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 with Dr. Otway Louie, Dr. Jay Granzow, and Dr. J. Brian Boyd. I received outstanding microsurgical training from them during my time training at Harbor-UCLA.

Brian P. Dickinson, M.D.

Self Study: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.

Capsular Contracture: Reconstructive Breast Surgery or Revision Aesthetic Breast Surgery?

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As I continue to learn about both aesthetic and reconstructive breast surgery, I find that the same tools, skill sets, and planning that I use for aesthetic breast surgery apply to reconstructive breast surgery and vice versa.

Frequently, I see many women in consultation who have undergone first a breast augmentation, second a breast reduction, and often present desiring further reduction of their breasts or require surgery for capsular contracture.
I enjoy these challenging cases as it is important to be knowledgeable of the blood supply of the nipple areola complex, the prior surgeries, and how to most effectively manage the capsular contracture.

Women who present after numerous operations often have thinning skin or breast tissue, asymmetry, capsular contracture, or unwanted motion of the implant, and desire correction.

I have found that the breast surgery techniques taught to me by Handel have been very effective for identifying, addressing, and managing these difficult cases. Capsular contracture can be very painful for the patient and interfere with daily activities and be psychologically distressing.

The patient in the above photograph is happy with her removal of her saline implants in exchange for silicone implants, change of implant plane, nipple areola reduction, and mastopexy. The scars are still hyperemic in this early one month post-operative result. I routinely educate patients that scars tend to be the most indurated and red approximately one month after surgery and then soften as the collagen in the scar remodels.

I have found that as larger saline implants are removed and exchanged for smaller lighter silicone implants, it is easier for patients to excercise, return to the gym, and loose weight.

Brian P. Dickinson, M.D.

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Mastopexy Augmentation Reductions.

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Frequently, I encounter more women in consultation who present to my office desiring a revision of their breast augmentation from 8 to 10 years prior. Frequently these women have had saline breast implants in for almost ten years and now want to exchange their saline breast implants for silicone breast implants.

Often women who have had larger implants and now want to downsize desire to have the breasts placed more centrally on their chest wall away from their armpits, with a reduction in the size of their areola, and a lift of the breast.

Depending upon the age of the patient and whether or not she has had children and/or breast fed, the incision pattern used to make the breast appear more youthful depends upon the degree of breast ptosis. Breast ptosis or the "breast fall" can be corrected by different methods or incisions patterns depending upon the degree of breast ptosis. The youthful appearance of the breast is best corrected by the relationship of the nipple areola complex to the breast crease or inframmary fold.

I use in consultation, the breast ptosis method as classified by Regnault with modification: Grade 1 ptosis - The nipple areola complex has descend to the level of the inframammary fold. Grade 2 ptosis - The nipple areola complex has descended below the inframammary fold. Grade 3 ptosis - The nipple areola complex has descended below the inframammary fold with no lower pole tissue below nipple.

In general I have found that Grade I ptosis can be corrected with the placement of an implant and/or a superiorly placed crescent mastopexy incision. Often a Benelli type mastopexy can be incorporated to reduced the diameter of the nipple areola complex. Grade II ptosis often necessitates a vertical incision with/without a lateral limb extending from the nipple areola complex. Grade III ptosis often requires a vertical component and horizontal component(s) to make the breast appear youthful.

As one can understand from the photograph above in the after picture on the left, the breast appears more youthful based on the relative size of the nipple areola complex and its position relative to the breast crease. Furthermore the breast has been centralized with its take-off no further lateral than the anterior axillary line. This position of the breast on the chest wall facilitates physical exercise. At three weeks post-operatively, I anticipate that the scars will soften and the swelling will subside giving an even more natural and youthful appearance to the breast as time progresses. Full post-operative change and swelling takes approximately 6 months to one year.

Brian P. Dickinson, M.D.
www.drbriandickinsonmd.com

RoxBariatric:Putting Patients First

The RoxBariatric program continues to grow as more patients enroll for the lap band procedure. Upon enrollment patients meet with Bariatric Medicine Specialists who calculate their BMI.

BMI stands for body mass index which is in units of (kg/m ^2)

BMI (kg/m2) = Weight in kilograms/Height in meters ^2.

People with a BMI below 18.5 are Underweight.
People with a BMI between 18.5-24.9 are Normal.
People with a BMI between 25-29.9 are Overweight.
People with a BMI above 30 are Obese.

