Ischemic Complications in Pedicle, Free, and Muscle Sparing Transverse Rectus Abdominis Myocutaneous Flaps for Breast Reconstruction

Single-Pedicled, Supercharged, or Bi-Pedicled? A Multi-Institutional Outcome Comparison of Pedicled TRAM Flap for Autologous Breast Reconstruction

INTRODUCTION

A direct comparison of outcomes among the 3 main types of pedicled TRAM-single-, supercharged, and bi-pedicled-has yet to be conducted.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database (2008-2022) was analyzed to identify female patients who underwent pedicled TRAM flap breast reconstruction. Patients were stratified by TRAM flap type, and their 30-day postoperative outcomes were compared.

RESULTS

A total of 2022 patients (mean age: 53 ± 9.4 years; mean BMI: 29 ± 6.4 kg/m2) were included, of whom 73% (n = 1473) received single-pedicled, 16% (n = 327) supercharged, and 11% (n = 222) bi-pedicled TRAM flaps. Overall, 433 (21%) patients experienced complications, with 155 (7.7%) surgical and 190 (9.4%) medical complications. Multivariate analysis showed generally comparable outcomes among the 3 types, but bi-pedicled flaps had a higher risk of medical complications (OR: 1.6; P = .04). Smoking, higher ASA classes, and higher BMI were independently associated with the occurrence of any complication (OR: 1.74, P = .001; OR: 1.76, P < .001; OR: 1.04, P < .001), surgical complications (OR: 1.85, P = .01; OR: 1.71, P = .002; OR: 1.035, P = .002), and readmission (OR: 2.54, P < .001; OR: 1.62, P = .02; OR: 1.04, P = .002). Smoking (OR: 2.38, P < .001), higher BMI (OR: 1.03, P = .004), and hypertension (OR: 1.47, P = .02) correlated with an increased likelihood of reoperation.

CONCLUSION

This study revealed that outcomes after single-, supercharged, and bi-pedicled TRAM flaps are generally comparable. Yet, bi-pedicled TRAM flap reconstruction was seen to be associated with a higher risk of medical complications. Smoking, obesity, higher ASA class, and hypertension were identified as risk factors for adverse events.

Imaging of the Reconstructed Breast

The incidence of breast cancer and, therefore, the need for breast reconstruction are expected to increase. The many reconstructive options available and the changing aspects of the field make this a complex area of plastic surgery, requiring knowledge and expertise. Two major types of breast reconstruction can be distinguished: breast implants and autologous flaps. Both present advantages and disadvantages. Autologous fat grafting is also commonly used. MRI is the modality of choice for evaluating breast reconstruction. Knowledge of the type of reconstruction is preferable to provide the maximum amount of pertinent information and avoid false positives. Early complications include seroma, hematoma, and infection. Late complications depend on the type of reconstruction. Implant rupture and implant capsular contracture are frequently encountered. Depending on the implant type, specific MRI signs can be depicted. In the case of myocutaneous flap, fat necrosis, fibrosis, and vascular compromise represent the most common complications. Late cancer recurrence is much less common. Rarely reported late complications include breast-implant-associated large cell anaplastic lymphoma (BIA-ALCL) and, recently described and even rarer, breast-implant-associated squamous cell carcinoma (BIA-SCC). In this review article, the various types of breast reconstruction will be presented, with emphasis on pertinent imaging findings and complications.

Whole Breast Reconstruction in Developing India: a Cancer Surgeon's Experience with the Pedicled Transverse Rectus Abdominis (TRAM) Flap

Challenges in the Indian surgical oncology practice are varied - too many patients per surgeon, long operative waitlists, lacking infrastructure, and often a dearth of plastic surgeons. Immediate whole breast reconstruction is rarely offered after mastectomy. Given the unavailability of a dedicated plastic surgery team, we initiated pedicled transverse rectus abdominis myocutaneous (TRAM) flaps in our practice to give patients a more holistic treatment. We present the first 33 cases done solely by a surgical oncologist. We retrospectively evaluated 33 patients from January 2017 to December 2019 who underwent pedicled TRAM flap for immediate whole breast reconstruction following mastectomy for cancer. The primary endpoint was to study the incidence of severe flap-related complications of the pedicled TRAM flap at the mastectomy site when done by a surgical oncologist. Secondary endpoints were flap necrosis-rates and donor site morbidity. Exclusion criteria were age > 60 years, body mass index > 30 kg/m2, diabetes mellitus, and prior abdominal surgery. Flap-related complications were classified according to Andrades et al. and donor site complications were classified as wound dehiscence, infection, hematoma, seroma, and hernia. Frequencies and percentages and median with interquartile range were used respectively for categorical and continuous variables. Flap-related morbidity was 21.2% (7/33), while donor site complications were 24.2% (8/33). Flap necrosis (partial or total), mastectomy-related complications, and incisional hernia were not seen in any of the patients. Median operative time was 180 min. Pedicled TRAM flap is feasible and safe when performed by surgical oncologists, immediately after mastectomy, in the developing world. Psychosocial acceptance remains challenging, and requires dedicated counselling and inter-patient communication.

