Chest Wall Perforator Flap (Partial Reconstruction)

Chest Wall Perforator Flap (Partial Reconstruction)

General Surgery

Name of procedure: Chest wall perforator flap. This can include Lateral Intercostal Artery Perforator Flap (LICAP); Thoracodorsal Artery Perforator Flap (TDAP); Anterior Intercostal Artery Perforator Flap (AICAP) and others. It has been recommended that you have a wide local excision (lumpectomy), which is removal of the affected part of your breast together with a clear margin all around, as the surgical treatment for your breast cancer or Ductal Carcinoma In-situ (DCIS). The operation involves making an incision in the skin of your breast. The breast cancer is then cut away with a margin of normal tissue around it.

What is a chest wall perforator flap procedure for partial breast reconstruction?
This is a procedure where the soft tissue from the side of the chest is used as a flap to fill the cavity remaining after a wide local excision for tumours which are usually located in the outer or lower parts of the breast. The aim of the procedure is to replace the tissue lost during the wide local excision and to restore the size and shape of the breast. The procedure is suitable for those who have small to moderate sized breasts, and where a suitable amount of soft tissue is available below the armpit or on the upper abdominal wall. After examination, your doctor will be able to tell whether you are suitable for this procedure. This procedure may be done along with the operation to remove your breast lump or as a second procedure.

This leaflet explains some of the benefits, risks and alternatives to the operation. We want you to have an informed choice so you can make the right decision. We recommend that you read this leaflet carefully. You and your doctor will also need to record that you agree to have the procedure by signing a consent form, which your health professional will give you. Please ask your surgical team about anything you do not fully understand or want to be explained in more detail.

Benefits of the procedure
The aim of your surgery is to remove the diseased part of the breast. If you have been told that you have cancer, surgery gives the best chance of cure, although treatment may need to be combined with other therapies such as chemotherapy, radiotherapy, antibody or endocrine (tablet) therapy. When a patient needs to have more than 20% of their breast removed, as part of a wide local excision, reconstructive surgery of this sort aims to restore the size and shape of the breast.

Serious or frequent risks
Everything we do in life has risks. There are some risks associated with this type of surgery.

What are the risks of a chest wall perforator flap procedure?
The main thing to understand about this procedure is that it involves additional surgery for aesthetic benefit (to improve the appearance of the breast that can be negatively impacted by the surgery for the cancer). It will require a longer or additional scar and movement of an area of healthy tissue outside the breast so that it comes to lie within the breast skin.

The main risks of this procedure are:

• A longer scar – sometimes extending beyond the breast onto the chest wall.
• Damage to the blood supply to the flap. This can result in hardening of the breast where the flap is placed. There is a small risk of ‘flap’ failure, where blood supply is completely damaged. This will require further surgery.

The general risks of surgery include problems with:

• the wound (for example, infection); and
• blood clots (for example, in the legs or occasionally in the lung).

Those specifically related to breast surgery include problems with:

• Swelling, usually settles over a few months.
• Seroma, this is a collection of fluid under the wound that may develop post-operatively. A seroma may need to be drained using a needle and a syringe. This is a very simple procedure that can be done by a member of the breast team in the Outpatients Department.
• Occasionally after an operation a haematoma (collection of blood) may develop. This may require an operation to remove it and stop any bleeding vessels.
• Minor skin burn. Due to heat conduction used to stop bleeding during surgery.
• The appearance and shape of your breast will be altered, depending on the volume of tissue that needs to be removed and your original breast size.
• It is not uncommon to have altered sensation in the skin of your breast after surgical treatment. This is sometimes a nuisance but is not harmful and usually improves with time.
• There is a chance that you will require further surgery if the margin of normal tissue around the cancer or DCIS is not adequate when looked at in the laboratory under a microscope. This will be discussed with you at your follow up clinic visit.

Most people will not experience any serious complications from their surgery. The risks increase for elderly people, those who are overweight and people who already have heart, lung or other medical conditions such as diabetes or kidney failure. As with all surgery, there is a risk that you may die.

You will be cared for by a skilled team of doctors, nurses and other healthcare workers who are involved in this type of surgery every day. If problems arise, we will be able to assess them and deal with them appropriately.

