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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

Houston Methodist offers new reconstruction technique for breast cancer survivors

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Some women no longer feel like they ever had breast cancer when they look in the mirror, thanks to a complex new procedure available at Houston Methodist in The Woodlands.

Breast Cancer does not run in Tana Key’s family. The occupational therapist had a normal mammogram. But not even a full year later, she began to feel what was only suspected to be a small, flared-up lymph node.


A thorough investigation in the dense tissue eventually resulted in the discovery of a small spot of Ductal carcinoma in situ — breast cancer, stage 0. But the diagnosis was not a death sentence.

After deciding to remove both breasts, a bilateral mastectomy, Key, 48, learned that precancerous cells were found in her other breast as well. She believes the early detection made it possible to prevent the potentially fatal spread.



“I chose the more aggressive surgical route because I didn’t want to have to worry anymore,” Key said.

Following the emotional experience, she turned to the Houston Methodist Institute for Reconstructive Surgery at the hospital off Texas 242 in The Woodlands, where she became the first patient there to undergo a less commonly performed, profunda artery perforator flaps procedure, also known as a PAP flap surgery with “ReSensation” technique.


The procedure involves taking excess fat tissue and small blood vessels from deep within the back of the patient’s thigh, along with donated nerve grafts, to give the woman innervated breasts that not only look but feel natural.


Now Key has not only defeated cancer, but regained sensation, confidence and peace of mind.

She praises the Houston Methodist team for their care and skill, which inspired her to return to work for the hospital system’s outpatient therapy clinic and gave her a chance