Q: I had a Mastectomy in July 2000. Prior to surgery I told my surgeon that I was not interested in reconstructive surgery in the future, but he did not listen to me and followed his own routine, leaving me with a large "dog ear" which is causing me great physical and psychological distress. Six months ago, I developed lymphedema and with daily CDT, am keeping it well under control. I would really like the "dog ear" to be surgically removed, but am concerned about worsening the existing LE, or possible swelling in my chest. What would you advise?
A: First, for those of you who do not know what a "dog ear" is, this is a flap of tissue which is left on purpose by the breast surgeon when s/he closes the incision after the mastectomy. Many women decide to undergo reconstructive surgery after finishing their post-cancer therapy and this extra tissue is useful in the design & sculpting of a new breast. It avoids transplanting tissue from the abdomen (Tram flap) or latissimus dorsi muscle (from the flank), which requires additional complex surgery. Indeed, the down side with your already compromised lymphatic system is that having this flap removed could worsen the lymphedema in your arm and possibly in the chest wall. My recommendation is to not only continue your daily self-care, but also wear a well-fitted bra specially made to equalize compression across the chest and redistribute the excess tissue (see list of Suppliers in the NLN Resource Guide). This should improve the discomfort. I would suggest that surgery, in your case, be the last choice.
Q: I am a large woman who underwent a modified radical mastectomy six months ago. I do not have LE and I hope I never will. My husband and I are anxious for me to undergo reconstructive surgery and my plastic surgeon recommends the latissimus dorsi flap (LD). I know this is major surgery and I would like your expert opinion if this is safe after my axillary node dissection.
A: As you may know, after axillary node dissection you will be at risk for the rest of your life, with or without reconstructive surgery, of developing lymphedema. You will need to follow preventive methods closely. You are right that the latissimus dorsi is major surgery, one that requires an incision under the collarbone where a temporary tunnel is created under the skin. Part of the LD muscle from the back, which is covered with fat and skin, are pulled through this tunnel and relocated/transplanted to the breast area. This procedure leaves a 12-15 cm scar in the flank, which raises concerns of blockage of the lymphatic flow, and negative aesthetic implications. Despite the above concerns, there are numerous anecdotal stories from patients who have not only done very well with this surgical procedure, but who have actually seen improvement in their existing LE. In your case, without LE, I recommend that you request the Lymphoscintigraphy diagnostic procedure prior to the surgery. This diagnostic test can visualize the lymphatics and determine whether there is a normal or sluggish lymph system. If normal, and you decide to move forward, I highly recommend that you see a certified LE therapist prior to surgery, and be educated in self-Manual Lymph Drainage as a prophylactic method, to be continued after surgery.
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