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.

http://www.drbriandickinson.com/

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.

www.drbriandickinson.com

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.

http://www.drbriandickinson.com/