Other procedures that are available
Other forms of treatment may be used in the treatment of your cancer such as radiation therapy (using high-dose x-rays to kill cancer cells), chemotherapy (using drugs to kill cancer cells), antibody therapy (to stimulate your immune system to attack cells) and endocrine therapy (using tablets to stop the cells from growing). However, the present recommendation by the breast team health professionals is that in your case surgery is the best form of treatment at this stage.

Your pre-operative assessment
Before you are admitted for your operation, you may be required to attend for a pre-operative assessment, to ensure that you are fit for surgery. It is important that you attend for this appointment to avoid delaying your surgery.

Not all patients require a detailed pre-operative assessment and a health questionnaire is used to determine which patients require a full assessment. The health questionnaire may be on paper or on a tablet/computer. The information required includes all medical conditions, regular medications, allergies to medications and your previous anaesthetic history. The information you give will be reviewed by the pre-operative assessment team. If you require further assessment you will be given an appointment to attend the pre-operative assessment clinic.

At the clinic, the nursing staff will confirm the medical information you have previously given. Further tests may be required, such as a blood test, X-ray, heart or lung test. If a more detailed assessment or discussion is required you may see an anaesthetist prior to your admission for surgery. This may require an additional appointment. If you are taking prescribed medicines please bring a copy of your repeat prescription to your appointment and a copy of the operation consent form (if you were provided with a copy at your out-patient appointment).

Following your assessment, the staff will provide you with written information regarding preparation for your surgery and a point of contact. It is important that you follow the fasting instructions given on your admission letter.

Being admitted to the ward
You will usually be admitted on the day of your surgery. We will welcome you to the ward and check your details. We will fasten an armband containing your hospital information to your wrist.

To reduce your risk of blood clots in your legs after surgery, we will usually ask you to wear support stockings before and after your surgery and we will usually give you heparin injections after your surgery. We will usually ask you to continue with your normal medication during your stay in hospital, so please bring it with you.

Your anaesthetic
We will usually carry out your surgery under general anaesthesia. This means that you will be asleep during your operation and you will feel nothing.

Before you come into hospital
There are some things you can do to prepare yourself for your operation and reduce the chance of difficulties with the anaesthetic.

• If you smoke, consider giving up for several weeks before the operation. Smoking reduces the amount of oxygen in your blood and increases the risks of breathing problems during and after an operation. Using a vaporiser instead of smoking may help the lung and breathing issues but does not significantly reduce the risk of post-operative wound problems.
• If you are overweight, many of the risks of anaesthesia are increased. Reducing your weight will help.
• If you have loose or broken teeth or crowns that are not secure, you may want to visit your dentist for treatment. The anaesthetist will usually want to put a tube in your throat to help you breathe. If your teeth are not secure, they may be damaged.
• If you become unwell or develop a cough or cold the week before your surgery please contact the pre-operative assessment team on the number provided. Depending on your illness and how urgent your surgery is, we may need to delay your operation as it may be better for you to recover from this illness before your surgery.

Your pre-surgery visit by the anaesthetist

• After your admission to hospital, the anaesthetist will come to see you and ask you questions about:
  • your general health and fitness;
  • any serious illnesses you have had;
  • any problems with previous anaesthetics;
  • medicines you are taking;
  • allergies you have;
  • chest pain;
  • shortness of breath;
  • heartburn;
  • problems with moving your neck or opening your mouth; and
  • any loose teeth, caps, crowns or bridges.
• Your anaesthetist will discuss with you the different methods of anaesthesia they can use. After talking about the benefits, risks and your preferences, you can then decide together what is best for you.

On the day of your operation

Nothing to eat and drink (nil by mouth)
It is important that you follow the instructions we give you about eating and drinking. We will ask you not to eat or drink anything for six hours before your operation. This is because any food or liquid in your stomach could come up into the back of your throat and go into your lungs while you are being anaesthetised. You may take a few sips of plain water up to two hours before your operation so you can take any medication tablets. Please refrain from chewing gum.

