April & May 2015 Surgery Sisters

little-k, blue dye usually passes out in the urine over 24-48 hours. Some blue staining on the breast is very common and this will fade gradually over a few weeks or months. In some cases, it takes longer. This study has some percentages on follow up, where 8.6% of the study participants showed some residual staining at the injection site after 3 years, but 36.5% had staining after 1 year. If your medical records don't indicate the staining agent used, ask your BS what was used on you. Blue dye staining agents used include Isosulfan Blue (trade name Lympazurin and also called patent blue violet), Patent Blue V (trade name Bleu Patenté V Laboratoire Guerbet and also known as E131-food colouring and cosmetics dye, acid blue 3 and disulphine blue), and methylene blue (trade names Urolene Blue or Methylene Blue Vitas). Isofulfan Blue and Patent Blue V are both triarylmethan dyes and are very similar molecules (Patent Blue V has an extra hydroxyl group). Methylene blue is much less costly than the other two dyes and it is used extensively in third world countries. My expectation would have been that methylene blue would not be used in the US to a great degree, but I was surprised to see that Cedars Sinai website references use of either Isosulfan Blue or methylene blue. I have no idea whether this is surgeon preference, or whether insurance companies drill down to this level for approval of procedures, or whether it was employed because of a known allergic reaction.

Isosulfan blue and Patent Blue V can pose allergic and anaphylactic risk in 1-3% of patients. Methylene blue needs to be injected deeply, because it can cause necrosis of the skin with intradermal injections. It is a smaller molecule that either Isolsulfine blue or Patent Blue V, so it will stain the skin more intensely.

The SNB procedure carries about a 4-5% risk of false negative results (after the more accurate pathological review of formalin fixed paraffin embedded slides, not intra-operative frozen section analysis), meaning that the actual first node to which the tumour drained is not identified by staining or the radiotracer. Because of the risk of complications and negative SEs of ALND, it is deemed an acceptable level of risk.

Speaking of SNBs, I see a lot of DCIS with SNBs on this board. Every woman has to make her own decision with which she is comfortable and peace of mind is critical. Personally, depending on the extent and characteristics of the DCIS, personal breast history and whether there are any other suspicions of further disease present, I would question my surgeon to justify why this is being done, as I think the real risk of lymphedema in particular, plus nerve injury and pain, wouldn't justify the value of the procedure. If you are more comfortable trusting your BS and just want to go with her/his recommendation, that's absolutely fine. Do whatever helps you get through your BC treatment. Here's my experience and personal decision making process. I had a very small IDC, encapsulated in a fibroadenoma, with no LVI. I had been sliced and diced in the upper outer quadrant, and because I had a mini-Grand Canyon chasm, my lymphatics had been destroyed, which is a scientific proven predictor of technique failure (not surgical expertise) for SNB. There was a 20 minute consultation between the nuclear tech, radiologist and my BS on how/where to inject the radiotracer. My SNB failed and my BS wanted to make a second attempt during my BMX. After reading at least 40 journal articles on SNB and surgical textbooks and it was my opinion that the original node to which my tumour drained could not be mapped with a high degree of confidence. I have since purged a lot of that info from my brain, but I had stats and percentages and relative risk numbers up the ying-yang that I quoted to him. Yes, I knew my BS would get a mapped node, but if it wasn't the 'true' sentinel node, it served no value to me. I felt that the incremental value of the information from a second SNB (given the specific pathology and characteristics of my tumour) was not worth the risk of my two biggest fears: lymphedema and motor nerve damage. So, I told him that I would not consent to a second attempt and why. I read on a thread somewhere about conducting an SNB post-mastectomy and that this was being done by a surgeon whose area of expertise was in this specific area. I believe that the surgeon was in Boston or NYC. The lymphatic system regenerates after it is damaged, excised, or injured to a fair degree. Personally, I don't see how anyone can say with a high level of confidence that she/he can map the original node to which the tumour drained, when the original lymphatic system is long gone. Does it regenerate as an exact replica of its former self. Nope. Can they make a reasonable guess? Perhaps, but it is impossible to do so definitively with a high degree of confidence. Just my opinion. Peace of mind is the most important factor through this BC experience and it is different for everyone.

edited to add study on blue dye skin staining

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC372871...

MaryAgatha, I'm sure there are lots of women who have TEs, fills and exchange surgery without complications. This board is skewed toward the negative experience side and that's OK, because BC can be extremely nasty and traumatic and it's good to have a sounding board where people who have been through it, get it, and can provide support and advice. Since you are an ideal candidate for direct to implant, I'd jump at that. You will save yourself the inconvenience of the fill process and possibly a revision surgery. You will be able to resume your normal activities sooner. My PS is a self-admitted perfectionist and I can't believe how good my breasts look at 3 weeks post-op. I was an A cup and my implants are a B on me. Direct to implant requires precise pocket work by your PS and I really don't think I am going to require a second surgery to tweak anything. I do have an Alloderm sling. By suturing this to the breast margins, it provides a better contour at the inferior, medial and lateral positions. It is very challenging to get a nice round contour of the lower pole area with muscle coverage alone. By creating an Alloderm sling, this eliminates the need to elevate the serratus anterior muscle, which must be used to create the pocket in the absence of an ADM sling, so you have fewer muscles being dissected. It also helps prevent retraction of the pectoralis major. Alloderm coverage helps make the implant less visible, particularly with thin skin and maximizes the skin envelope in SSM and NSM. The surface area and height of the Alloderm piece is directly correlated to the final implant volume and is used to predict TE volume, when used with TE placement. There is purportedly decreased post-op pain and a reduced risk of capsular contraction with the use of Alloderm. Incidence of implant migration downward and toward the armpit is reduced with an ADM sling. Alloderm is the most widely used and studied dermal matrix product in breast reconstruction. It is expensive. A lower cost dermal matrix product is Strattice, which is of porcine origin.

Sending good wishes for your SNB procedure tomorrow.

Welcome April sister, lovevt. How active is your job? You have a harder recovery than those of us who have TEs/implants placed with 4 incision sites and the PAP sites take longer to heal as a result of their location. I hope you don't live somewhere really hot and sweaty. If you don't have any health conditions that will delay your recovery (e.g. diabetes) and have an average or better fitness level, I think you should push yourself to build up more stamina, a little more every day. If it hurts, stop; a little fatigue is fine. Walking is great. You can't do strenuous activities with your legs or arms at 3 weeks after your procedure. Are you wearing some kind of compression bandage/garment on your upper leg? Are your legs sore/tight at the donor site? Your legs will take longer to recover and resume strenuous activities than your upper body and arms. If your job is very active and requires a lot of leg work, like leg bends and lifting, I would think you might need 8 weeks prior to returning. Best to ask your PS, who can examine you and can evaluate your suitability for a return at 6 wks, based on the demands of your job. I just did a search on these boards for PAP and all the hits were for pap smears (I don't like the bco search algorithm and didn't look more than on first page), so I don't think we have many posters with whom you can compare notes. Good luck with your recovery.

Cheesequake, I second what mjh1 said. I had a stitch that poked out at 3 weeks and was bothersome following my Jan lx and my BS just snipped it with no concerns.