The Spy technology is an intraoperative Flouresence Imaging System that captures real-time images of blood flow in vessels and tissue perfusion. This allows Plastic and Reconstructive Surgeons to evaluate perfusion of perforator flaps.

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Journal of Clinical Oncology Reading Notes

The decision to use chemotherapy in addition to hormonal therapy in the treatment of axillary node-negative and estrogen receptor (ER) positive breast cancer should be based not only on baseline risk, but also on prediction of degree of benefit from chemotherapy.

A number of biologic and clinical clues have suggested that not all patients derive the same degree of benefit from chemotherapy. An overview of randomized trials suggests that younger women may benefit more from chemotherapy.

A 21-gene assay has been developed that includes genes involved in tumor cell proliferation and hormonal response, characteristics that have been reported to be associated with chemotherapy response in general.

The recurrence score is calculated on a scale from 0-100 and is derived from the reference-normalized expression measurements for the 16 cancer-related genes (Ki67, STK15, Survivin or BIRC5, CCNB1 of cyclin B1, MYBL2, GRB7, HER2, ER, PGR, BCL2, SCUBE2, MMP11 or stromelysin, CTSL or cathepsin L2, GSTM1, CD68, and BAG1, and the five reference genes.

Patients with node-negative , ER-positive breast cancer in the NSABP B20 study did not benefit equally from chemotherapy. Patients with tumors who had high RS (greater than 31) experienced a large chemotherapy benefit. Patients with tumors that had low RSs derived minimal, if any, benefit from chemotherapy treatment.

For many women with high RSs, the anticipated benefit of adding chemotherapy appears to be very favorable when compared with the risks.

Oncotype DX: Reading Notes

Oncotype DX is a diagnostic test that helps identify which women with early-stage, lymph node negative and estrogen receptor-positive breast cancer are more likely to benefit from adding chemotherapy to their hormonal treatment.
The Oncotype DX test measures the activity of different genes in a woman's breast tissue tumor tissue.

Women with lower (RS) recurrence scores have a lower risk that their cancer will return. These women also have a cancer that is less likely to benefit from chemotherapy. A lower recurrence score does not necessarily mean that there is no chance that the breast cancer will return.

Women with a higher (RS) recurrence score have a stronger chance that their breast cancer will return, but may also benefit largely from chemotherapy. A higher recurrence score does not mean that a woman's breast cancer will definitely return.

Identifying perforators in Breast Reconstruction with 3D CT-Scans

The CT-angiogram has shown great utility for DIEP flap, SIEA flap, free TRAM flap, as well as the pedicle TRAM flap in identifying blood supply to the abdominal tissue used in breast reconstruction.

In certain breast reconstruction candidates who have had prior abdominal surgery the CT-angiogram of the abdomen is useful to me not only to plan out the orientation of the flap used in breast reconstruction but also to position the scar on the abdominal wall to facilitate healing.

The illustration below gives an example of a rectus flap planning CT-scan used in breast reconstruction.

Brian P. Dickinson, M.D.
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3D CT-Angiogram for Flap Planning in Breast Reconstruction

I have found the CT-angiogram to be very helpful for flap planning in breast reconstruction. The CT-angiogram allows the operative surgeon to have a road map for vessel selection, may facilitate orientation of the flap for breast reconstruction, as well as facilitate positioning of the scar on the abdominal wall for flap harvest.

The CT-angiogram is specifically helpful in the patient who has had previous abdominal operations to determine the integrity of vessels as well as determine which flap may be an appropriate option for the patient such as TRAM, TRAM flap with pre-delay procedure, free TRAM, DIEP, or SIEA.

The 3D reconstruction shown below gives an example of how the surgeon can appropriately evaluate vessel integrity in a previously operated abdomen.

Brian P. Dickinson, M.D.

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Deep Inferior Epigastric Perforator Flap Publications

Reconstruction of Total Laryngopharyngectomy Defects with Deep Inferior Epigastric Perforator Flaps:

Otway Louie, Brian Dickinson, Jay Granzow, J. Brian Boyd

Journal of Reconstructive Microsurgery. 25(9):555-558, November 2009

It is truly a great honor and distinct pleasure to publish in the Journal of Reconstructive Microsurgery. I received outstanding microsurgical training from them during my time training at Harbor-UCLA. Deep Inferior Epigastric Artery Perforator Flaps provide well vascularized tissue for distant tissue transfer while minimizing the abdominal donor site.

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Book Chapter Review Notes.

Surgery of The Breast Principles and Art Ed. Scott Spear
Chapter 33. Prosthetic Reconstruction in the Radiated Breast.

Prosthetic breast reconstruction in the radiated breast is a complex issue.

-Radiated reconstructions tend to be of poorer quality than non-radiated reconstructions.
-Radiation increases the complication rates associated with reconstructive options
-Not all radiation is the same.
The dose, location, type, and purpose of radiation substantially affects the local tissue response and thus indirectly the hospitality of those tissues to reconstructive surgery.

