Diep and abdominal swelling
My abdomen is still swollen after my Diep surgery back on March 3rd. A cat scan shows no hernia, but "deformity of abdominal wall muscle" per my family doctor. I'm waiting to speak to my PS about my the noticeable bulge on my right side - and in the meantime, found this very recent article (May 2008) about complications after Diep in women who had abdominal scars (I'm assuming they are including women who had c-sections; I had 3 c-sections and a left-side hernia operation - but my PS told me I was still a good candidate for Diep. This article makes me wonder.....no use crying over spilled milk, but for everyone else considering Diep surgery, "to be forewarned is to be forarmed.")
http://www.ncbi.nlm.nih.gov/pubmed/18453974
Here's the part that impacts me - I had all THREE problems (abdominal wound breakdown, seroma AND abdominal bulge) 
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There were no significant differences between the control and scar groups in DIEP flap loss (1.8 percent versus 2.9 percent), partial flap loss (1.8 percent versus 1.0 percent), or fat necrosis (15 percent versus 14 percent, respectively). However, the scar group had a significantly higher rate of abdominal donor-site complications (24 percent) compared with the control group (6.7 percent; p = 0.003).
The most common complications were abdominal wound breakdown (12 percent), seroma requiring operative drainage (6.4 percent), and abdominal laxity or bulge (5.1 percent). CONCLUSIONS: With minor technical modifications, DIEP flaps can be performed successfully without increased flap complications in patients with preexisting abdominal incisions. Despite these design modifications, patients should be informed of an increased risk for donor-site complications.
Comments
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I had unilateral Diep 2/15. No previous abdominal scars. I was at PS office for follow-up appt. in April and he noticed my right abdominal muscle protruding when I lifted my head and shoulders off table.(I can see slight difference left to right standing in front of mirror) I asked about nightly swelling, or swelling during an active day. He said swelling can last for months and is normal.
I am having stage 2 next week and he plans to stitch my muscle together where he separated it to access veins. He said it hadn't healed properly. I am hoping this will rectify the problem.
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Thanks for sharing your info with me FLtricia......it makes me feel better knowing I'm not alone with my complaint and knowing that the plastic surgeon can possibly DO something to improve it! I'm hoping my PS will give me some good news as to what he can do for me - my stage 2 won't happen until next year when I'm finished with the Herceptin. I don't mind waiting for a "fix" to a problem - as long as my PS admits that there IS a problem and offers me a solution so I don't have to live like this forever.
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I had some of the same problems (prior c-section and abdominal surgery). My HMO told me they didn't do DIEP, but gave me a referral to go anywhere in the US I wanted to have it done.
I made an appt. with a plastic surgeon that does DIEP in Seattle. But had him speak to my regular PS to see if I was a good candidate. Together they both decided that DIEP was not the best choice for me, but instead the best choice was a Pedicle Tram Flap.
To say I was disappointed was an understatment. At first I thought about going to a different DIEP surgeon, but the more I thought about it the more I became convinced that I should do what is medically best.
My surgeons thought my c-section was not a problem, but had concerns about what damage had happened internally from my abdominal surgery (exploratory surgery during pregnancy, ended up having appendectomy). According to my PS the scars on the outside are like a book cover, you never really know what's inside until you get there.
My gut told me that if I had two surgeons telling me it's not the best option, then I shouldn't keep looking until I find one that say's yes. After all, we all know there are doctors that will say yes, when everyone else is saying no.
After the surgery my PS told me that internally the prior surgeons had done a very good job and that I probably could have had a DIEP, although I would have had to gain a little more weight. I'm still very comfortable with my decision to have the pedicle tram flap.
Now reading that article and hearing your story, I am very glad that I had two plastic surgeons that were erring on the side of caution in my case.
I hope that things turn around for you and that eventually you can get to a point where you can enjoy your reconstruction.