Many insurance companies will authorize lap band surgery if patients meet the following indications:
1. An individual has clinical severe obesity, BMI >40, or BMI> 35 with co-morbidities such as heart disease, diabetes, hypertension, sleep apnea, or degenerative arthritis.2. An individual has suffered from morbid obesity for at least five years. 3. An individual has failed non-surgical attempts at weight loss over the years.4. An individual is at a high-risk for obesity-associated morbidity or mortality. 5. An individual is motivated and has an acceptable operative risk.

Once individuals have had their lap band surgery, they are usually candidates for post-bariatric body contouring surgery 9 to 12 months after. I stress to the patients in our program the importance of adequate protein intake prior to their body contouring operations. For the post-bariatric body contouring patients, it is important to eat 1-2 mg of protein for every kilogram of ideal body weight (IBW) provided they have normal kidney function.

When pre-operative labs are drawn before surgery, it is optimal to have serum albumin levels between 3.5-5 g/dl. It is optimal to have serum pre-albumin levels on the high end of normal levels 17-40 mg/dl. Pre-albumin has a half-life of 1.9 days compared to the half-life of albumin which has a half life of 21 days. Therefore pre-albumin levels tend to be more reflective of the more recent nutritional protein intake.

Brian P. Dickinson, M.D.

Hand & Microsurgery:Fight Bite

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The "fight bite" injury typically occurs during altercations where the clenched fist of one individual comes into contact with the incisor teeth of another individual.

These injuries can be serious for two reasons: 1. There is often a laceration of the extensor tendon that crosses the metacarpal joint that strikes the teeth, 2. There is often an injury to the underlying joint capsule that not only causes injury to the joint capsule, but also introduces bacteria into the joint.

I prefer to treat these injuries in stages, with the first stage being washout, irrigation, debridement of the joint followed by antibiotics. Once there has been no declaration of infection I find it safe to proceed with repair of the extensor tendon. The goal is to minimize extensor lag and permit full flexion of the digit.

Brian P. Dickinson, M.D.
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Hand & Microsurgery: Flexor Tedon Injuries

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While I enjoy all aspects of plastic and reconstructive surgery, hand and microsurgery are particularly enjoyable as the anatomical dissections closely resemble the diagrams in the text books. In fact, surgery of the hand is what stimulated my interest in plastic & reconstructive surgery. I find that I use mostly the techniques taught to me by Dr. Miachael Hausman, Dr. Prosper Benhaim, and Dr. Neil F. Jones.

I find that studying and performing surgery of the hand, improves techniques for microsurgical breast reconstruction and vice versa.

It is important when repairing flexor tendons in zone II of the hand, to preserve the A2 and A4 pulleys. After fenestrations have been made in the synovium between the pulley system of the hand the injured flexor tendon can be easily identified. Occasionally I have found that the cruciate pulleys often need to be partially excised so that adequate purchase can be made on the flexor tendons to ensure a strong and durable repair.

Immediate post-operative mobilization with the Duran protocol is important to ensure adequate flexor tendon gliding.

Brian P. Dickinson, M.D.
http://www.drbriandickinson.com/

Breast Augmentation Porportion

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I find that the most important aspect of breast augmentation, is that the operative plan needs to be individualized for each patient. I have found that different breast implant profiles work very well and can produce a similar aesthetic look depending upon the anatomic dimensions of the patient and tissue characteristics.

It is important when operating on a patient with a short nipple to inframammary fold distance to select a breast implant that not only is proportionate to the base diameter, but also to the breast height. While it is important to maintain superior fullness of the breast it is important that the "take off" of the breast contour is not placed to superiorly or that the chest to breast angle is not too acute.

This patient is very happy with her breast augmentation as her breast/waist/hip ratio is in better proportion. Selection of appropriate breast implant size and dimension is paramount to an optimal outcome.

There are three different dimensions and profiles of breast implants. Mentor corporation makes a moderate, moderate plus, and high profile silicone gel breast implant. Allergan produces a style 10, style 15, and style 20 for their breast implants. These labels respectively correspond to breast implants with increasing projection to base diameter ratios.

Brian P. Dickinson, M.D.

www.drbriandickinson.com

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

Regular Diet. 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.

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.

Brian P. Dickinson, M.D.

www.drbriandickinson.com

Capsular Contracture Treatment

Capsular contracture symptoms usually begin with the patient noticing a distortion of their breast implant shape or the beginning of an occasional pain around the implant or the breast.

