Mastectomy & Immediate Breast Reconstruction

Lateral Chest Wall Excision

Body

What is a lateral chest wall excision?

As we age, or after losing a lot of weight, it is common to develop a bulge of loose skin and soft tissue, which overhangs the upper edge of the bra in the axillary area. This is characterised by excess skin from under the armpit, which extends to the upper back. The lateral chest wall/upper back reduction procedure is designed to excise this extra skin to improve contouring and clothing options.

What does the surgery involve?

Vertical scar excision: This is a combination of liposuction and skin excision to remove excess soft tissue and fat. It tightens the skin on your back and anterior chest wall, using a vertical scar, which starts in the arm pit and passes down the side of the chest, curving into the fold under the breast. This results in a better contour and removes the large amount of loose skin.

It is the best incision for patients who choose to wear swimming costumes as opposed to bikinis. The scar is hidden on the chest wall under the arm.

Horizontal excision: This technique resembles the vertical excision by incorporating liposuction and skin removal. However, the scar is positioned horizontally along the base of the bra, making it ideal for patients who prefer to wear bikinis. The incision length varies based on the amount of soft tissue that needs to be removed, extending from the crease under the breast to the middle of the back.

What are the risks and side effects of surgery?

Having cosmetic surgery should be a very positive experience. Complications are infrequent and usually minor. However, all surgery is not without risk, and it is important that you are aware of possible complications. All the risks will be discussed in detail at your consultation. However, if you have further questions or concerns, do not hesitate to discuss them. Decisions about this surgery should never be rushed.

Scars

These are hidden in most positions and either run vertically (down the side of the chest wall from the axilla to the crease under the breast), or horizontally (from the crease under the breast across the back). The scars can be shorter or longer depending on the degree of laxity. They normally settle remarkably well, so that they are barely perceptible. However, some patients heal with noticeable thickened, thin or stretched scars.

Bruising and swelling

Bruising and swelling is very common and may take approximately 3 weeks to settle.

Haematoma

This is clotted blood that collects in the operated area. It is very uncommon as there is no open space to collect fluid/blood. However, if a haematoma does develop it tends to occur within the first 4 to 6 hours post-surgery. Any increase in swelling or pain should be reported immediately so that you can be assessed. If you have a significant haematoma you will need to have it washed out in theatre and any bleeding vessel identified and cauterised. This does not normally delay your recovery or change the cosmetic result.

Infection

There is a risk of infection in any surgical procedure. You are given antibiotics during the surgery and for 14 days after surgery to minimise the risks. Infections occur in less than 1% of patients and rarely require any intervention apart from antibiotic treatment.

Asymmetry

Each side is slightly different and will continue to be following surgery. The two halves of our body are never identical, and it is common for one to be larger than the other. However, if you have noticeable asymmetry before your surgery then this will be corrected as part of the surgery and will be discussed with you.

Numbness, reduced sensation or oversensitivity

A reduction in sensation occurs in most patients and often recovers to some degree, although it may never completely recover.

Wound healing problems

These are not uncommon and normally self corrects. Healing difficulties can range from minor problems, such as small areas of wound separation, to major issues, resulting in skin loss. Although very rare, this may require a skin graft to close the wound, meaning more surgery.

Patients who have diabetes, smoke, are obese or elderly are at an increased risk of delayed healing.

DVT/PE

Following any surgical procedure it is possible to develop a blood clot in your legs, which could potentially break off and travel to your lungs. If the blood clot is large enough, it could prove fatal.

The overall risk for cosmetic surgery is less than 1%, but to reduce any risks of a DVT/PE, you will be provided with special stockings to wear in bed together with a blood thinning injection, if you are not mobile or have previously had a DVT or PE.

What happens after the operation?

The incisions are closed with dissolvable sutures that do not require removal.

I use transparent glue and tape dressings (Prineo®), which are waterproof and can be peeled off approximately 2 to 3 weeks after surgery, when they start to lift at the corners.

You can shower as soon as you like after surgery and do not require any dressing changes.

Before you are discharged from Hospital you will be given a follow up appointment to see the nurse after one week post-operatively to check your incisions. I normally see you in clinic approximately 2 weeks following your procedure.

You will not be able to drive yourself home from Hospital and, ideally, you should have someone to stay with you for the first few days to assist you. If you have any concerns during this period, please contact the clinic for advice.

Once the dressings are removed, I recommend that you massage the incisions, using small circular motions at least twice a day for 5 minutes. You can use any moisturising cream of your choice and apply firm pressure until it blanches.

The scars will also benefit from Silicone scar gel (ScarAway®or Kelo-Cote®) twice a day, which will soften and fade them, as well as applying sunblock for 12 months to provide sun protection.

The ScarAWAY® can be purchased from Healthcare Pharmacy at Governors Square in Grand Cayman.

What is the estimated time for recovery, absence from work and return to usual activities?

When you get home, you should take things easy for the first week or so. Most people take around 2 to 3 weeks off from work.

It is important to ensure that you regain gentle movements of your arms and shoulders as soon as possible to avoid stiffness. I will teach you gentle exercises, but you may benefit from physiotherapy.

You should be able to drive from 2 weeks, return to the gym for lower body work at 4 weeks and begin upper body exercises at around 6 weeks.

I recommend wearing compression garments to help reduce swelling, as well as shaping the arms and encouraging the skin to retract naturally. You need to wear these day and night for 2 to 4 weeks.

I hope you find this information useful. If you have any questions or require a little more information then please do not hesitate to contact me.

Anne Dancey
Plastic and Reconstructive Surgeon FRCS(Plast), MBChB(Hons), MMedSci(Hons) and MCh(PASP)