Best wishes,
Alison
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Thanks for sharing your info Alison - I'm so happy that you've recuperated well from your surgery! I'm still a bit confused as to why your surgeons would say you were a good candidate for a pedicle tram flap, but not Diep after your prior abdominal surgery (usually it's the other way around) but then again, I get easily confused since I'm no surgeon! Lol! I did a ton of research before my decision to get a Diep - but nothing prepared me for the twists and turns my recovery took and the serious problems I've encountered. Thus I continue to do research and find new information that may benefit women who are still trying to make informed decisions.
I'll be bringing the article I quoted above with me to my next visit to my PS - I'm not blaming him for what happened to me, but new research is out now - and if I had known that prior abdominal surgery increases the risk for abdominal complications after Diep 24% I'd have seriously considered going flat.
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Alison,
Who was your surgeon in Seattle? I had my DIEP at UW...just curious if we shared the same dr.
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Bumping up for a newbies' info - also to clarify that after getting a copy of my operative reports, it turns out I didn't have a Diep after all - my surgeon gave me a "muscle-sparing free tram", which may partly explain the complications I received in the abdominal donor site. It is very well known that a muscle-sparing free tram has more abdominal complications than a Diep.............however I believe this Diep study is still important and women researching Diep surgery need to bring it to the attention of their plastic surgeon.
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Swim angel, in your post op report, does it talk about the percent of muscle your surgeon used in your Free TRAM?
Also, an abdominal bulge that isn't a hernia can still be repaired. My brain is a little slow today-- how many weeks out are you?
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Sorry- I scrolled back up-- so you're about 5 months out...
check out this link and scroll to the bottom:
http://www.breastreconstruction.org/Section3/FlapRevision.html
This patient had a bulge, not a hernia-- and it shows the repair, and underneath explains how the repair was made. What does your PS say to you about all of this??
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I had a bilateral DIEP after having had 3 previous abdominal surgeries. All my previous surgeries had some issue with delaed healing. Quite a common side effect of an abdominal surgery with a large incision and all of them except DIEP involved packing. My abdominal incison post DIEP did have two areas of eschar that became debrided with help from a wound care nurse and healed reasonably quickly. I do think that given the length of these incisions it is more of a miracle that many of these heal without difficulty. Last fall I had a laporscopic ooph and hyster and even one of those incisions had some delay in healing. Seromas also are pretty common. I have no experience with abdominal bulging or hernia but I understand fom a co worker that she was told she was not a candidate for TRAM or DIEP because of a previous hernia repair however she also had a consult from a different surgeon and I would conjecture that she may have had a different opinion from a different surgeon. I also think that a particular surgeon's experience is critical in developing any complications. This is not something many wishing to undergo this surgery can control since your choice of surgeons depends on issues like insurance and how long one waits to get on the doctor's schedule. Again my main point is this is a BIG surgery and more likely to have an association with some complications
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Thanks Beth - I found the right page on the web site - and yes, that's how my abdominal bulge looks, maybe not as distended. I'm hoping that by losing weight, I can help reduce the bulge from the "inside out" before I have revision surgery. I'm sooooo NOT looking forward to having my abdomen opened up again for the mesh (my PS said he'll might use Alloderm - I'm going to get an opinion from another PS though) - I'm so afraid of more healing problems, but I can't live with this bulge forever.
I agree with you Grace that it IS quite a miracle that most of these abdominal wounds heal without difficulty.........and that even mine eventually healed. The human body is amazingly adaptable - and as I had to daily remind myself, "time heals all wounds" - with the help of great doctors and prayers! Thanks again ladies for your support!
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There can always be some benefits to having that scar reopened. In my case, about a year or so after surgery I developed a very small bulge. It was scar tissue. My original belly scar after my stage one, was a little uneven, and where the old belly button was, the scar kind of formed a little circle. When I had the scar reopened to remove the scar tissue, a few good things came from it.
