Final PPT Si

Post-Op Care of Breast
Surgery Patient
Marrium Hashmi
Intern
P.G.M.E
OBJECTIVES
1. How to care for the patient after breast surgery with and
without axillary clearance
2. Possible complications expected after breast surgery
3. Alerting signs and how to identify and manage them.
INTRODUCTION
• Most common cancer affecting females (< 1% in males)

• 1 in 8 females will develop breast cancer
• Commonly develops after age 50
• Probably combination of hormonal, genetic & environmental
factors
Breast Cancer Facts & Figures 2017-2018, American Cancer Society, Inc., Surveillance Research
TREATMENT OPTIONS
1. Surgical options
2. Other options in addition to surgical options.
TREATMENT OPTIONS
1. Surgical Options
• Without Axillary Dissection • With Axillary Dissection
1. Simple mastectomy 1. Radical mastestomy
2. Breast conserving Surgery 2. Modified radical mastectomy
1. Lumpectomy.
2. Quadrantectomy or segmental
mastectomy
3. Partial mastectomy/Wide local
excision
4. Skin sparing mastectomy
5. Nipple-areolar sparing
mastectomy
3. Breast reconstruction after surgery
TREATMENT OPTIONS
2. Options in addition to Surgery
1. Radiation.
2. Hormonal therapy.
3. Chemotherapy.
4. Targetted therapy.
Axillary lymph node dissection (ALND)
• Evaluation of the axilla provides information for treatment decisions in patients with invasive
breast cancer.
• ALND remains the standard initial approach for breast cancer patients who have :
• locally advanced breast cancer (T4a, b, c).
• Inflammatory breast cancer (T4d).
• Needle-biopsy-proven metastatic disease in axillary lymph nodes.
Seth P Harlow, MDDonald L Weaver, MD (2018), Management of the regional lymph nodes in breast cancer, In: Post TW (ed), UpToDate. UpToDate, Waltham.
https://www.uptodate.com/contents/management-of-the-regional-lymph-nodes-in-breast-cancer
Sentinel lymph node biopsy (SLNB)
• Standard initial approach for all other patients with early stage breast cancer who are clinically
node negative.
• Following SLNB, a completion ALND (cALND) is indicated when there are:
• Three or more positive lymph nodes found in patients with small (≤5 cm) tumors (T1 or T2),
• Any number of positive lymph nodes found in patients with large (>5 cm) tumors (T3) or
extranodal extension of tumor cells.
• Any number of positive lymph nodes found in those who will not undergo whole breast
irradiation.
Zahoor S, Haji A, Battoo A, Qurieshi M, Mir W, Shah M. Sentinel Lymph Node Biopsy in Breast Cancer: A Clinical Review and Update. J Breast Cancer. 2017;20(3):217-227.
POST-OP CARE
POST-OP CARE
1. Recovery room care

2. Diet
3. Medications
4. Mobilisation of patient
5. Wound care
6. Drain care
7. Excercise
8. Psychological Support
POST-OP CARE
1. Recovery Room Care
• The theatre team hand over the care of the patient to the recovery staff.
• Monitoring in recovery room:
• Vital parameters.
• Consciousness.
• pain.
• hydration status .
• Patient can be discharged from the recovery room when they fulfill the following criteria:
. Fully conscious.
• Respiration and oxygenation is satisfactory.
• Patient is normo thermic, not in pain nor nauseated.
• Cardiovascular parameters are stable.
• Oxygen, fluids and analgesics had been prescribed.
• There are no concerns related to the surgical procedures.
Bailey & Love's Short Practice of Surgery 26E. edited by Norman Williams, P Ronan O'Connell
POST-OP CARE
2. Diet
• Nutrition is important in recovering from the surgery.
• Eating a well balanced diet and increasing fluid intake help with the healing process.
• Once the patient is fully awake, start with clear liquids and progress to the normal diet if the patient
is not nauseated.
• CO-MORBIDS:
• If Patient is having Diabetes:
• -
• -
• If the patient is having Hypertension:
• -
• -
POST-OP CARE
3. Medications
Analgesics
• Analgesics are provided for the relief of pain in the early phase of recovery when the pain is severe.
• Once the pain decreases usually 2 to 3 days after surgery, analgesics may be used every 4 to 6 hours
as needed.
Anti-biotics
Antimicrobial prophylaxis is usually not warranted for clean breast procedure because the chances
of infection is usually very low (1.3 -2.9%).
• Antimicrobial prophylaxis is required if there are additional risk factor for infection are present
• Usually the choice of antibiotic is cefazolin for breast cancer procedure and clean procedure in
patients with other risk factor for infection.
Crawford CB, Clay JA, Seydel AS, Wernberg JA. Surgical Site Infections in Breast Surgery: The Use of Preoperative Antibiotics for Elective,
Nonreconstructive Procedures. Int J Breast Cancer. 2016;2016:1645192.
POST-OP CARE
4. Mobilization of Patient
• Early mobilization of the patient after surgery is encouraged to reduce the risk of DVT, urinary
retention, atelectasis, pressure sores and fecal infections.
• Support for the arm and shoulder during the first 24 post operative hours and avoidance of active
stretching or pulling until after the drains are removed are helpful.
POST-OP CARE
5. Wound Care
• The incision of the skin is closed with either:
• Dissolving sutures that doc not require removal; or
• Removable sutures or staples which will be removed in 10-14 days.
• The patient must be advised to wear a brassier for support in breast conservation surgeries.
• Wound should be inspected if there is any concern about the condition or the dressing needs
changing
• Inspection of the wound should be performed under sterile condition if the would looks inflamed a
wound swab may be need to be taken and sent for gram staining and culture.
• Infected wound and hematoma need treatment with antibiotic or even a wound washout.
Factors that delay wound healing:

• Patients who are malnourished, or have vitamin A & C deficiency.
• Steroids
• Diabetes
POST-OP CARE
6. Drain Care
• Most often used drain for breast surgeries is the Jackson-Pratt in breast wound and axilla.
.Drains aprevent seroma formation and to reduce the risk of infection.
• Volume for drain removal is ≤30 mL per day.
• Maximum drainage:in 24-48hours after surgery.
• Cleanse drain site with soap and water twice a day.
• After emptying the drain, record the dran output with date and time.
• Squeeze it as much as possible and close the plug.
• Empty the drain if it becomes half full or devac.
Uslukaya Ö, Türkoğlu A, Gümüş M, et al. Factors that Affect Drain Indwelling Time after Breast Cancer Surgery. J Breast Health. 2016;12(3):102-106.
Published 2016 Jul 1. doi:10.5152/tjbh.2016.3070
POST-OP CARE
6. Drain Care
POST-OP CARE
7. Exercise
• It is important to recommend the arm and shoulder exercises.
• The patient should be encouraged to use the arm for normal daily activities, within the limits of
pain, to prevent arm and shoulder stiffness.
• If the drain is in place, the shoulder and arm exercises must only be recommended to shoulder
height until the drains are removed.
POST-OP CARE
8. Psychological Support
• -
• -
• -
• -
POSSIBLE POST-OP COMPLICATIONS
1. Early complications
1. Local complications
2. Systemic complications
2. Delayed complications
1. Post-operative Edema.
1. Early Complications / Local
1. Seroma/Haematoma
2. Wound infection
3. Skin flap necrosis
4. Pain
5. Phantom Breast Syndrome
6. Arm Morbidity
7. Branchial Plexopathy
8. Mondor’s Disease
9. Nerve Injury
Seroma :
A collection of serous fluid under the skin flaps. It presents as enlarged, tender breast and overlying
skin may have ecchymosis or bruising . The incidence of hematoma is overall low (<2 percent).
Untreated seroma formation results in delayed wound healing, wound infection, wound dehiscence,
flap necrosis, delayed recovery, and poor cosmetic outcome.
Postoperative hematoma typically develops within the first 12 to 24 hours after surgery.
Treatment :
exploration of the breast
drainage of the hematoma and establishing hemostasis.
Any underlying coagulation abnormalities must be addressed and corrected.
Postoperative seroma formation in breast reconstruction with latissimus dorsi flaps: a retrospective study of 174 consecutive cases.Tomita K, Yano K, Masuoka
T, Matsuda K, Takada A, Hosokawa K Ann Plast Surg. 2007;59(2):149.
Wound Infection
The rates of postoperative wound infection after breast surgery are low (1.3-2.9%) because these are
clean procedures.
Risk Factors: Obesity, Smoking (4x), Older age, Diabetes mellitus
-Higher rate of infection caused by Gram-negative organisms.