Morbidity of the Donor Site and Complication Rates of Breast Reconstruction with Autologous Abdominal Flaps: A Systematic Review and Meta-Analysis

Background. Numerous studies have evaluated the use of autologous abdominal tissue for breast reconstruction; nevertheless, complications and donor site morbidity rates vary significantly. The study aims to compare the literature regarding morbidity of the donor site and complication rates of breast reconstruction with autologous abdominal flaps. Methods. The databases of MEDLINE, EBSCO, Scopus, Wiley Library, and Web of Sciences were searched for studies that compared different flaps in terms of complications and donor site morbidity. The procedures studied included pedicled transverse rectus abdominis myocutaneous flap (pTRAM), free TRAM (fTRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery perforator (SIEA) flaps. A total of 34 studies were included. Of these, 28 were retrospective studies and 9 were prospective cohort studies. Results. When compared to DIEP, fTRAM flaps were found to have a decreased incidence of flap fat necrosis, hematoma, and total thrombotic events, yet a higher risk of donor site hernia/bulging. pTRAM flaps were also associated with an increased risk of hernia/bulging at the donor site, as well as wound infection, yet flap hematoma was less common. On the other hand, SIEA flaps showed the lowest risk of donor site hernia/bulging while still having a high risk of wound infection. Conclusion. fTRAM procedures comparatively had the least complications. However, regarding flap choice, patients would benefit most from a case-by-case analysis, taking into consideration individual risk factors and preferences.

Liberal versus Modified Intraoperative Fluid Management in Abdominal-flap Breast Reconstructions. A Clinical Study

Background:

The outcome of reconstructive microsurgery is influenced by the intraoperative anesthetic regimen. The aim of this study was to compare the impact on the intra- and postoperative complication rates of our modified fluid management (MFM) protocol with a previously used liberal fluid management protocol in abdominal-flap breast reconstructions.

Methods:

This retrospective study analyzed adverse events related to secondary unilateral abdominal-flap breast reconstructions in two patient cohorts, one with a liberal fluid management protocol and one with a MFM protocol. In the MFM protocol, intravenous fluid resuscitation was restricted and colloid use was minimized. Both noradrenaline and propofol were implemented as standard in the MFM protocol. The primary endpoints were surgical and medical complications, as observed intraoperatively or postoperatively, during or shortly after the hospital stay.

Results:

Of the 214 patients included in the study, 172 patients followed the MFM protocol. Prior radiotherapy was more frequent in the MFM protocol. Surgical procedures to achieve venous superdrainage were more often used in the MFM cohort. Intraoperative as well as postoperative complications occurred significantly more frequently in the liberal fluid management cohort and were specifically associated with partial and total flap failures. Prior radiotherapy, additional venous drainage, or choice of inhalation agent did not have an observable impact on outcome.

Conclusions:

The incidence of adverse events during and after autologous breast reconstructive procedures was reduced with the introduction of an MFM protocol. Strict intraoperative fluid control combined with norepinephrine and propofol was both beneficial and safe.

Overall Complication Rates of DIEP Flap Breast Reconstructions in Germany-A Multi-Center Analysis Based on the DGPRÄC Prospective National Online Registry for Microsurgical Breast Reconstructions

While autologous breast reconstruction has gained momentum over recent years, there is limited data on the structure and quality of care of microsurgical breast reconstruction in Germany. Using the breast reconstruction database established by the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC), the presented study investigated the overall outcomes of deep inferior epigastric perforator (DIEP) flap reconstructions in Germany. Data of 3926 patients and 4577 DIEP flaps performed by 22 centers were included in this study. Demographics, patient characteristics, perioperative details and postoperative outcomes were accounted for. Centers performing < Ø 40 (low-volume (LV)) vs. ≥ Ø 40 (high-volume (HV)) annual DIEP flaps were analyzed separately. Overall, total and partial flap loss rates were as low as 2.0% and 1.1% respectively, and emergent vascular revision surgery was performed in 4.3% of cases. Revision surgery due to wound complications was conducted in 8.3% of all cases. Mean operative time and length of hospital stay was significantly shorter in the HV group (LV: 385.82 min vs. HV: 287.14 min; LV: 9.04 (18.87) days vs. HV: 8.21 (5.04) days; both p < 0.05). The outcome and complication rates deduced from the national registry underline the high standard of microsurgical breast reconstruction on a national level in Germany.

Perioperative Fluid Resuscitation in Free Flap Breast Reconstruction: When Is Enough Enough?

Perioperative liberal fluid resuscitation (LFR) can result in interstitial edema and venous congestion and may be associated with compromised perfusion of free flaps and higher incidence of wound complications. We hypothesized that restrictive intraoperative fluid resuscitation improves flap perfusion and lowers the wound complication rate in free flap breast reconstruction.