1. He only opened the very center of the scar, a few inches in each direction
2. After he removed the scar tissue, he closed me super tight (total bonus cause i gained weight and the skin was ever so slightly loose- and I wanted it back to the way it was after surgery).
Lastly, I got a perfect thin straight scar line, that has healed quickly.
So-- if there's any scar revision stuff you want, you can address that at the same time! The one thing about the bulge is that the longer you wait for the repair it MAY get worse-- You know your body, and if it looks like it's changing, definitley book the surgery (remember most PS's book months in advance)
Keep us posted
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Thanks again Beth - yes, I am worried about waiting too long - the bulge does seem bigger than it started out, so I'll be sure to complain to my PS soon - and I'll ask him about revisions to my scar (which is very wide in the middle underneath my navel.) Also - to answer your earlier question about the percent of muscle used - the operative report only said "1cm of muscle was taken with the perforators".
I was swimming earlier today and it's amazing - my left abdominal muscles feel almost 98% normal - but I have a lot of pulling on my right side where the muscle was taken. Still, when I stand in the water, my abdomen is completely flat - it's only when I get out of the pool that the big bulge pops out again. Water is amazing therapy - I recommend swimming and pool exercises for everyone! My range of motion in my right arm is great - no more pulling or pain near the foob either!
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1% is such a tiny cuff of the muscle, and the fact that you are already doing so great in the pool, even with the bulge, I already know that you will be completely NORMAL (yes, normal) within the year. And by normal, I mean, doing sit ups. Which I don't do even though I can, because I am lazy.
You should definitely get the scar revision at the surgery!! Even though you'll be sore, you will also feel relief from the bulge. You didn't do nips yet right? So you should book it all for the same procedure. 1-2-3, flat tummy, thin scar line, and nipples.
When do you see your PS next?
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Hi Swimangel...this is the other Beth (Beth 777) I'm jumping in on this thread to tell you that I did get to talk to a woman that her her diep by Dr Mark Smith. She absolutely loved him and couldn't say enough good things about him. Her results are excellent and her recovery was FAST! By 6 weeks,she was back to pretty much normal and back to work. I felt so reassured after talking to her. By the way, she is an executive at a very well known TV show. I don't feel like I should reveal her identity but you would be impressed.She loved Dr Smith, loved her results, loved Beth Israel, easy recovery...she had nothing bad to say.Just wanted to let you know that and thank you for all your support and prayers. I will be praying for you too as you work out all the details! Love, Beth 777 0
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Oh my, I was considering the DIEP, now I'm not so sure. I've had 3 c-sections and my gallbladder was removed. Maybe I shouldn't do this.
Diane
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I too, am seeing a surgeon in Seattle to discuss the DIEP reconstruction surgery. But now I'm not so sure. I've had 3 c-sections and my gallbladder removed so this may not be so good for me. Are you happy with the results of your surgery?
Diane
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Diane, even though the risk of complications might be higher than if you hadn't had the surgeries, all of us who've had wound healing problems lived through them. Our recoveries were prolonged somewhat, but we did heal. The best source of information is from a DIEP surgeon, who can evaluate your previous surgery sites and determine if they might pose a problem. And even though the risk of a possible temporary post-op hitch might be increased, that doesn't mean you will have problems. The majority of women do not. I did have a rare problem with a seroma, but did not have previous abdominal surgery. The odds are in your favor that you will do just fine, as most women do.
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My next appointment with my PS isn't until September 22 - and doing "1-2-3, flat tummy, thin scar line, and nipples" is a fantastic recommendation - thanks BethNY!
And Beth777 - that's great news about Dr. Smith! I'm so happy to hear he's well-loved! I composed an email to him about 2 months ago which I never sent, but now I will!
