This is something I can write about with whole hearted conviction at the moment as I am currently recovering from TUG Flap Reconstruction (Day 10 to be precise!).
Today is a turning the corner kind of day. Waking up this morning I know that my full recovery is within my reach and things can only get better from here!
What is TUG Flap Reconstruction?
TUG Flap reconstruction was first trialled around 1993 but wasn’t necessarily the first reconstruction of choice. These days not every centre has the expertise to be able to offer it.
If you want to read the technical stuff here it is.
I was lucky because geographically I am in the right area that my breast surgeon could collaborate with the plastics team in East Grinstead (home of pioneering plastic surgery).
TUG stands for Transverse Upper Gracilis. This is a small muscle in the upper inner thigh which helps (but does not solely control) adduction (moving your leg back in towards your body). During the flap surgery a flap of skin, muscle and fat is removed along with all the attached vessels and used to reconstruct the breast.
Cleverly the scar from the removal can be hidden in the crease at the top of your thigh.
There are various reasons women and their surgical team may opt for a TUG reconstruction over another type.
Chiefly this has to be body shape dependent.
- For reconstructing a large breast the tissue taken in a TUG may not be enough.
- For women with smaller tummies a TUG may be better suited to provide the required tissue.
- Some women may not wish to have the scar across the tummy that occurs as the result of a DIEP reconstruction.
So What Can I Expect Recovering from a TUG Flap Reconstruction?
Don’t worry if you don’t know quite what to expect – this is normal.
Even when the operation and surgery is fully explained it can be difficult to get your head around it and apply it to yourself. Everyone is different so although there can be broad similarities in recovery no two people will be completely the same.
I think recovery is helped by talking through with the preadmissions nurse and your surgeon what to expect and having a rough idea of types and probable amounts of painkillers that tend to be needed after this op. We all have different pain thresholds though so this isn’t a hard and fast rule.
Recovery can be divided into several ‘phases’:
- Immediate Post Op
- The First Week
- The Second Week
- Towards the Future!
Recovering from TUG Flap Reconstruction – Immediate Post Op
You can expect to wake up in recovery and feel relatively comfortable and pain free straight after the op. The surgeon and anaesthetist will make sure that you have plenty of painkillers ‘on board’. They may also have injected local anaesthetic into the operation sites which will last a few hours after you have woken up.
Different hospitals will have different regimes but usually some form of PCA (patient controlled analgesia) this is a system which allows you to use pain control when you need it without waiting for the nurses to access the drugs cupboard, check the drug etc. These systems are regulated to make sure you are safe and don’t use too much.
I actually only used PCA once for back pain which turned out to be due to the way I was lying anyway. Immediately post op this isn’t a horrendously painful procedure.
One of the most important post op checks that will be done as you leave theatre is Doppler of the new breast. Doppler is not invasive and is carried out with a small probe pressed into the newly grafted area of the breast. It enables the surgeon to hear the blood supply to the graft to ensure it is working properly (it sounds a bit like listening to the baby’s heart during pregnancy).
The reason for doing this is that this type of surgery involves incredibly fiddly ‘microsurgery’ to attach the tiny blood vessels of the TUG to the blood vessels at the site of the mastectomy. Because this is such difficult surgery there is a risk that this may not have been successful.
The nurses will continue to Doppler through the night every 20 minutes or so. They will also check the colour, warmth and softness of the graft. At this stage this may sound a bit odd but, believe me, it is something that becomes normal fairly quickly!
One of the other things that sticks in my mind immediately post op is the heat. In order to ensure that the graft takes correctly it needs to be kept warm. Unfortunately (especially if, like me, hot flushes have become your mortal enemy) this means you will, unavoidably, be kept warm too. I was lucky as my team stopped short of covering me in a Bair Hugger and made do with blankets and towels over the breast.
Because of this don’t forget to take a mini fan into hospital with you and once you are drinking keep pushing the cold fluids. Icy water will never have tasted so good!
The Dreaded Catheter
Nobody particularly relishes the thought of having a catheter but there are certainly times when having one is really useful. I count this time as one of those times! After such a long anaesthetic, although you will have had (and probably do still have) a drip up you will be thirsty. It is actually quite a relief to sit and rehydrate (once you feel up to it) without having to haul yourself up to get to the loo! (Told you I was a positive person!)