To explain the changes in the shape of the implanted breast with the development of capsular contracture it is important to understand the following:

Most breast implants while they may vary slightly depending upon profile are the shape of a disc. When the lining around the implant starts to aggressively contract symmetrically, the shape that forms is a sphere. Now the breast implant which was once a fixed volume in a defined surface area is now changed to the same volume being compressed into a smaller surface area by the capsular contracture. This change not only distorts the augmented breast, but the augmented breast also becomes firm. This firmness can cause capsular contracture symptoms such as sharp pain, dull pain, pain with movement of the breast, or with exercise. When the capsule implant complex becomes painful, the patient has developed a Baker IV capsular contracture.

Typically in these patients, my preferred method of capsular contracture treatment is total "en bloc" capsulectomy so that the entire capsule and implant contents can be removed in their entirety. Removal "en bloc" allows for an optimal plane with which to attempt implantation.

In the picture shown above, the one appreciates the spherical shape of the hard capsule lining which has compressed the discoid silicone implant. In this case the silicone implant shell was ruptured with the silicone remaining within the capsule.

I will continue to research capsular contracture treatment and prevention.

Brian Dickinson, M.D.
www.drbriandickinson.com

Capsular Contracture and Saline Implant Valve Failure

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There are an increasing number of patients who come into my office for consultation regarding capsular contracture pain. Recently, I am seeing more patients come to both the Beverly Hills and Newport Beach offices from the South, Midwest, and East Coast with capsular contracture symptoms.

Frequently these patients present with signs and symptoms related to their capsular contracture such as change in shape of their breast, asymmetry, pain, and more frequently I see women who present with malfunction of their saline breast implants. Occasionally if saline implants have been in place for a long period of time, the shell may undergo “fold flaws" and rupture at the weakest location of the shell.

Most recently, I have seen several cases where a capsular contracture has started to cause breast pain and soon after the patient experiences a deflation of their saline implant. While the leakage of saline does not cause any physical harm to the patient, it is nonetheless very distressing and post rupture may cause more pain to the patient.

In a recent case, as depicted above, I noticed that a small portion of the capsule had grown into the saline valve. While I cannot prove this, I believe that the continued pain experienced by the patient is the adherence of the capsule to the chest wall, muscle, or skin and the mobility of the ruptured implant within the capsule lining.

This motion with exertion, movement, etc. can be extremely painful to the patient and warrant surgical removal and replacement of the mammary prosthesis. More frequently, I am seeing more patients from outside of California who present with either Baker Grade IV capsular contracture or Baker Grade III capsular contracture who also have a malfunctioning of their breast prosthesis. Capsular contracture surgery is frequently performed at both the Beverly Hills and Newport Beach, CA surgery centers.

Brian P. Dickinson, M.D.

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Surgery After Weight Loss: RoxBariatric

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The RoxBariatric post-bariatric plastic surgery program continues to grow and expand. Post-bariatic body contouring surgery is becoming very popular as we are seeing patients not only from Southern California, but now patients from the Midwest who travel to Beverly Hills and Newport Beach to have their post-bariatric surgery performed. More patients are coming to the RoxBariatric Center to meet our team of plastic & reconstructive surgeons and then be introduced to a bariatric surgeon who will perform either a lapband procedure or gastric bypass procedure.

Occasionally, in patients who undergo bariatric surgery or simply loose weight through a bariatric diet, they develop excess of overlying abdominal skin termed a “pannus”.

Patients are coming to the RoxBariatric Plastic Surgery Program from out of state to have their panniculectomy or body contouring surgery performed by our team of plastic & reconstructive surgeons.

Insurance companies will pay for patients to have a panniculectomy performed or removal of this overhanging skin as long as certain criteria are met that deem the procedure medically necessary. These criteria include:

1. Panniculus hangs below the level of the pubis; and
2. Patients have chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs for a period of over 3 months while receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period of 3 months.
Frequently patients with subcostal scars present for these operations. Subcostal scars are normally right sided scars used to remove the gallbladder. We have seen many patients who have been turned away for abdominoplasty or panniculectomy operations due to the presence of these scars.

These operations can be performed, but need to be performed carefully by plastic & reconstructive surgeons who have demonstrated experience in these operations to ensure proper wound healing. When addressing panniculectomy or abdominoplasty in these patients it is important to respect the remaining blood supply to ensure rapid healing and prevent infection. Adequate nutrition is paramount for proper wound healing.

Brian P. Dickinson, M.D.

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RoxBariatric Health & Lifestyle Program

The RoxBariatric program continues to grow with as the most recent five patients who underwent lap band procedures continue to loose weight. We are starting to see not only significant reduction in weight of these patients, but ancillary physical signs improve as well. Notably one patient has lost a significant amount of weight in his neck and no longer snores at night. Not only has this improved his sleep patterns, but also those of his spouse.