Hi Diane - I'm sorry if I'm guilty of making you second-guess your decision to get a Diep. My purpose wasn't to scare anyone - merely to provide more information regarding risk factors - information that you need to discuss with your plastic surgeon. If he's any good, he should be up-to-date on all of this information - and he should be able to discuss your personal risk factors in detail. I hope your PS can reassure you about everything - and if he doesn't - it helps so much to get a second opinion. As Sandy said - most women do not have these complications! As of now - I'm not totally thrilled with the results of my surgery - thus I'm looking into switching PS's for my Stage2 revisions. But there are many women here who ARE thrilled with their results. So much has to do with the experience level of your PS. Be sure you ask your PS how MANY Diep surgeries he's performed - and what his complication and success rates are. Ask him to show you before and after photos - and to give you the names of several patients who would be willing to talk to you. I ended up with an abdominal staph infection which complicated my recovery - so the tummy-tuck really didn't end up being a "benefit" for me. Still - ask me again this time next summer, maybe I'll be singing a different tune! BethNY has me convinced I will be!
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bumping for newbies!
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Thanks for bumping this. I had a pedicled tram flap in April and have developed a bulge on the side where the muscle was turned. I just had a CT scan today to rule out hernia and hopefully will hear from my PS tomorrow about the results. She doesn't think it's a hernia but rather a weak spot that may require some mesh to fix.
The bulge is also painful and I would like to get rid of it, but really dread being opened again. Even with 2 previous c-sections, my ab incision has healed beautifully. Unfortunately I've been dealing with a wound on my breast for over 6 months now so I hate to tempt fate by reopening a nicely healed incision.
I looked at the website Beth referenced and my bulge is no where near that large but it's in a different place. It's higher and to the side of my new belly button which my PS tells me is a strange place to develop a bulge. At this point I'm just hoping it is something that can be fixed and I can begin to move beyond all this.
Good luck with your recovery.
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This is an interesting post to me,too. I had a bilateral diep exactly one month ago today. I am healing well for the most part...slow and steady...
Yesterday, I had a follow up with my ps. I told him I was concerned about the swelling just to the left of my new belly button. It looks the same as the other side but it "feels" bigger and a little tender,like it is pulling more. He thinks it is just swelling and took a wait and see approach. He mentioned lipo down the road if I want but said to wait to see if it resolves itself better with time. I am a little concerned because I didn't notice it till recently. Overall, I feel good but this seems more annoying than before. I am thinking I have been doing too much too soon and maybe I am just swelling more.
Also, yesterday, he had to work on my abdominal incision a little. He took a small blade and cut away some of the scabbed area to make it heal better. OUCH. This area is right below where he cut so maybe that made me feel worse in that swollen area.
He didn't think it was a hernia or anything like that...just normal swelling.By the way, he swears he didn't take any muscle. It was a true diep.
Also, today, my underarm is sore. That's a new problem. Like I said, I think I am acting like I am totally recovered and lifting things etc...I am going to take it really easy today and see if I feel better.
Probably some of you set yourself back a little too by doing too much too soon. It's such a beautiful fall day and I want to do so many things but my body is saying KNOCK IT OFF!
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Beth, I had a tender swollen area above my belly button to the right that developed last November after my abdominal incision was opened up and cleaned out. It would become more swollen and start to burn when I wore pants with a tighter waistband, like jeans, being right above the top of most of my pants. My surgeon liposuctioned in that area in April and said he removed some scar tissue, and although it seemed better for a week or two, it then swelled up again. I asked what would transpire if it didn't go away (and after six months, that didn't seem likely), and was told to wait 9-10 months and if it didn't resolve, my abdominal incision would likely have to be opened for the fourth time. It persisted all summer, like an egg under my skin. In September, 10 months after it first appeared, we were at a trade show in Las Vegas and I walked 6-8 miles of endless aisles of the latest clothing and shoes, and then went back to our room and flung myself on the bed---the dumb thing was so swollen!! I rubbed it, rather firmly, for 10-15 minutes, in circles, from side to side, and pressed on it. Life went on and it wasn't until about two weeks later that I realized that it had not been bothering me. I thought back to when I had rubbed it hard, and all I can think of is that it was scar tissue that finally got broken up enough that it flattened out and softened. My PCP had ordered ultrasound and they found nothing, so the radiologist thought it was probably scar tissue. I've continued to firmly massage that area, and my egg is virtually gone now. I'm not recommending that you do the same, but you can ask your doctor about massage. Mine told me it probably wouldn't help, but couldn't hurt. It just took me a few months to try it!