The catheter is usually taken out the following day but in the immediate post op 24 hours the nurses will be measuring how much you have drunk and how much the catheter has drained to check your kidneys are working at full speed!
What are drains? Drains are plastic tubes left in the operation sites after this type of surgery. They drain out excess fluid and help to stop the formation of a seroma. The nurses monitor the drains for the first 24 hours to see how much fluid is draining. If the fluid loss from the drain has stopped or is very low then the drains can be removed.
Recovering from TUG Flap Reconstruction – The First Week
So, there I was, feeling all chuffed – I had got over the many hours of surgery and actually felt fine. Then someone must have run over me in a bus without me noticing! Everything hurt and I didn’t remember anyone mentioning they were going to let an elephant sit on my chest…..
In other words, you may feel absolutely knocked sideways – don’t forget, when you come round from the op at first you are still benefitting from all the meds given to you during the surgery. The long acting painkillers and the local anaesthetic injected into the operation sites. Once these wear off it is normal to feel rubbish! Think about the feeling you get 48 hours down the line after intense exercise or heavy lifting.
Prevention of Thrombosis
You will need DVT prophylaxis (to stop you getting blood clots in your legs from having a major operation and having had cancer) which will probably take the form of below knee stockings and 7 days of once daily heparin injections into your tummy.
This is a time when it is absolutely fine to sit and do nothing, delegating as many tasks as you can. Although you may find sitting uncomfortable as the scar goes below the buttock so, as in my case, a soft cushion may become your latest accessory!
It may take a while to get into this mindset but in terms of healing and recovery this is time well invested. Your body has been through a lot so be kind to yourself!
Mobilising after TUG Flap Reconstruction
The key here is gentle mobilisation. Strenuous activity is advised against until 4 weeks post op. You may find that walking is hard depending on how much swelling you have around the leg wound or you may have several sets of stitches some of which are removed at ten days. Each case can be slightly different but don’t push it too much too soon.
I am speaking from experience – it is so tempting to go for a long walk especially after being cooped up inside but this can risk damaging the scars and not giving them enough chance to heal. So, do as I say, not as I did (and am now regretting) and build up gradually. Once you get back to normal life you may well be hitting the ground running!
Make sure before you go in to hospital that you have stocked up on paracetamol and ibuprofen(unless there is a reason you cannot take either). I found these simple painkillers very helpful and effective for all the odd aches and ‘pulled muscle’ type sensations that occur during this first week.
Recovering from TUG Flap Reconstruction – The Second Week
My second week started off with a wound infection of the donor site (the thigh) which is not uncommon because of the positioning of the incision.
Infection can present with redness and increased soreness around the wound (mine did), discharge from the wound or feeling unwell. If any of these occur its really important to seek medical attention. In most cases a course of antibiotics taken in table form is enough to sort out the problem.
A seroma is a pocket of lymph that can accumulate around the sites of operation. This is because the lymph channels become damaged when the surgery is carried out. This can present as a lump or swelling or just sudden discharge (I stood up on day eleven and felt like my waters had broken!). Once this happened there was quite a feeling of relief.
After this type of surgery it is quite usual to have decreased sensation of a small area of the top of the back of the thigh and also of the breast. Over time this sensation may return but not completely. The central area of the breast may remain numb.
I find at the moment that I keep accidentally knocking my reconstruction as my brain hasn’t adapted to where it is in space. This should improve as time goes on…..
Towards the Future
This surgery feels like it signifies the start of the future. As my consultant pointed out before the operation – reconstruction is the first time along the way you start to focus beyond the cancer and look towards the next phase of life.
Following any reconstruction there are a number of ‘tweaking’ surgeries which may be needed, this isn’t a one stop shop. It is really difficult to match the new breast with the remaining one. In fact there may be some remaining asymmetry even once everything is completed – but actually, naturally, nobody is perfectly symmetrical.
There is also the issue of nipple construction and tattooing but these feel relatively minor considering what is now in the rear view mirror.
I feel that, thanks to the wonders of plastic surgery and the skill of my surgeon and his team I can launch myself on the rest of my life proud that I have come through this and am physically relatively unscathed. I hope that’s where most of us are at this stage whichever type of surgery we have opted for.