Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Total Reconstruction of Breast


Related Terms

  • Autologous reconstruction
  • Breast Reconstruction
  • Reconstructive Breast Surgery
  • TRAM reconstruction
  • Transverse Rectus Abdominus Myocutaneous Reconstruction

Specialists

  • General Surgeon
  • Plastic Surgeon

Factors Influencing Duration

Some factors that might prolong recovery include chronic medical conditions, recurrence of cancer, unresolved complications of the procedure, and excessive activity. Adherence to a moderate exercise program is essential for regaining range of motion, however, and lack of adherence may increase duration.

Medical Codes

ICD-9-CM:
85.70 - Total reconstruction of breast, not otherwise specified
85.71 - Latissimus dorsi myocutaneous flap
85.72 - Transverse rectus abdominis myocutaneous (TRAM) flap, pedicled
85.73 - Transverse rectus abdominis myocutaneous (TRAM) flap, free
85.74 - Deep inferior epigastric artery perforator (DIEP) flap, free
85.75 - Superficial inferior epigastric artery (SIEA) flap, free
85.76 - Gluteal artery perforator (GAP) flap, free
85.79 - Other total reconstruction of breast

Overview

Total reconstruction of the breast may be performed after mastectomy if it is the woman's preference. It can be performed immediately or can be delayed if chest wall radiation is part of the adjuvant treatment. Several reconstructive methods have been used to give the breast the proper symmetry and shape, including prosthetic implants, free flaps, and the use of autogenous tissue from the patient's abdomen to reconstruct the breast. Reconstruction with prosthetic implants is still the most common technique for breast reconstruction, but the durability and naturalness of the cosmetic result is reported to be greater with free flap reconstruction (Deutsch). The transverse rectus abdominis myocutaneous (TRAM) flap, a microsurgery introduced in 1982, is a way to avoid using prosthetic implants after mastectomy; it is becoming the procedure of choice, performed in 25% to 50% of breast reconstruction surgeries in the US (Zenn). Sometimes women may wait several months to have their nipple reconstructed after the mastectomy and the breast reconstruction; other women do not wish to have the procedure done; still others may procrastinate and wait years to have the surgery done. Rates of reconstruction can be low simply because women do not want additional surgery after mastectomy. Older women and poorly informed women less apt to heed medical advice are less likely to have reconstruction.

Several TRAM methods are employed, including midabdominal TRAM, double pedicle TRAM, supercharged TRAM, free TRAM flap, and deep inferior epigastric perforator (DIEP) flap. Not all women are appropriate candidates for the free TRAM flap, however, because they have less muscle tissue and fascia to form the flap or had a previous surgery that prevents harvesting the flap. Other free flap surgeries for patients who are not candidates for TRAM flaps include the superior gluteal free flap, lateral transverse thigh free flap, and the latissimus flap, which is sometimes used in conjunction with an implant.

The psychosocial benefits of breast reconstruction are well described in studies of women who have had the surgery. Nipple reconstruction is especially important in restoring breast form and nipple sensitivity and in preserving the ability to breastfeed in women who wish to have more children. Women who have nipple and areola loss following breast cancer surgery may suffer continued psychological stress from their disfigurement. Nipple reconstruction is usually done several months after the breast itself has been reconstructed. Numerous techniques are performed, including intradermal tattooing, skin grafting, and nipple sharing.

Source: Medical Disability Advisor



Reason for Procedure

Total breast reconstruction is performed in women who wish to reconstruct the breast after the breast tissue has been removed to treat cancer or by some other trauma. A skin-sparing mastectomy usually precedes total breast reconstruction; in this type of mastectomy surgery, rather than removing the entire breast, an "envelope" of breast tissue is left intact, and this envelope can be filled either with an implant or transferred tissue. Nipple-areola reconstruction is performed to restore both appearance of the breast and nipple erectile ability, sensation, and future breastfeeding capability. The surgery may also be performed to correct a congenital absence of the nipple-areolar complex.

