Breast Surgery Before and After Care

Before you undergo breast surgery, Dr. Pautler will ask you to do the following:

• Have a mammogram: If you are 35 or older, Dr. Pautler will send you for a mammogram. A mammogram is a special way to take a digital image of your breasts. Having a mammogram is purely a precaution to make sure that there are no suspicious areas in your breast. If there is a positive finding on the mammogram, Dr. Pautler will consult with you and refer you to a general surgeon before proceeding with breast surgery. If you have a very strong family history of breast cancer, Dr. Pautler may send you for a mammogram even if you are younger than 30.
• Stop smoking: Cigarettes contain nicotine, a powerful substance that decreases blood circulation, especially in the areas that need it most: your plastic surgery wounds. Smoking after your breast surgery, your plastic surgery wounds heal slowly, infection risk increases, and recovery from surgery may be prolonged. You need to stop smoking at least six weeks before and four weeks after your planned breast surgery. Nicotine-containing chewing gums and patches are as harmful as cigarettes, so do not use them. If you absolutely cannot curb your smoking, Dr. Pautler asks that you be honest about it and let her know, because she may need to alter her surgical plan for you.
• Take vitamin C: This vitamin helps boost plastic surgery wound healing. It is available over-the-counter and is helpful to take two weeks before and two weeks after breast surgery.
• Stop taking aspirin, ibuprofen or other non-steroid, anti-inflammatory medications including herbals and supplements that cause blood-thinning, such as Ginko Biloba: These types of medications and supplements can increase your risk of a bleeding complication during and after breast surgery, so avoid them. Aleve, Advil, Motrin, Naprosyn, Bufferin, Anacin, Toradol, Alka Seltzer and similar products are examples of products to avoid before and after breast surgery. Inform Dr. Pautler of all medications and supplements that you take to see what you need to avoid. Tylenol is permitted, as are the pain medications that Dr. Pautler prescribes after breast surgery. Examples of blood-thinning medications include Plavix, Lovenox, or Coumadine and their generic alternatives. Inform Dr. Pautler if you are taking this type of medication, as these will need to be stopped as well for breast surgery.
• Discontinue birth control pills three weeks before breast surgery if you are a current smoker or if you have a history of blood clots, high blood pressure, or heart disease. Resume the birth control pills three days after breast surgery.
• Bring button-down top to wear home from surgery: Pullovers are cumbersome and can cause discomfort or damage at your plastic surgery wound sites as you raise your arms to get the top on and off. Wear button-down tops during your recovery from breast surgery, because they will be easier to put on and take off without risking injury.

After Your Breast Surgery

After your breast surgery, there are several items to do and consider for your own health and plastic surgery wound healing. They are:

