The Pedicled TRAM Flap for Breast Reconstruction: Animation of the Procedure

The TRAM (Transverse Rectus Abdominis Muscle) flap procedure requires taking the entire Rectus Muscle (1 set of the 6-pack abdominal muscles) to reconstruct the breast.  It can be done as a Pedicle Flap (as shown here, the blood vessel and muscle is still attached), or as a free TRAM flap requiring microsurgery to reconnect the tissue to blood vessels in the chest area.    The DIEP flap procedure has evolved from the free TRAM flap where the muscle is preserved and the skin and fat is removed from the abdomen with only the blood vessels.   

Exparel in postoperative pain managment after reconstructive breast and abdominal surgery

Taking Great Pains: EXPAREL® helps improve postop pain after breast reconstruction

Published on September 23, 2014, Plastic Surgery Practice

By Charles K. Lee, MD, FACS

The past decade has brought major treatment advances in breast reconstruction surgery. Most notably, autologous flap procedures have vastly improved the patient experience. But despite significant strides on the surgical front, one constant that continues to diminish the quality of life of patients undergoing breast surgery is postsurgical pain. Inadequate pain control after surgery has been correlated with long-term chronic pain,1 which affects between 27% and 48% of patients following breast surgery.2,3

While pain management is integral to an optimal recovery for all surgery patients, given the tremendous psychological and physical disease burden breast cancer patients endure prior to undergoing reconstruction, the need for exceptional postsurgical analgesia is especially critical for this population.

The current standard of care for postsurgical pain management following breast reconstruction consists of a combination of continuous nerve blocks, catheters (anywhere between two and four, in addition to two drains), opioids, and NSAIDs. While effective, the standard regimen has its share of downsides ranging from opioid-related adverse events, which prolong recovery and increase cost of care, to catheter-related issues such as infections at insertion sites, pump errors, and delayed ambulation due to continuous tethering to pain pumps. Despite the well-recognized drawbacks and due to a lack of comparably effective, yet more tolerable alternatives, blocks and pumps have become a fixture in the postsurgical pain-management toolbox.

Enter EXPAREL

A lot changed in 2011 with the US Food and Drug Administration approval of a novel formulation of bupivacaine, called EXPAREL® (bupivacaine liposome injectable suspension). EXPAREL can provide up to 72 hours of local analgesia and reduced opioid requirements via infiltration at the surgical site. Unlike standard bupivacaine, which produces a 6- to 8-hour analgesic effect, the bupivacaine in EXPAREL is encased in liposomes which break down over time to extend the release of the active drug over a 3-day period.

I was initially skeptical about the promise of a non-narcotic local anesthetic that produced prolonged pain relief without catheters, pumps, or IVs, and significantly reduced opioid burden. However, after a few initial cases, it was clear that EXPAREL could greatly enhance the recovery experience of all my patients, especially those undergoing breast cancer surgery and reconstruction.

Evidence Builds

As part of a broader effort to gain formulary acceptance, I conducted a small study with 25 patients to demonstrate the clinical value of EXPAREL in comparison to previous cases using a standard pain regimen (bupivacaine HCl block supplemented by opioid-based rescue, administered via patient-controlled analgesia [PCA]). Patients treated with EXPAREL, half of whom underwent breast reconstruction while the other half underwent aesthetic procedures, reported an average pain score of 3 (using a NRS scale of 1 to 10), compared to 7 for patients who received the standard pain regimen. In addition, patients who received EXPAREL reported being “highly satisfied” with their pain relief.

While the measurable reduction in pain was a key driver of pharmacy acceptance, the cost savings and reduced infection risk associated with the elimination of catheter-based pain control modalities also helped move the needle. Since we added EXPAREL to our pharmacy, I have almost entirely eliminated the use of PCAs, and patients report being more comfortable, able to ambulate sooner, and highly satisfied with their quality of care.

During the past 2 years, I have used EXPAREL in more than 300 cases, including hand and leg surgery, breast surgery, and facelifts, and observed consistent results in terms of pain reduction, opioid reduction, and satisfaction. By controlling pain during the critical few days after surgery without requiring invasive ports, and eliminating high opioid requirements, EXPAREL allows reconstructive surgery patients to focus on the vitally important psychological and practical aspects of healing from a life-changing procedure. Based on my experience, EXPAREL promises to redefine our approach to intraoperative and postoperative pain control.

Tips and Techniques

As a surgeon, I considered myself experienced in local infiltration techniques. However, EXPAREL ® behaves differently from traditional anesthetics, including bupivacaine HCl, in a few important ways. For starters, the liposomal composition makes EXPAREL more viscous than standard bupivacaine, so once placed, EXPAREL remains local and does not disperse.

Unlike Marcaine, which can be liberally applied around the site and massaged into the targeted region, EXPAREL needs precise placement into soft tissues in the region of the sensory nerves, as well as the muscle and fascia, to produce the desired effect. A 20-mL vial of EXPAREL (266 mg) can be expanded with up to 280 mL of preservative-free normal sterile saline for a total volume of 300 mL.