Radiation may be delivered to the breast under a variety of circumstances:

-As part of breast conservation treatment, along with lumpectomy and axillary sampling.
-Postmastectomy, according to the American Society of Clinical Oncology Guidelines
-Postmastectomy for a local recurrence.
-After immediate reconstruction for unfavorable tumor
-After immediate or delayed reconstruction for recurrence

If radiation prior to reconstruction:

Indications
Dose of radiation
Quality of tissues after radiation

Lumpectomy and radiation often 5,000 cGY
Patients radiated after mastectomy more likely high-dose radiation because radiation recommended on basis of extensive or aggressive disease.

Lower dose radiation: tissues look and feel reasonably normal
Higher dose radiation: tissues look tight, inelastic, thickened.

All radiation increases risk of complications.
Obvious radiation damage advised to undergo autologous or autologous assisted types of reconstruction.

Indications for radiation by American Society of Clinical Oncology:

Tumor greater than 4 cm.
4 or more positive lymph nodes
Tumor near resection margins (skin or chest wall)

Radiation dose for these indications is usually substantial 9,500 to 10,000 cGy.

Breast Reconstruction Post-Op Protein Requirements.

Proper nutrition should be an important part of everyone's daily life. Both aesthetic and reconstructive surgery place an increased metabolic demand on the body. It is important both pre-operatively and post-operatively to ensure adequate protein intake before and after surgery. Frequently nutrition comes up in consultations, so I have included below a standard post-operative diet protocol as well as an easy method for patients to understand the amount of protein they will need post operatively.

The post-operative diet below is for tissue expander/implant reconstruction. It is modified for TRAM, DIEP, and SIEA reconstructions.

Post-Operative Breast Reconstruction Diet Protocol Pathway
Post-Op Day 0

Clear Liquid Diet as Tolerated.

Post-Op Day 1

Advance to Regular Diet as tolerated. Ensure 1 can three times per day between meals.

Post-Op Day 2

Regular Diet. Ensure 1 can three times per day between meals.

Discharge Diet:
Breast reconstruction surgery is very energy consuming to the body. There is also protein loss from drain output. It is important to maintain a high protein diet for two to three weeks post-operatively to maximize healing.

Regular Diet high in protein + Ensure three times/day between meals.

Goal is to eat 1 gram of protein per kg of bodyweight:

For example, if your body weight is 140 lbs, then your weight in kg is 140/2.2 or 63 kg. Therefore, patient with normal renal and liver function should eat at least 63 grams of protein per day.

Ensure 1 can: 9 grams of protein
Glucerna 1 can : 10 grams of protein

Therefore, three cans give you 30 grams of protein.

1 can of tunafish contains approximately 25 grams of protein.

or

1 chicken breast contains approximately 30 grams of protein.

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Breast Reconstruction Post-Op Pain Protocol

Post-operative patient comfort is of paramount importance in breast reconstruction following mastectomy. Controlling pain can be challenging for both the patient and surgeon. The patient's goal is to have a pain score of close to zero. While this is also the surgeon's goal, many of medications used to treat pain may contain their own inherent undesirable sequelae such as nausea, vomiting, insomnia, hives, disorientation, etc.

I have found that using several different medications that work on slightly different pain receptors or that have slightly different pain targets to be the most effective. I have posted the following pain protocol pathway that I am currently using so that patients can know what to expect during their hospital stay. If significant side effects occur from the pathway or the pathway is not effective, adjustments can be made accordingly based on age, allergies, weight, and renal function.

Pre-operatively:

Emend 40 mg by mouth with a sip of water the morning of surgery to prevent nausea.

In Hospital Pain Regimen:

Post-Op Day 0:

Toradol: Loading Dose 30 mg IV x 1 then:
Toradol: 15 mg IV 4 times per day x 48 hours.
Dilaudid PCA pump. PCA. Patient controlled analgesia. 0.2 mg IV every 6 minute lockout for max of 2 mg/hr.
Diazepam 5 mg by mouth every 6 hours as needed for muscle spasms (tissue expander reconstruction)

Post-Op Day 1:

Continue Toradol 15 mg IV 4 times per day
Dilaudid PCA pump. PCA Patient controlled analgesia for ½ day with transition to:
Percocet 5mg/325mg i-ii tabs by mouth every 4 to 6 hours as needed.
Diazepam 5 mg by mouth every 6 hours as needed. (tissue expander reconstruction)
Colace 100 mg by mouth twice a day.

Post-Op Day 2:

Discontinue Toradol IV and transitio to Toradol Oral 10 mg po qid
Percocet 5mg/235 mg i-ii tabs by mouth every 4 to 6 hours as needed.
Diazepam 5 mg by mouth every 6 hours as needed. (tissue expander reconstruction)
Colace 100 mg by mouth twice a day.

Discharge Medications Home:

Percocet 5/325 mg i-ii tabs by mouth every 4 to 6 hours as needed.
Diazepam 5 mg by mouth every 8 hours as needed. (tissue expander reconstruction)
Ambien 10 mg by mouth at night as needed for sleep.
Colace 100 mg by mouth twice a day.

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