Your normal medicines
Continue to take your normal medicines up to and including the day of your surgery. If we do not want you to take your normal medication, your surgeon or anaesthetist will explain what you should do. It is important to let us know if you are taking anticoagulant (blood thinning) drugs.

Your anaesthetic
When it is time for your operation, a member of staff will take you from the ward to the operating theatre. They will take you into the anaesthetic room and the anaesthetist will get you ready for your anaesthetic.
To monitor you during your operation, your anaesthetist will attach you to a machine to watch your heart, your blood pressure and the oxygen level in your blood.

Pain relief after surgery
Pain relief is important to aid your recovery from surgery. This may be in the form of tablets, suppositories or injections. Once you are comfortable and have recovered safely from your anaesthetic, we will take you back to the ward. The ward staff will continue to monitor you and assess your pain relief. It is important that you report any pain you have as soon as you experience it.

What are the risks?
The risk to you as an individual will depend on whether you have any other illness, personal factors, such as smoking or being overweight and surgery that is complicated or prolonged.
General anaesthesia is safer than it has ever been. If you are normally fit and well, your risk of dying from any cause while under anaesthetic is less than one in 250,000. The side effects of having a general anaesthetic include drowsiness, nausea (feeling sick), muscle pain, sore throat and headache. There is also a small risk of dental damage Your anaesthetist will discuss the risks with you and will be happy to answer any questions you may have.

After your surgery

• You will be taken to the recovery room to the general or day care ward. You will need to rest until the effects of the anaesthetic have worn off. You will have a drip in your arm to keep you well-hydrated.
• You will be encouraged to get out of bed and move around as soon as possible, as this helps prevent chest infections and blood clots.
• Your surgical team will assess your progress and answer any questions you have about the operation.

Leaving hospital

Length of stay
How long you will be in hospital varies from patient to patient and depends on how quickly you recover from the operation and the anaesthetic. Most patients having this type of breast surgery will be able to go home the same day or the following morning.

Medication when you leave hospital
Before you leave hospital, the pharmacy will give you any extra medication that you need to take when you are at home.

Recovery
How long it takes for you to fully recover from your surgery varies from person to person. It may take up to 3 to 4 weeks. You should consider who is going to look after you during the early part of this time. You may have family or close friends nearby who are able to support you or care for you in your home during the early part of your recovery period or you may consider going to stay with relatives.

Stitches
Your wound will be closed with dissolvable stitches, surgical glue and/or steristrips (paper stitches). Please keep your wound dry for the first 48 hours.

Personal hygiene
After 48 hours you may bathe and shower as normal, but try not to soak the dressing.

Exercise
Please read the exercise sheet in your Information Folder. These exercises can be started on the second day following your operation and will help to keep your shoulders supple. Try to go for a daily walk.

Sex
You can continue sexual activity as soon as you feel comfortable.

Driving
You should not drive until you feel confident that you could perform an emergency stop without discomfort. It is your responsibility to check with your insurance company regarding your insurance cover after an operation. You do not need to notify the DVLA of surgical recovery unless it is likely to affect driving and persist for more than 3 months.

Work
How long you will need to be away from work varies depending on:

• how quickly you recover
• how your wounds heal
• whether you need further surgery or other treatments
• whether or not your work is physical

You can usually begin gentle work within a week or two, but you might need to wait a little longer before resuming more vigorous activity. If you need a medical sick (FIT) note for work for the first two weeks after your surgery, please ask the nurses on the ward prior to being discharged.

Emotional support
It is not uncommon to feel a bit ‘down’ after any operation so do ask your doctor or breast care nurse if you feel you need more psychological support. Some find treatment for cancer a frightening experience so please tell your nurse or doctor about any concerns that you have.

Outpatient appointment
Before you are discharged we will either give you a follow-up appointment to come to the outpatient department or we will send it to you in the post.

Contact details
If you have any specific concerns that you feel have not been answered and need explaining, please contact the following.
Worcestershire Breast Unit
Telephone – 01905 760261
Email – wah-tr.breastcarenursingteam@nhs.net

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you.

Feedback
Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.
Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.
If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: wah-tr.PALS@nhs.net

Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.

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