In most of my cases, I will expand the volume to approximately 60 to 100 mL, depending on the surface area to cover. For a DIEP flap, I expand the volume of EXPAREL up to 200 mL and infiltrate the tissues and muscle around the breast and abdomen, as well as the fascial planes (versus the subcutaneous area), and in the region where sensory fibers may be.

References

1. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367(9522):1618-1625.

2. Carpenter JS, Sloan P, Andrykowski MA, et al. Risk factors for pain after mastectomy/lumpectomy. Cancer Pract. 1999;7(2):66-70.

3. Poleshuck EL, Katz J, Andrus CH, et al. Risk factors for chronic pain following breast cancer surgery: a prospective study. J Pain. 2006;7(9):626-634.

- See more at: http://www.plasticsurgerypractice.com/2014/09/taking-great-pains-exparel-helps-improve-postop-pain-breast-reconstruction/#sthash.esDmyv6B.dpuf

Infected Mesh is an Infected Implant -- It must be removed.

      Prosthetic mesh is often used in hernia repair surgery, with over 20 million such procedures done annually around the world.   Mesh is used to augment tissue repair in hernias to reduce tension at the suture line where the "weakness" is strengthened or plugged to hold back internal structures (such as intestine or omentum) that want to bulge through these areas.    The mesh can be made of various materials, such as Polypropelene, Gortex, and other plastic materials which allows the body to grow scar tissue around it.  The thing remember about prosthetic mesh, is that it is NOT alive or biologically active.  Your body recognizes it as a foreign substance, and because of that, there are inherent risks.
     For the most part, prosthetic mesh works and does its job; however, when it becomes a problem, it usually becomes a BIG problem.   The worst problem of all is when the mesh becomes infected.  In that situation, with rare exception, the mesh must be removed--completely.   It must be completely removed because any portion that remains may harbor bacteria which the body cannot clear away (even with the most powerful antibiotics), leading to a chronic wound, deeper infection, absesses, or systemic infection.
     The treatment of infected mesh requires a step-wise approach with the first step in removing the mesh and debriding (cleaning) the wound.  This step may be repeated multiple times until the area is clean. Once deemed clean, the area that the mesh covered will need to be reconstructed, preferably with your own tissue (flaps), or in combination with a Biologic mesh that can grow with your tissues and that your body ultimately recognizes as "self" tissue.   It will take at least 6 weeks from the time of the final reconstruction to fully heal, and depending on the complexity of the wound, infection, and anatomy of the infected mesh, several months in total.
      Far too often, I have seen patients who have lived with this problem for too long.  A small, chronic wound, may be a sign of a much bigger problem deep down below.  Appropriate evaluation, diagnosis, and management is critical, but just as importantly, it is important to first recognize and know that you may have mesh in your body.  If it is close to an area that is draining or infected, the mesh must be ruled out as a potential source of problem.   Afterward, it may be necessary to find a team of surgeons, including a general surgeon and plastic surgeon, to work together to solve this difficult problem.

Where can the lymph nodes be taken for a lymph node transplant for Lymphedema surgery?

There are several accessible areas around the body where lymph nodes may be harvested with its blood vessels to be transplanted in an arm or leg for lymphedema treatment.   This includes the groin area (the area near the hip bone (Groin Flap)), the subaxillary region (arm pit region(Subaxillary Flap), and the neck/collar bone area (Transverse Cervical Flap)).   Each area contains a lymph node basin which can be harvested with the flap tissue.  Careful dissection and evaluation of the area needs to be done prior to using the tissues from each specific area.

Be sure to have a thorough discussion with your surgeon regarding your "donor site" options for lymph nodes when considering lymph node transplant to treat lymphedema.

Angelina Jolie and Breast Cancer Reconstruction

I applaud Angelina Jolie's candid approach to her recent treatment for breast cancer.  Because of her “star” status, she is able to put a significant spotlight upon current issues in breast cancer treatment today.  This includes the BRCA gene, which places her at high risk for breast cancer, that many people may not know much about.   It also highlights her approach to this situation with her getting prophylactic bilateral mastectomies and immediate breast reconstruction with tissue expander implants.

 Many people may wonder why someone would want to undergo bilateral mastectomies at this stage of her life while not actually having breast cancer but having a high risk gene.   She explains it quite well:  she wants to decrease her chances as best as possible, even at the cost of losing her breasts.   The complete removal of the breast tissue (mastectomy) early on decreases the chances for breast cancer significantly in the future.   In the meantime, she can undergo breast reconstruction which will still allow her to have excellent breast aesthetics.   By undergoing prophylactic mastectomy with nipple preservation, she will also avoid any radiation treatment which can severely deform the breasts--radiation has its own set of problems including wound issues, implant infections, contracture, radiation changes to the heart and lung.

 The other option that she may have considered is autologous breast reconstruction using her own tissues without an implant. This includes the DIEP breast flaps from her abdomen transplanted to her chest via microsurgical technique which would preserve her “super six pack.”   This would allow her to have breast reconstruction at the same time with her own tissues and would get a potential tummy tuck as well.    My guess is that Angelina Jolie did not have enough abdominal tissue to undergo bilateral breast reconstruction and that is why she chose tissue expander and implants.   She will need to undergo several expander injections and another operation for a final silicone implant.