Source: Medical Disability Advisor



How Procedure is Performed

If the patient prefers the look or feel of implants, saline or silicone implants may be used. The breast tissue remaining after skin-sparing mastectomy is stretched to conceal an implant by slowly refilling an empty implant with saline to determine the appropriate breast size. Then a final implant is put in place through a surgical incision beneath the breast after the tissues have expanded the correct amount. A latissimus flap is sometimes used to create sufficient skin for implant coverage when the surgical site does not offer adequate coverage.

The two reconstruction procedures that use the patient's own body tissue (autogenous flap) to shape the breast are the TRAM flap and one of its variations, the DIEP flap. DIEP breast reconstruction is an advanced TRAM procedure that uses autologous tissue transfer to reconstruct the breast. However, the DIEP technique uses fatty (adipose) tissue from the abdomen to create the flap without dissecting the rectus abdominus muscle, which preserves the woman’s abdominal strength. In some cases, if not enough breast tissue is present, skin, fatty tissue, and blood vessels from the buttocks (GAP flap) or the thigh (TUG flap) can be used and grafted to create the breast without affecting abdominal muscles. The DIEP procedure is more complex than the standard TRAM surgery described below; more and more surgeons are performing the procedure, which is described as the breast reconstruction of the future (DIEP).

Indications for a TRAM flap include radical mastectomy with a large area needing tissue replacement, previous chest wall radiotherapy, a large opposite breast that can’t be matched with an implant, a small opposite breast that is difficult to match with an implant, prior failure of an implant, or excess lower abdominal tissue and possible benefit from simultaneous abdominoplasty (Zenn). In TRAM flap surgery, adipose and muscle tissue is surgically removed from the abdomen to create a transverse rectus abdominis myocutaneous flap. The entire rectus muscle may be used, or it may be split; women who do not want to lose muscle function are advised to have the DIEP flap procedure or a free flap TRAM procedure. The flap is reconstructed on perforators through the rectus abdominus muscle, and its blood supply will come from the epigastric arterial system. The abdominal incision is closed with sutures and sometimes with mesh inserted for additional support of tissue. The procedure takes about 4 to 8 hours, during which 90% of the reconstruction is performed; the surgeon shapes the new breast mound by matching the opposite breast as much as possible and anticipating the result after healing, scar tissue formation, and possible shrinkage (10% is expected) (Zenn). Four to five days in the hospital are required for observation, healing the abdominal closure, draining the surgical site, and beginning range-of-motion exercises.

The latissimus flap is used for women who are slender with limited soft tissue available to create a flap, or who have had prior abdominal surgery so that the rectus abdominus muscle cannot be used. A latissimus flap may also be used in conjunction with breast implants or for women who wish to have future pregnancies. Latissimus surgery uses the latissimus dorsi, which is a flat, triangular muscle on the lumbar region of the back. Use of this muscle to create a flap does not compromise muscle action of the back because other muscles compensate for the dissected latissimus muscle. The blood supply also arises within the muscle tissue and provides adequate perfusion of the latissimus flap. Because of the location and flexibility of the latissimus muscle, it can be rotated to allow transfer for breast reconstruction.

The nipple and areola are reconstructed as a separate procedure; as the last step in breast reconstruction, it is typically performed about 3 to 4 months after TRAM or other flap surgery so that nipple placement is determined after the reconstructed breast tissue has settled. The position, size, shape, and color of the nipple-areolar complex must all be determined prior to the surgery. Intradermal tattooing is an easy-to-perform, one-step procedure, which creates an optical effect with no complications and usually a good aesthetic result. However, it does not have structural support and does not reproduce the texture of the nipple-areolar complex. Autologous tissue for skin grafts is obtained from pigmented tissue of the opposite nipple-areolar complex or the medial thigh-vulva area. Grafted skin is first shaped into a nipple by creating a 3-dimensional structure that resembles the natural nipple. Local skin flaps of varying shapes can be used, such as the skate flap, bell flap, opposing tab flap, star flap, top-hat flap, or twin flap. Filler injection may help to firm the grafted skin. Autologous cartilage may also be used to construct the nipple. The areola can be constructed with myocutaneous grafts obtained from thick skin of the lower abdomen or back and then tattooed to make it look darker. The patient must remain in the hospital anywhere from 4 to 7 days after the procedure to observe for infection or development of complications.