• Refraining from taking aspirin, ibuprofen, other non-steroid anti-inflammatory medications, blood thinners and other herbals and supplements for at least two weeks after your breast surgery.
• Diet: No restrictions. You can eat what you like provided you don’t have an upset stomach from the anesthesia you received during your breast surgery.
• Stop smoking: NO SMOKING FOR AT LEAST 6 WEEKS AFTER BREAST SURGERY! Dr. Pautler strongly advises that you stop smoking altogether for your overall health as well.
• Scar maintenance: You should massage your plastic surgery scars a few times a day with a product such as vitamin E oil, cocoa butter or Mederma, applying pressure while massaging the scars. The pressure during the massage is more important than the type of cream product used. Combined with massage, these emollients can help accelerate softening, fading and maturation of scars from breast surgery. Silicone preparations are also available, but costly, and more suitable for patients that have a known tendency to form poor scars. Every individual is unique. Some women heal quickly and some heal slowly. In general, skin type determines the quality of the scar. Even with the most meticulous technique, some individuals heal poorly, while others heal beautifully. Age can also play a factor in healing time after breast surgery. The older you are, the less red and tender your scars may appear, while younger women may have pink or reddish scars that will be tender for several months and may take up to a year to fade. For certain breast surgeries, the scars involved are fortunately very small.
• Limit activity: Refrain from any exercise or strenuous activity for the first two to three weeks after breast surgery, including housecleaning, vacuuming, anything requiring arm movement, and brisk walking. After about 10 days from your breast surgery, it is permissible to go out or run errands, but do not carry any heavy bags. Limit your lifting to no greater than 12 pounds. Do not lift or carry small children. Instead, have someone else put them on your lap and you can hold them. Two weeks after your breast surgery, Dr. Pautler will remove your sutures, assess your level of plastic surgery wound healing and determine whether or not you can increase your activity level. Typically six weeks after breast surgery, restrictions are lifted and exercise can be resumed. For less-extensive breast surgeries, lifting restrictions should occur before six weeks.
• Bathing: After being discharged from the hospital, it is permissible to shower two to three days after your breast surgery. If Dr. Pautler has placed a support during surgery, it is only permissible to shower after she has removed it. NO BATHS OR SWIMMING until your wounds are healed and it is approved with Dr. Pautler.
• Obtain compressive sports bras: If you go home from breast surgery in a support bra, you should wear it day and night for the first two weeks. If you have a compressive type of sports bra that fastens in the front and is seamless, you can switch to it after the first two weeks. Bring this bra to your two-week check-up after breast surgery so that Dr. Pautler can verify that its support is adequate. Afterwards, you will need to wear a compressive bra up to six weeks for the daytime and for long trips where you will do an extensive amount of walking. After exercise is permitted, the compressive bra must be worn for it. If your breast surgery is minimal, compressive bras are not necessary for as long a time. Going without a bra is strongly discouraged. The amount of time you do not wear a bra should be very brief, especially for extensive breast surgeries. In some cases, especially if you have a large cup size, you should even wear a light compressive bra while you sleep.

Risks with Breast Surgery

The following is a description of the possible complications that could occur following breast surgery:

• Scars on the breasts: These may be quite pink initially. With time, massage and use of emollients, they should improve and fade considerably. See Scar maintenance in the After Breast Surgery directions.
• Bottoming out of the breasts: If this breast surgery complication occurs, it does so months after the breast surgery, and the nipple and areola may appear higher on the breast mound. This breast surgery complication can happen in individuals who have very stretchy skin or heavy breast tissue. If necessary, the breast appearance can be corrected by removing a wedge of skin under the breast through plastic surgery techniques.
• Shape change of the breasts: The breasts will be quite snug after breast surgery and need to be supported to maintain shape. However, gravity cannot be eliminated, and despite best efforts to compress with bras and tape, the skin may stretch with time. Usually a flatter upper portion of the breast appears. For breast surgery patients who have very stretchy skin, Dr. Pautler may perform the breast surgery in such a manner to account for eventual shape change of the breasts. Consequently, the breasts may initially have an unusually full upper portion after breast surgery. By anticipating the settling and stretching of skin during breast surgery, the fullness dissipates.
• Hematoma or seroma within the breasts: Rarely does a collection of blood or body fluid become large enough to necessitate aspiration or removal with plastic surgery. If so, it needs to be done to prevent infection or plastic surgery wound healing problems. Small collections of blood or body fluid are normal but must be watched carefully until they absorb on their own.
• Numbness of the breasts: There will be some numb areas on your breast, including the nipple. Most of these numb areas on the breast regain sensation over a few weeks. Numbness may be permanent, but sensation can return in most breast areas even up to two to three years after breast surgery. As sensation returns, it is not unusual to experience shooting pains, or “pins and needles.”
• Dog-ears: Little cones of excess skin can form at the end of certain scars. These cones usually show up after the settling and healing of the breasts is concluded. If bothersome to the patient, they can be removed in the office.
• Volume change: Weight loss or gain or the use of oral contraceptives can alter your breast size after breast surgery. Also, it is possible to have re-growth of breast tissue, which can occur with hormone changes. In the case of this unlikely complication, it may necessitate further plastic surgery.
• Fat necrosis of the breasts: In some breast surgery cases, fat in the breast may scar internally and form a lump. Typically, these lumps soften in time, but in rare instances, they can persist. Dr. Pautler can remove the lump through a plastic surgery technique using the same incision as the breast surgery. The lumps are then sent off and analyzed by a pathologist to make sure that all they are is fat.
• Changes on mammogram: With some breast surgeries, the breast tissue may get rearranged internally, causing scar tissue to appear on a mammogram that was not there before the breast surgery. When you go for your first mammogram after your breast surgery (usually 6 to 12 months after breast surgery) tell your radiologist about the surgery. This new mammogram will now serve as your new baseline for comparison against all subsequent mammograms.
• Infection: Highly unusual, but possible. An infection from your breast surgery requires treatment with oral, or possibly intravenous, antibiotics. Mild infections will resolve quickly. A more serious infection may require removal of the breast implant and delay replacement of the breast implant for six to eight weeks. Warning signs of a possible infection are warmth, redness of the breast, more pain on one side than the other and non-healing of the incision made during breast surgery. If you are contemplating any dental work before or after your breast surgery, please discuss with Dr. Pautler, as this could possibly increase your risk for infection from breast surgery.
• Delayed plastic surgery wound healing: In some cases, plastic surgery healing from breast surgery takes longer than two weeks and usually involves the upside-down “T” part of the breast surgery scar under the breast. This complication can occur in the shape of a small triangle under the breast, causing some separation of the incision. The area can seep and even bleed a small amount. This complication is very common and should not affect the overall result of breast appearance. This complication simply requires dressings and ointment applied for a few weeks. If the area of delayed plastic surgery wound healing is very large, Dr. Pautler may perform a breast surgery scar revision anywhere from 6 to 12 months after plastic surgery healing.
• Asymmetry: Some asymmetries may appear in your breast and abdominal plastic surgery scars after breast surgery, since parts of your plastic surgery scars may heal at different rates. Most of these plastic surgery asymmetries in the plastic surgery scars are cosmetically insignificant, but in rare cases, a plastic surgery scar revision is considered. Regarding the breasts themselves, some asymmetries may appear as the breasts settle. With time, evening out of the breasts can occur. If not, a touch-up or additional plastic surgery may be necessary if the asymmetry does not correct itself.
• Tissue loss: Rarely, due to some compromise of circulation to the breast tissue or abdominal skin and fat (such as smoking, diabetes, steroid use, or excessive tension and infection), there can be some tissue loss from breast surgery. This breast surgery complication can occur at the abdomen, but more commonly at the breast surgery area. Some of the dead skin or tissue may need to be removed in the office and with plastic surgery wound care, healing should proceed quickly. This breast surgery complication may require additional plastic surgery wound healing time. The shape and appearance of the breast or abdomen are usually not affected, but the breast surgery scars in the breast or abdomen may be a little wider or pinker and may necessitate plastic surgery scar revision in the future. Rarely could this breast surgery complication involve the nipple or areola. In the worst-case scenario, should a nipple be lost (VERY rare), a nipple reconstruction can be done.
• Breast size unpredictability: During breast surgery, Dr. Pautler will try her best to get you the breast size that you desire, but it is always possible to be either a slightly larger or smaller breast size than anticipated. Pre-operative communication and looking at pictures before the breast surgery are the best ways to avoid disappointment with breast size.

Risks with Breast Implant Surgeries

Plastic surgery involving a silicone or saline breast implant is inherently safe; however, some risks are involved. The following lists some of the potential complications from breast implant surgery and describes how Dr. Pautler solves any problem that could arise from breast implant surgery.

