often be able to answer these questions to some extent based on their own anecdotal experiences, but, as Dr Pusic asserts, such knowledge is often limited by certain patient demographics, and types of procedures. Moreover, there are aspects of recovery such as pain, fatigue, and physical distress that are only able to be appreciated by the patient themselves.
So, if we look at what this study has found, there may be some surprises for anyone who has heard the usual dogma of breast reconstruction.
1. Pain was similar across all reconstructions (flaps, expanders and definitive implants) at 1 week. At 3 months, patients who had had a tissue expander placed reported the most pain.
2. The study considered also “upper body well-being” as a separate component of recovery. Here, there were some interesting findings. Patients undergoing abdominally based reconstructions (DIEP and TRAM flaps) reported LESS upper body discomfort than patients who had undergone implant or expander reconstruction, and this finding extended out to the 3 month period.
3. Fatigue had not abated by 3 months, regardless of the type of reconstruction. This is one of the aspects of recovery that is frequently overlooked, yet in terms of addressing the questions above, this may be one of the most important. Patients are often able to overcome discomfort, but unremitting fatigue is a more limiting factor in return to work and normal activity.
These are very important finding with regards what I discuss with my patients who are considering their options for reconstruction. Surgeons persist in telling patients that an implant or expander reconstruction will offer a quicker recovery, and less impediment to returning to work or normal day-to-day activity. Yet it would seem that what has been accepted for so long has yet again been shown to be not quite true.
So, what do I tell my patients?
I tell them that irrespective of their reconstruction, it is normal to experience tiredness, fatigue, low mood and even sadness for several months after their operation. This is, it seems, common across different surgical specialties, and it relates to the intense physiological stress of major surgery. I recall during my early training when I was working in a cardiothoracic surgical unit in Brisbane, being told by the surgeon I worked for that it was vital that we inform our patients that such a phenomenon occurs after open heart surgery. I took that lesson away with me and subsequently my own anecdotal experience in Plastic Surgery has confirmed that this is also true for our patients who undergo major reconstruction. It is gratifying to see that we now have evidence to support what I have been telling my patients over the last few years.
“…it is normal to experience tiredness, fatigue, low mood and even sadness for several months…”
What I haven’t told my patients, but I now will, is that the chest discomfort that should be expected after implant or expander reconstruction may well be worse than after autologous flap reconstruction of the breast. And I think it is time we put to bed the persistent claim that implant reconstruction offers a more rapid recovery than flap reconstruction.
Of course, there are gaps in this study. The greatest is the fact that Dr Pusic has only accounted for “upper body” symptoms. The problem with this is that any woman who undergoes a DIEP flap or TRAM flap reconstruction, will also have an abdominal wound, which I tend to counsel my patients will be the greatest source of discomfort post-operatively. The significance of this, with regards pain, is the phenomenon of distraction. A patient with a wound and pain which is significant (such as the abdomen), may be less aware of pain elsewhere (in this case, in the chest). So it would be disingenuous to suggest that overall, the pain of implant based reconstruction is greater than free-flap reconstruction – this is yet to be resolved.
Yet again, this brings us back to the fact that every patient has a range of issues to consider when choosing the right form of breast reconstruction. It is a distinctly individual choice based on individual factors.
Quick Facts:
- Pain is a common feature of all surgery, and it is a common feature of all forms of breast reconstruction. However, upper body discomfort may be greater for women who undergo implant-based reconstruction.
- It is normal to expect ongoing tiredness and fatigue for more than 3 months after your surgery.
- These factors alone should not be the major factors in choosing your reconstruction, however awareness of what to expect post-operatively is vital for patients to make an informed choice.
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