It is very common now for me to see patients who seek to undergo prophylactic mastectomies and immediate breast reconstruction.  It allows the patient to be treated at an earlier stage stage in a proactive way,  based on genetic information or early diagnosis.  Our team of breast surgeons, oncologists, pathologists, and plastic surgeons can treat women in the same, proactive way that Angelina Jolie sought with outstanding results.  

I thank and applaud Angelina Jolie’s courage in sharing this deep and personal part of her life to help others.   She is a super star in my book.

 

 

Advanced Treatment for Lymphedema of the Arm and Leg

Lymphedema is a very difficult condition to treat and many patients are told that they must suffer with lifelong compression dressings, pain and swelling. Anyone suffering from arm lymphedema from postmastectomy lymph node dissection and/or radation, or lymphedema of the legs from injury or pelvic lymph node removal/radiation understands that this is not an acceptable option. Very often, patients are young and active and maybe otherwise healthy and are seeking more long-term solutions to improve their quality of life.

Lymphatic venous anastomosis has been a treatment option for over 30 years. It has waxed and waned in terms of treatment efficacy and therein lies the controversy. Only more recently, with the advent of super microsurgical techniques and instruments, have higher rates of success with vessels and lymphatics at 0.5 mm and less, become the norm. There have been significantly improved outcomes since the early days of microsurgery. Dr. Isao Koshima in Tokyo, Japan has been pushing the envelope for decades with advanced super microsurgery techniques. He is a pioneer in super microsurgery and has some of the most extensive experience and long-term follow-up of lymphatic patients in the world.

Lymphatico Venous Anastomsis as seen under the Operating Microscope

(Performed by Dr. Charles K. Lee at St.Mary's Medical Center, San Francisco, CA, October 2012)

I was fortunate to learn from Dr. Isao Koshima directly on his techniques and share knowledge and experience with colleagues from around the world about the latest treatments for lymphedema. I am fortunate to have both Drs. Koshima and Dr. David Chang at M.D. Anderson Cancer Center as my mentors in this regard.

With Drs. David Chang (Left) and Dr. Isao Koshima (Center)

at Tokyo University, Tokyo, Japan, September 2012.

In combination with lymph node transplantation as a free tissue transfer from the groin, abdomen, axilla, shoulder, or neck (large lymph node basins) with additional lymphatic venous anastomosis, this two-pronged approach to addressing improved lymphatic flow has likely made the greatest advances in the treatment for lymphedema to this date. This two-pronged approach allows to redirect lymphatic flow from the interstitial space in the subcutaneous layer to the venous system and helps regenerate lymphatics in areas where they may have been removed.

Liposuction to address lymphedema has also been described. It is more of a cosmetic treatment for lymphedema as the patient is still is left with permanent lifelong compression and reaccumulation of lymph as soon as the compression garment is removed. Liposuction does not treat the cause of lymphedema and therefore does not cannot be a long-term solution.

The power of Lymphatic Venous Anastomosis (LVA) and Lymph Node Transplant (LNT) lies in its ability to treat the causal pathway to lymphedema; it is a physiologic and long-term solution to improving lymphatic flow and ultimately, patient's quality of life. I have personally seen and treated patients with dramatic improvements, that can range from 40% to 80% reduction in circumference, 60%-80% reduction in pain and swelling, with improved range of motion, wound healing, and improved quality of life by not having to wear compression or decrease the amount of time in compression.


I encourage patients who are trying to learn more about the latest treatments for lymphedema contact our office for more information and to continue learning more about the most advanced treatments for this difficult condition.

Exparel for Post Surgical Pain Relief in Reconstructive Surgery

Exparel is a high-tech new form of a commonly used local anesthetic (bupivicaine/marcine).   It is FDA approved and is catching on quickly with surgeons who want the best for their patients in post surgical pain relief.     I have been fortunate to have been one of the first plastic surgeon in the Bay Area to have used Exparel since April 2012.     Patients who have undergone both cosmetic plastic (breast augmentation, tummy tuck) and reconstructive plastic surgery (breast reconstruction, hand and leg surgery) have benefited from this medication.  It is currently also being used in general surgery (eg: hernia), orthopedics, and other procedures.

Typically, Marcine/Bupivicaine lasts only 6-8 hours after it is injected in the surgical area.  With Exparel-- Marcaine + Depofoam technology-- it can last up 72 hours.   The most painful time after surgery is within the first 48-72 hours, so the timing is excellent to address this critical time.   In addition, my patients can avoid the use of the "pain pump" which basically infuses marcaine over a period of time, but the inconvenience of the additional tubing and bulbs, and the possibility of this tubing sitting near an implant, is avoided.

Ultimately, using this medication can help significantly with pain relief and decrease the use of narcotics which come with significant side effects -- nausea, vomiting, constipation, mood changes, etc.

Exparel is an excellent addition to my practice and I am fortunate to be able to offer this high-tech pain reliever to my patients. Ask your surgeon if you might benefit from Exparel for your next procedure.