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Thanks,Sandy! I will ask my doc about massage next time I see him. Sorry I didn't respond sooner...I haven't been online. Thanks for taking the time to post about your "egg" Mine still feels the same today.
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bumping for a newbie
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I am going for delayed bilaterial DIEP surgery on Jan 9. Have had 4 c-sections and had no idea this might compromise my recovery. is there anybody else out there who has had c-sections and DIEP and can share their experiences??
thanks
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Hi Momto4 - I hope you'll get a response soon from women who have had better outcomes than myself. My purpose isn't to scare anyone right before their surgery - but to inform so what happened to me won't happen to anyone else. You should definitely show the study I referenced above to your own PS - mine was very surprised at the results - unfortunately for me, it was published months after my surgery. I believe it's only ethical for a PS to give you total information about your personal risk of complications PRIOR to your surgery - it's part of informed consent.
I brought this article to the attention of another Diep surgeon online - you can read his comments here:
http://diepbreastreconstruction.org/forum/viewtopic.php?t=94
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Hi Momto4,
I had 3 c-sections, one for a set of LARGE twins (I am only 4'11") - one vertical and two horizontal incisions from those....as well as 3 laproscopic abdominal procedures for cysts, including removal of an ovary. I had a DIEP Nov. 10 and my tummy is GREAT. No more ugly pooches under the belly button, and no problems with the new incision. Can't say I even had much swelling. My PS cut very low - and you would never know that I had all those other surgeries! BTW, I am 48.
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Hi wildbreeze & swimangel
thank for your responses. I am just over two weeks post surgery and I think I am okay. I do not have abdominal swelling though I am still sore. I have about a four inch part of the abdominal incision which is taking a little longer to heal. PS put me back on antibiotics, just in case. I am hoping it will not become infected or anything. Swimangel, when did your infection start and was your swelling and hernia immediate?? thanks. I hope you are okay now. I am loving the flat tummy and the reduction in the number of stretchmarks. my breast turned out pretty good. starting to feel more like a woman again.
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Hi Momto4 - it's great to hear that you're doing well two weeks out! The worst is really over now! I hope your incision totally heals - but as long as there's no redness spreading around the edges or any discharge, it should be fine especially since you're on antibiotics. I'm assuming your drains are removed - which is another big plus. Drains themselves can introduce infection. My abdominal swelling didn't appear for at least a month after my surgery, and it has grown larger over time - but my infection was probably immediate. I came home from the hosptital on day 5 and went back in on day 7 - and had to stay there for another two weeks on IV antibiotics. Then another week at home on Zyvox.........I'm nearly 100% certain that the MRSA staph occurred during the surgery. It's not like I got a sore in my skin which became infected - the infection was deep under the skin, on my right side, where the PS removed the perforators and small piece of muscle.. So you shouldn't worry - you're well on your way to a nice recovery and I hope a beautiful, flat tummy and new breasts!
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Bumping for newbies........and to let everyone know, I still haven't had the surgery to correct my abdominal bulge - it's scheduled for July 6th with a different PS and general surgeon who work together (thanks to BethNY for helping me find them!) They both disagreed with my original PS about the use of Alloderm mesh which could become infected. They'll be using a newer mesh that's resistant to staph (it's called Strattice). The surgery is in July because I'll be off for the summer (I'm on the support staff at a middle school). I can't wait to get it over with........to put all this behind me! My foob revision will take place on May 6th - outpatient surgery - so hopefully I won't lose much time from work then.
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