-Occurs in the setting of procedure involving macerated, moist environment e.g. under the axilla of an
obese individual and in patients with diabetes.
-Wound infection in these cases can by the addition of flouroquinolones and gentamycin.
-A small number of postoperative infections will develop into an abscess requiring drainage by
reopening the original surgical incision.
Skin Flap Necrosis
• The rate of skin flap necrosis from modified radical mastectomy (MRM) or simple mastectomy is
estimated at 10 to 18 %.
• Full-thickness skin flap necrosis requires surgical debridement and may require skin grafting, and
result in delays in adjuvant treatment and diminished cosmetic outcome .
• RISK FACTORS: Prior radiation treatment, obesity, older age, smoking history
• Technical methods of decreasing the risk of skin flap necrosis include minimizing the use of electric
cautery method in dissection, maintaining appropriate skin flap thickness, and avoiding tension on
closure of the incision.
Salvage of tissue expander in the setting of mastectomy flap necrosis: a 13-year experience using timed excision with continued expansion.AUAntony AK, Mehrara
BM, McCarthy CM, ZhongT, Kropf N, Disa JJ, Pusic A, Cordeiro PG SOPlast Reconstr Surg. 2009 Aug;124(2):356-63.
Pain
• Burning, aching, and tight constriction of the axilla, upper arm, and chest wall with superimposed
lancinations and scar sensitivity are characteristic of postmastectomy pain.
• Risk Factors:
• Axillary dissection.
• breast reconstruction with implants after mastectomy.
• Submuscular implant placement can cause injury to the long thoracic, thoracodorsal, lateral-
pectoral, and medial-pectoral nerves. Capsule formation around the implant also may entrap the
long thoracic and the two pectoral nerves.
Chronic postoperative breast pain: danger zones for nerve injuries.AUDucic I, Seiboth LA, Iorio ML SOPlast Reconstr Surg. 2011;127(1):41.
Phantom Breast Syndrome
• A change in chest wall sensation after mastectomy.
• The sensation of residual breast tissue can persist for years after surgery.
• The most common complaint is pain, but itching, nipple sensation, erotic sensations, and
premenstrual-type breast soreness are also described.
• Patient education before mastectomy, outlining the possible changes in chest wall sensation and
the possibility of phantom breast syndrome, may help to relieve patient anxiety if symptoms
develop and may even reduce the frequency of this syndrome.
Phantom breast syndrome.Jamison K, Wellisch DK, Katz RL, Pasnau RO, Arch Surg. 1979;114(1):93.
Arm Morbidity
• Arm morbidity is common after mastectomy and can include arm swelling, arm pain, arm
numbness, arm stiffness, shoulder stiffness, shoulder pain, or nerve injury.
• Postmastectomy radiation also contributes to arm morbidity and shoulder dysfunction.
• After breast cancer surgery, patients should be provided with rehabilitation services as needed and
informed about methods to improve shoulder function and reduce the risk of lymphedema.
Persistence of restrictions in quality of life from the first to the third year after diagnosis in women with breast cancer.AUArndt V, Merx H, Stegmaier C, Ziegler H,
Brenner H SOJ Clin Oncol. 2005;23(22):4945.
Branchial Plexopathy
• Patients can develop brachial plexopathy from a stretch injury caused by malpositioning in the
operating room.
• This can be avoided by careful positioning and the use of padded arm boards.
Mondor’s Disease
• Mondor disease is an uncommon condition more commonly occurring after breast augmentation
but it has been reported following breast reconstruction.
• It presents as a firm or painful cord on the anterior abdominal wall leading up to the breast,
typically within the first month after surgery.
• It generally resolves over a short period of time with supportive care. Although the veins recanalize
in one to two months, warm compresses and no steroidal anti-inflammatory medications may be
offered for symptomatic relief.
Incidence of mondor disease in breast augmentation: a retrospective study of 2052 breasts using inframammary incision.Khan UD, Plast Reconstr Surg. 2008;122(2):88e.
Nerve Injury
• The risk of major motor nerve injury following an ALND is <1 percent.
• Injury to the long thoracic nerve results in a winged scapula.
• Injury to the thoracodorsal nerve weakens shoulder abduction and internal rotation.
• Injury to the medial pectoral nerve may lead to atrophy of the lateral aspect of the pectoralis major
muscle, which may impact the overall cosmetic result.
Chronic postoperative breast pain: danger zones for nerve injuries.Ducic I, Seiboth LA, Iorio ML, Plast Reconstr Surg. 2011;127(1):41.
1. Early Complications / Systemic
1. DVT
2. Pulmonary Embolism
1. DVT
• Clot formation in the deep veins of the body.
• Occurs most commonly in the leg; can occur anywhere such as the veins in the arm, abdomen, or
around the brain.
• Symptoms includes
• Pain,
• Swelling,
• Discoloration (bluish, purplish or reddish skin color); and
• Warmth
Thrombolysis for acute deep vein thrombosis, Watson L, Broderick C, Armon MP.Cochrane Database Syst Rev. 2016 Nov 10;11:CD002783. Review. PMID: 27830895
2. Pulmonary Embolism
• A potentially life-threatening complication of deep vein thrombosis (DVT)
• Occurs when a blood clot breaks off, travels through the blood stream and lodges in the lung.
• Symptoms of Pulmonary Embolism (PE):

• Shortness of breath
• Chest pain (which may be worse with deep breath)
• Unexplained cough (may cough up blood)
• Unexplained rapid heart rate
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2. Delayed Complications
1. Post-operative Lymph edema.
2. Delayed Complications
1. Post-operative Lymphedema:
It is a serious complication of axillary lymph node dissection.
Radiations in addition to ALND increases the risk of lymphedemato 80%.
H Sakorafas, George & Peros, George & Cataliotti, Luigi & Vlastos, George. (2006). Lymphedema Following Axillary Lymph Node Dissection for Breast
Cancer. Surgical oncology. 15. 153-65. 10.1016/j.suronc.2006.11.003.
ALERTING SIGNS, IDENTIFICATION AND
MANAGEMENT
1. Severe discomfort or pain.

2. Redness/Swelling.
3. Bruising.
4. Post-op fever.
5. Unusual puss or drainage (Wound/incision or drainage tube).
6. Extensive bleeding.
7. Difficulty breathing.
8. Persistent nausea and vomiting.
QUESTIONS?

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Post-Op Care of Breast

• Most common cancer affecting females (< 1% in males)

1. Recovery room care

Factors that delay wound healing:

Risk Factors: Obesity, Smoking (4x), Older age, Diabetes mellitus

-Higher rate of infection caused by Gram-negative organisms.

• Symptoms of Pulmonary Embolism (PE):

1. Severe discomfort or pain.

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