• Breast implant rupture: Although rare, a breast implant can develop a leak or rupture. With silicone breast implants, it is possible to diagnose a rupture with an MRI or ultrasound. The FDA recommends frequent MRI monitoring yearly, starting three years after receiving your breast implants. With saline breast implants, it is obvious that a breast implant has ruptured. In either case, further breast augmentation surgery to replace the breast implant is required.
• Breast implant palpability (ability to feel the breast implant): It is normal to feel the breast implant at the bottom of the breast, and all patients experience this sensation to some degree.
• Wrinkling or ripples appearing on the breasts: The breast implants can be visible with patients who are extremely thin, even if the implant is placed under the muscle. Typically, you can only see the breast implant in certain positions. Although not visible in clothing, breast implant rippling or wrinkling can be bothersome. Possible solutions include placing additional fluid in the breast implant (rendering it a little harder in feel), replacing the breast implant to a different shape or type of breast implant, or breast implant removal. This risk tends to occur in extremely thin women who desire dramatic breast augmentation.
• Breast implant distortion: When the breast implant is placed under the pectoral muscle, flexion of this muscle can temporarily change the shape or flatten a breast implant, but it resumes its normal breast shape when the muscle relaxes. This is a normal condition of breast implant placement underneath the pectoral muscle and is not harmful.
• Breast implant displacement: A more common risk with shaped breast implants, but can also occur with round breast implants. This breast surgery complication refers to dislocation of the breast implant from a variety of factors, including trauma, lifting arms over the head too early after breast surgery, or breast implant pocket stretching from a seroma or hematoma, described previously. If the breast implant displacement appears unappealing or causes a very obvious asymmetry, additional plastic surgery may be needed to reposition the breast implant.
• Breasts feel slightly harder, uncomfortable, or are sitting slightly higher; it may be a capsular contracture: This is the rare case of a tightening of the natural capsule that your body forms around the breast implant. The capsule may need to be loosened or removed to provide a more-pliable pocket where the breast implant can be positioned. The capsule where the breast implant was placed can shrink or contract and become thicker and tougher, causing the breast implant to feel firmer. This can happen soon after breast augmentation surgery or years later, in one or both breasts. What causes this breast augmentation complication to occur is unclear, but some sources believe that a very low-grade infection or blood around the breast implant could contribute. This breast augmentation complication is not a health risk, and minor cases usually do not need further treatment, but if severe, a procedure called a capsulectomy may need to be done. This plastic surgery procedure removes the capsule to loosen the space where the implant sits, so the breast implant feels soft again. The risk of capsular contracture from breast surgery cannot be eliminated, but Dr. Pautler minimizes the risk during breast surgery and with early massage of the breast implant.
• Loss of cleavage: Extremely rare, this breast augmentation complication occurs when the breast implant pockets come in contact and the skin and muscle on the breastbone is lifted. This breast augmentation complication is correctable with a plastic surgery procedure, but it may necessitate temporary removal of breast implants or placement of post-operatively adjustable breast implants to allow the breast tissues to re-adhere to the breastbone. The risk is slightly higher for this breast augmentation complication in two situations: when large breast implants are placed on a relatively small chest or when breast implants in the breast tissue are removed and replaced under the muscle during the same breast augmentation procedure.
• Mammograms with breast implants: You can still receive mammograms with breast implants, but additional views will need to be taken. When breast implants are placed in the breast tissue itself, some tissue is obscured. With implants under the muscle, more tissue can be imaged, but there is always a chance that some tissue will not be visualized on the mammogram, so continued self breast exams are important. The presence of breast implants does not affect breast cancer risks.
• Breastfeeding with breast implants: Many women are able to breastfeed successfully after a breast surgery with breast implants; however, there is always a chance that it may not be possible.
• Asymmetry of the breasts: Very few women have perfectly symmetrical breasts, especially in regards to nipple placement. Asymmetries of the breasts can be more obvious after a breast augmentation surgery. Rarely, an asymmetry with respect to pocket placement of the breast implants can occur, where one breast implant sits a little higher or lower than the other. This breast augmentation complication may not be apparent during breast augmentation surgery, but it may become a problem during recovery as healing proceeds. Minor cases of this breast augmentation complication can be corrected with massage or a special band worn above the higher breast. A secondary plastic surgery procedure may be required to correct the problem.

Notes Regarding Breast Reduction Surgery

The following notes detail various issues relating to breast reduction surgery:

• Breast cancer: Studies show that a breast reduction can reduce cancer risk by 40% but it cannot eliminate the risk. It has been documented in the literature that on RARE occasions, a cancer has been detected in the breast during breast reduction surgery. A mammogram is obtained prior to the breast reduction surgery to see if there are any breast areas that should be studied prior to breast reduction surgery, but an occasional lump can be missed. Should this unusual circumstance arise during breast reduction surgery, it is possible that breast conservation surgery may not be possible and that eventually a mastectomy may need to be performed
• Breastfeeding after breast reduction surgery: Many women are able to nurse successfully after breast reduction surgery; however, it cannot be guaranteed. If breastfeeding is something you absolutely wish to do, you may want to consider holding off on the breast reduction surgery until finished with childbearing.