將肉毒桿菌素應用在進行乳房重建手術的乳癌患者
這是一篇最新的美國，關於乳癌患者進行乳房重建手術時，美國有些醫師，開始嘗試將肉毒桿菌素應用在這些患者身上，到底怎麼應用？讓我們來看看
The decision to undergo a double mastectomy and breast reconstruction surgery was an easy one for Erin Graves.
The 40-year-old Portland woman had tested positive for a mutation to her BRCA2 gene, one of two breast cancer susceptibility genes. Doctors estimated she had an 87 percent chance of getting breast cancer.
But the procedures were cause for some concern for Graves.
She had heard stories of terrible muscle spasms from other women who underwent reconstruction. She feared the pain from the reconstruction would leave her unable to care for her two young children, 4-year-old Richard and 2-year-old Reese.
這是一個發生在一位40歲的女性身上的故事；Graves 她的基因中有所謂的乳癌基因；BRCA2。再加上其他的評估因子，醫師認為她將來罹患乳癌的機率，高達87%，所以建議她接受乳房切除及重建手術。但是Grave 從其他的患友聽到的消息，都說乳房重建手術後，會非常痛，所以她一直猶豫不決。
But Graves didn't experience any pain from muscle spasms. The only pain she encountered was the expected soreness from the surgery.
"I was able to function with the kids from day one," she said.
Graves credits her spasm-free recovery to Dr. Allen Gabriel and his use of Botox during breast reconstruction.
手術後，Grave 幾乎感受不到什麼疼痛，除了傷口應有的些許痠痛，姊妹們事前告知的劇烈疼痛感，完全沒有感覺到，甚至手術後第二天，就可以跟她的孩子們，進行正常的日常活動了。
Gabriel, a plastic surgeon at PeaceHealth Medical Group Plastic Surgery, pioneered the use of the drug as a way to manage breast reconstruction pain without prolonged use of heavy narcotics.
"Botox plays a very important role in their healing, in my opinion," Gabriel said.
Preventing spasm pain
During breast reconstruction, an expander is placed on top of the pectoralis minor chest muscle and beneath the pectoralis major muscle.
Fluid is put into the expander — during both the surgery and subsequent office visits — to stretch the pectoralis major muscle and create a pocket for an implant. Once the expander is filled and the muscle heals, it is replaced with an implant.
During the expansion process, however, the fluid puts pressure on the muscle and can cause painful spasms. An injection of just 10 cubic centimeters, which is equivalent to less than one tablespoon, can cause spasms, Gabriel said.
"The biggest fear of reconstruction is the pain of the expanders," Gabriel said.
After seeing so many patients in pain, Gabriel and his mentor Dr. G. Patrick Maxwell, who practices in Nashville, Tenn., started thinking of ways to reduce pain. They theorized that Botox injections would offer pain relief by temporarily paralyzing the pectoralis major muscle during the expansion process.
原來在乳房切除之後，醫師會在胸大肌下面放置一個擴張用的水球，在日後門診的時候，會定時注入食鹽水來擴張水球，而其實接受重建手術的病人，最擔心的就是每次在門診打水的時候，因為只要10 CC 的水，就足以引起疼痛的感覺。而美國醫師Gabriel 開始利用在胸大肌注射肉毒桿菌素，來減少病患因為每次打水的時候，因為肌肉收縮造成的疼痛。
So in 2007, they launched a small study to test the theory. Thirty women scheduled for mastectomies and reconstruction were divided into two groups. One group received Botox injections in four spots in the pectoralis major muscle. The other group received saline injections.
Gabriel didn't know which patients received saline and which received Botox, but he quickly figured it out during post-surgery, follow-up exams.
"We could tell right away," he said. "It's a night-and-day difference."
Patients who received Botox didn't experience muscle spasms and stopped taking pain medications within days, rather than weeks, Gabriel said. And because the patients weren't experiencing painful spasms, they could receive more fluid during expander injections, he said.
With Botox, Gabriel typically injects 90 to 110 cubic centimeters of fluid at one time into the expanders. That means the expanders can be filled in just two or three injections as opposed to six to eight injections, he said.
The Botox takes three to seven days to kick in and lasts about three months, which covers the typical length of the reconstruction process, Gabriel said.
從2007開始，醫師開始使用這個方法，並且作了一個雙盲試驗，就是醫師本人也不知道那些患者打了肉毒，而那些只打了食鹽水。但是當病人一回診的時候，馬上就分辨出來了，因為施打肉毒的患者，相當可以忍受打水的過程，因此每次可以注射90-110 CC 的食鹽水，而且，注射後，口服止痛藥的服用，也從需要幾周，縮短到幾天就可以。而兩組病人相比，施打肉毒者，只需2-3 次的注射，反之，則需要六到八次之多。( 因為每次可以容忍的注射量大很多 )
Off-label use
The use of Botox during breast reconstruction is an off-label use, which means it's being used in a way different than what is described on the Food and Drug Administration-approved label. Off-label drug use is not regulated, but it is legal in the U.S.
Patients have to consent to the drug's use, but because it's off-label, insurance companies will not pay for it, Gabriel said.
Gabriel has used Botox on nearly all of his breast reconstruction patients — more than 300 women — since September 2008. PeaceHealth Southwest Medical Center and hospital foundation grants cover the cost of the Botox so the patients aren't charged, Gabriel said.
當然，保險是不會給付這些肉毒桿菌的使用，因為這是所謂的 off-label use。(非指示用藥的使用方式 )
所以，要不要花這個錢來止痛？就是消費者自己決定囉！
另外，胸大肌這麼大塊肌肉，需要多少的肉毒桿菌素？文中並沒有提到。我想，一邊一瓶 ( 100 單位 )，應該是基本要求，也就是說，需要起碼四五萬新台幣，這真是讓人陷入長考啊！
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