Surgical protocol reduces opioid use for breast reconstruction patients

Breast cancer surgeries can be quite painful, so a team at Houston Methodist West Hospital has worked to develop pain management protocols that help some patients while reducing the use of narcotics.

Dr. Candy Arentz, a breast surgical oncologist, and Dr. Warren Ellsworth, a plastic surgeon, have been using an enhanced recovery after surgery (ERAS) protocol with non-narcotic medications and nerve blocks to lessen pain and the need for narcotics in reconstructive surgeries.


A DIEP flap reconstruction uses tissue and fat from the abdomen and other areas to reconstruct the breast after a lumpectomy or a mastectomy. Ellsworth said the reconstruction can be beneficial because it can look more natural than implants and can last the rest of a patient’s life. But it can be more painful because of the extra incisions. He recognizes that opioid overuse is an issue and said that is just one reason why he and Arentz are working to reduce opioid use.

“We have also, I would say, across the entire house of medicine known about this opioid overuse, opioid dependence and all these challenges that our narcotics impose on our patients, not only the basic side effects of narcotics like nausea, vomiting, constipation, but of course, the dependency,” Ellsworth said.

The ERAS protocol helps patients with pain starting the day before the surgery. “So it prepares their body for the surgery and the pain that could occur, and then we continue the pain control throughout the surgery and then of course postoperatively and have found a significant reduction in the use of narcotics because of this protocol,” Ellsworth said.

As Arentz and Ellsworth were coming up with the protocol, Ellsworth consulted with plastic surgeons at the University of Pennsylvania and Stanford University, modeling the Methodist West protocol after their programs. But according to Ellsworth, Methodist West is the first in the Houston area to make the non-narcotic protocols a priority with their patients in the area of DIEP flap reconstructions.

Ellsworth said starting ERAS required bringing in others in the hospital on board, including the head of anesthesiology so that anesthesiologists could administer nerve blocks, or long-lasting numbing injections into patients’ nerves, and the head of the ICU (intensive care unit) because the new protocols were a big change in pain management. Arentz said it required patient buy-in as well.

“It starts with our conversations in clinic and assuring the patients that they will have decreased pain afterwards than probably what they were expecting,” Arentz said, adding that the protocol is done without using IV medications, which is what most people expect when they are going to have surgery.

Arentz and Ellsworth had planned to start using ERAS in February or March, but COVID-19 shifted it back some. So they started in April. Ellsworth said that all

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Full Mouth Reconstruction, Rehabilitation, Restoration

Medically Reviewed by: Thomas K. Hedge, DDS

Full mouth reconstruction, rehabilitation and restoration are terms often used interchangeably to describe the process of rebuilding or simultaneously restoring all of the teeth in both the upper and lower jaws.

Full mouth reconstruction typically involves general or restorative dentists (performing procedures like crowns, bridges and veneers), and can incorporate dental specialists like periodontists (specializing in the gums), oral surgeons, orthodontists (specializing in tooth movements and positions) and endodontists (specializing in the tooth pulp).

The need for full mouth reconstruction may result from:

  • Teeth that have been lost due to decay or trauma.
  • Teeth that have been injured or fractured.
  • Teeth that have become severely worn as a result of long-term acid erosion (foods, beverages, acid reflux) or tooth grinding.
  • Ongoing complaints of jaw, muscle and headache pain requiring adjustments to the bite (occlusion).

How the Process Begins

If you think you need reconstruction, see your dentist for a comprehensive examination. Your dentist will examine your mouth to determine the extent of the problem and the treatment options that can be used to correct it. In particular, he or she will examine the condition of your:

  • Teeth: The condition of your teeth will determine what restorative procedures may be needed, such as porcelain veneers or full-coverage crowns, inlays or onlays, bridges or implants restored with a crown. In particular, your dentist will make note of any cavities and decay, tooth wear, cracks, short/long teeth, root canal issues and any tooth movement.
  • Periodontal (gum) tissues: If your gums are not healthy, you will most likely need scaling and root planing to treat periodontal disease. You may require more intensive treatments from a periodontist to ensure that your newly reconstructed teeth will have a solid foundation. Such treatments could involve soft tissue or bone grafts to build up your gums and underlying jaw bone. Your dentist will look for deep pockets, excessive or insufficient gum tissue, periodontal disease and bone density irregularities.
  • Temporomandibular joints, jaw muscles and occlusion: A stable bite – one in which you are not in pain when you close your mouth or chew and one that does not cause wear or destruction of your teeth – is important to your overall oral health. Occlusal changes need to be taken into consideration when your dentist plans your restorations. In fact, you may require orthodontics or some other type of treatment (night guard or bite reprogramming orthotic) to correct occlusion before additional restorative procedures can be performed.
  • Esthetics: The color, shape, size and proportion of your teeth, and how they appear in relation to your gums, lips, mouth, side profile and face, are also important factors in full mouth reconstruction.

The examination process requires records of your mouth, such as X-rays and photographs, impressions of your upper and lower teeth, models of your teeth that are made from the impressions and a model of your bite. Your dentist may also refer you to specialists (periodontist, orthodontist, oral surgeon) for a consultation in order

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