Bariatric patients often loose greater than 100 lbs of weight over the course of six months to one year post surgery. Not only do these patients desire body contouring surgery, but also rejuvenation of their face and neck. I have found that facelift and necklift techniques provide a significant change in the facial aesthetics and be quite rewarding to these patients.

Traditionally when body contouring and facelift procedures, our patients stay over one night at an aftercare facility where they are examined by a physician that evening and the next morning at the aftercare facility or at the office.

RoxBariatric Health & Lifestyle Bariatric Program

Post-Bariatric Body Contouring Surgery is very rewarding to both the patient and Plastic & Reconstructive Surgeon. It is truly a great to be a part of the RoxBariatric program in Beverly Hills, CA. The RoxBariatric program is a Comprehensive Health & Lifestyle program initiated by Plastic & Reconstructive Surgeons and Bariatric Medicine Specialists.

Many patients ask me, Dr. D. what is bariatric surgery?

Bariatric surgery, or weight loss surgery, are procedures performed on people who are dangerously obese, for the purpose of losing weight and improving their overall health. Weight loss is achieved by reducing the size of the stomach, through removal of a portion of the stomach, or by resecting and re-routing the small intestines to a small stomach pouch. These procedures are called gastric banding, sleeve gastrectomy, or gastric bypass surgery, respectively. Not only can these surgeries produce significant long-term loss of weight, but also improve diabetes, lower blood pressure, improve cardiovascular risk factors, and reduce mortality.

Many patients then ask me, Dr. D. can bariatric surgery be covered or partially covered by my insurance?

Generally insurance will assist in covering these procedures for obese people with a BMI over 40 or people with a BMI of over 35 with coexisting medical conditions.

Finally, patients will ask me, Dr. D. can the post-bariatric body contouring procedures be covered or partially covered by my insurance?

Patients who have bariatric procedures loose over 100 lbs of weight and are left with excess skin that they find impossible to loose. Occasionally, the abdominal skin that overhangs the pubis can cause rashes in the area between the skin. Typically, if patients have these rashes and they are not relieved by prescription medications or other conservative measures to treat them for over six months, then insurance will cover or partially cover a panniculectomy. A panniculectomy is the removal of the overhanging skin or pannus. Other post-bariatric procedures may be covered or partially covered by health insurance or patients may pay for these procedures out-of-pocket. The RoxBariatric program is unique in that patients develop a relationship primarily with the Plastic & Reconstructive surgeons who will be performing their post-bariatric body contouring procedures. The initial consultation into the program includes a consult with a plastic & reconstructive surgeon as well as Dr. Pouya Shafipour and his colleagues who are Bariatric Medicine specialists. Once patients are deemed physically fit for surgery, they undergo their lap band or gastric bypass procedure. The patients are closely followed by the physicians and physician assistants at RoxBariatric to guide them through their weight loss to their post-bariatric body contouring procedures.

I am frequently asked, Dr. Dickinson-What can I do nutritionally to prepare for surgery?

Post-bariatric body contouring procedures are significant surgeries that require a lot of energy expenditure for the body to heal. I typically tell patients to eat one to two grams of protein per kilogram of body weight 4 weeks prior to and 4 weeks after surgery to optimize their healing. This diet improves outcomes and prevents wound complications.

Plastic & Reconstructive Surgery Journal Publication

It is truly a great honor to contribute to breast augmentation research and publish in the Journal of Plastic & Reconstructive Surgery with Dr. Malcolm Lesavoy and Dr. Andrew Trussler. Dr. Lesavoy is a great mentor to me and is a pioneer and leader in the field of plastic and reconstructive surgery. Dr. Trussler is the best chief resident I have ever learned from and is well on his way to becoming a leader in academic cosmetic surgery. I am very fortunate to know such great individuals.

Facelift, Upper Blepharoplasty, Lower Blepharoplasty

I am a strong proponent of significant attention to the neck and jowls in facelift surgery. While I find it equally important to elevate the cheek and midface, I believe that many patients are immediately satisfied with the appearance of the neck.

I have found that SMAS flaps used to define the angle of the mandible are very effective. I have found that direct excision of fat to give the greatest control to defat the neck. Anterior platysmaplasty is most effective to reduce platysmal banding.

Upper blepharoplasty with excision of periorbital fat is beneficial to rejuvenate the eyes. I am a proponent of transconjunctival removal of fat for lower blepharoplasty and when indicated "skin pinch" lower blepharoplasty to rejuvenate the lower eyelid.

While I have found many positive aspects to all of the different facelift techniques, my preferred technique involves sub-SMAS dissection and wide subcutaneous undermining.