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New medication approach speeds recovery from breast-cancer surgery

The struggles faced by breast-cancer survivors often don't end once the disease is in remission. Patients who have had mastectomies are left with a physical – and psychological – reminder of breast cancer.

Reconstructive surgery has become a popular option for many women who want to restore the previous look and feel of their breasts, seen by many survivors as an important part of the healing process.

But breast reconstruction can be a painful ordeal that involves several days in a hospital bed on powerful drugs. Not only do patients spend a lot of time recovering in hospital, but nausea and other side effects from painkillers such as morphine can prolong the stay further.

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A health team at Toronto's Women's College Hospital is experimenting with a new way to treat patients who come in for a particular kind of reconstruction surgery – the transverse rectus abdominis myocutaneous flap procedure, or TRAM flap. It involves transferring skin, fat and muscle from the abdomen to the chest and using the tissues to construct a new breast.

Instead of waiting until the surgery is over to give women pain-killing drugs, a team led by John Semple, the hospital's chief of surgery, is medicating women before the procedure begins with a combination of drugs including Tylenol or Advil-type medications, the strong painkiller gabapentin, and sometimes a narcotic painkiller.

The method has greatly reduced hospital stays, and women are experiencing less post-operative pain, Dr. Semple said. The patients are also using significantly less morphine after surgery.

The team has treated about 30 patients with the new medication procedure, which it started offering earlier this year, and has found that, on average, patients are going home 23 hours after surgery instead of up to a week.

"It's a much more sophisticated system for pain control," Dr. Semple said.

Getting pain medication to the site of the operation even before the scalpel cuts into the skin appears to provide better pain control and reduce the need for morphine afterward. The approach reduces overall pain and minimizes morphine side effects.

The new method also represents an important step for Women's College Hospital, which is embarking on an ambitious program to get rid of its beds and reinvent itself as an outpatient hospital that emphasizes preventing illness and treating patients more efficiently.

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Hamila Lotfi is one of the women who underwent the new TRAM flap procedure. Initially, she was fearful that the post-operative pain would be unbearable, having read horror stories from other patients online, she said. But when she woke up from surgery, she was surprised that she didn't feel any pain. It's been more than two months since her reconstruction was done, and Ms. Lotfi said she didn't experience serious pain at all during her recovery.

"I figured for 10 days to two weeks I'd be at home in agony," said Ms. Lotfi, who lives in Toronto. "[But there was] no pain next day. … It was amazing. I don't know how these doctors did it."

As well as medication changes, new methods of breast reconstruction have been developed that help reduce pain and recovery time. One new operation, the deep inferior epigastric perforator (DIEP) flap procedure, involves moving skin and fat from the abdomen to the mastectomy area to reconstruct the breast. The DIEP flap procedure is more complex and takes a few hours longer than the TRAM flap because surgeons must perform microsurgery to connect blood vessels from the transferred tissue to the chest area.

But a key advantage to the DIEP procedure is that the abdominal muscles are left intact, which means women can recover faster, feel less pain and have a lower risk of losing core abdominal strength.

However, because it's a complicated and time-consuming procedure, few centres are performing the DIEP procedure, said Stefan Hofer, chief of the plastic surgery division at Toronto's University Health Network, who has started using it.

Dr. Hofer has teamed with Dr. Semple at Women's College to use the new method of medicating women before the DIEP flap procedure, and the approach .

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seems highly effective, he said. However, women still typically stay in the hospital for a few days to ensure there are no problems with the newly connected blood vessels.

The DIEP flap procedure remains superior in many respects, and can be performed on a wider variety of women than the TRAM flap procedure, because the blood supply is more reliable, Dr. Hofer said.

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About the Author

Carly Weeks has been a journalist with The Globe and Mail since 2007.  She has reported on everything from federal politics to the high levels of sodium in the Canadian diet. More

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