Source: Medical Disability Advisor



Prognosis

Satisfactory, long-lasting breast reconstruction results can be obtained with today’s microsurgical skin-engineering techniques. The TRAM flap is noted for success rates as high as 100% when used in reconstructing the breast after a skin-sparing mastectomy (Deutsch). The DIEP procedure uses only adipose tissue and blood vessels, not muscle, resulting in a quicker recovery with less pain and less risk of complications (DIEP). Some patients may experience a feeling of tightness and back pain for a period of months. Women may experience emotional problems and depression after their cancer diagnosis, mastectomy, and reconstruction surgery with a long convalescence. The individual is advised to continue breast self-examination, observing for lumps or masses. A recent study concluded that there is not a relationship between breast reconstruction and chest wall recurrence of cancer (Chagpar).

Source: Medical Disability Advisor



Complications

Some women experience the following complications from implants: implants breaking open, leaking, or moving out of place; pain; edema; or infection. Changes in color, lack of symmetry or projection, blisters, and death of the tissue (necrosis) are problems that patients may experience after nipple-areola reconstruction. Other complications of the TRAM flap include fat necrosis or incomplete destruction of the flap, occurring in 5% to 15% of procedures; less than 1% of patients experience death, deep vein thrombosis (DVT), pulmonary embolism (PE), or total loss of the TRAM flap (Zenn). Patients can develop an abdominal hernia, a bulge in their abdomen that looks like a hernia, and umbilical necrosis after an abdominal incision and muscle excision for flap procedures. Finally, radiation therapy and injury, as well as thickening of the flesh and contractures, can hurt the long-term outcome of nipple reconstruction.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Recovery times vary, depending on the type of reconstruction. For example, a patient can take from 6 to 12 weeks to recover from a TRAM flap reconstruction before returning to work (Zenn). Similarly, for 6 weeks, patients are usually restricted from heavy lifting and performing activities that are strenuous or require use of arms above shoulder level. Restrictions on lifting may be permanent.

Source: Medical Disability Advisor



References

Cited

"DIEP Breast Reconstruction." DIEP Breast Reconstruction. 1 Oct. 2009 <http://www.diepbreastreconstruction.org/>.

Chagpar, A. "Treatment and Outcome of Patients with Chest Wall Recurrence after Mastectomy and Breast Reconstruction." American Journal of Surgery 187 2 (2004): 164-169.

Chun, Yoon Sun, and Dennis P. Orgill. "Breast Reconstruction, Nipple Areola Reconstruction." eMedicine. Eds. Pankaj Tiwari, et al. 20 Aug. 2009. Medscape. 1 Oct. 2009 <http://emedicine.medscape.com/article/1274411-overview>.

Deutsch, Mark W. "Breast Reconstruction, Other Free Flaps." eMedicine. Eds. Pankaj Tiwari, et al. 16 Oct. 2008. Medscape. 30 Oct. 2009 <http://emedicine.medscape.com/article/1274236-overview>.

Kim, John Y.S., Jamal M. Bullocks, and Arturo Armenta. "Breast Reconstruction, Latissimus Flap." eMedicine. Eds. Pankaj Tiwari, et al. 15 Jun. 2009. Medscape. 1 Oct. 2009 <http://emedicine.medscape.com/article/1274087-overview>.

Zenn, Michael R. "Breast Reconstruction: Unpedicled TRAM." eMedicine. Eds. Pankaj Tiwari, et al. 4 May. 2007. Medscape. 1 Oct. 2009 <http://emedicine.medscape.com/article/1274334-overview>.

Source: Medical Disability Advisor






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