Photobiomodulation with polychromatic light increases zone 4 survival of transverse rectus abdominis musculocutaneous flap

OBJECTIVE

The aim of this study was to evaluate the effect of relatively novel approach of application of polychromatic light waves on flap survival of experimental musculocutaneous flap model and to investigate efficacy of this modality as a delay procedure to increase vascularization of zone 4 of transverse rectus abdominis musculocutaneous (TRAM) flap.

METHODS

Twenty-one Wistar rats were randomized and divided into 3 experimental groups (n = 7 each). In group 1 (control group), after being raised, the TRAM flap was sutured back to its bed without any further intervention. In group 2 (delay group), photobiomodulation (PBM) was applied for 7 days as a delay procedure, before elevation of the flap. In group 3 (PBM group), the TRAM flap was elevated, and PBM was administered immediately after the flap was sutured back to its bed for therapeutic purpose. PBM was applied in 48 hours interval from 10 cm. distance to the whole abdominal wall both in groups 2 and 3 for one week. After 7 days of postoperative follow-up, as the demarcation of necrosis of the skin paddle was obvious, skin flap survival was further evaluated by macroscopic, histological and microangiographic analysis.

RESULTS

The mean percentage of skin flap necrosis was 56.17 ± 23.68 for group 1, 30.92 ± 17.46 for group 2 and 22.73 ± 12.98 for group 3 PBM receiving groups 2 and 3 revealed less necrosis when compared to control group and this difference was statistically significant. Vascularization in zone 4 of PBM applied groups 2 and 3 was higher compared to group 1 (P = 0.001). Acute inflammation in zone 4 of group 1 was significantly higher compared to groups 2 and 3 (P = 0.025). Similarly, evaluation of zone 1 of the flaps reveled more inflammation and less vascularization among the samples of the control group (P = 0.006 and P = 0.007, respectively). Comparison of PBM receiving two groups did not demonstrate further difference in means of vascularization and inflammation density (P = 0.259).

CONCLUSION

Application of PBM in polychromatic fashion enhances skin flap survival in experimental TRAM flap model both on preoperative basis as a delay procedure or as a therapeutic approach. Lasers Surg. 51:538-549, 2019. © 2019 Wiley Periodicals, Inc.

ICG angiography in immediate and delayed autologous breast reconstructions: peroperative evaluation and postoperative outcomes

Postoperative complications in patients undergoing autologous breast reconstruction should be kept at the lowest possible level. Optimization of autologous breast reconstruction, especially techniques that can identify tissue perfusion and ischemia, will greatly benefit the patients and consequently society. Hence, the aim of this study was to evaluate the complication rates for autologous pedicle flap breast reconstructions, with and without the use of ICG-angiography. A single-institution retrospective review of mastectomy patients was performed. A total of 230 cases who underwent immediate or delayed, unilateral or bilateral pedicle autologous flap breast reconstruction between January 2013 and September 2016 was reviewed. Complication rates in the ICG-angiography and clinical assessment group were evaluated and compared. A total of 191 cases were identified of which 77 were evaluated with ICG-angiography, and 114 were evaluated clinically. There was no significant difference in overall complication rates between the two groups (ICG-angiography, 36.4%; Clinical assessment, 37.7%; p = .88). No significant difference was observed when stratifying for major or minor complications. However, when stratifying for the timing of the reconstruction, the rate of major complications was significantly lower in the ICG-angiography group (ICG-angiography, 0%; Clinical assessment 23.3%; p = .039). BMI was significantly associated with increased risk of minor complications (p = .018), whereas there was no correlation to age, prior smoking, chemotherapy, radiation, diabetes, or hypertension. Our study found that use of ICG-angiography was associated with a significant decrease in the rate of major complications for immediate autologous reconstructions.

Deep Inferior Epigastric Perforator Versus Free Transverse Rectus Abdominis Myocutaneous Flap: Complications and Resource Utilization

INTRODUCTION

Abdominal based breast reconstruction exists in a continuum from pedicled transverse rectus abdominis myocutaneous (TRAM) flap to deep inferior epigastric perforator (DIEP) free flap. DIEP flap has the advantage of complete rectus abdominis sparing during harvest, thus decreasing donor site morbidity. Aim of this study is to determine whether the surgical advantages of the DIEP flap impact postoperative outcomes versus the free TRAM flap (fTRAM).

METHODS

We reviewed the Nationwide Inpatient Sample database (2010-2011) for all cases of DIEP and fTRAM breast reconstruction. Inclusion criteria were: female sex and patients undergoing DIEP or fTRAM total breast reconstruction. Male sex was excluded from the analysis. We examined demographic characteristics, hospital setting, insurance information, patient income, comorbidities, postoperative complications (including reoperation, hemorrhage, hematoma, seroma, myocardial infarction, pulmonary embolus, wound infection, and flap loss), length of stay, and total charges (TCs). Bivariate and multivariate analyses were performed to identify independent risk factors of increased length of stay and TCs.

RESULTS

Fifteen thousand eight hundred thirty-six cases were identified. Seventy percent were white, 97% were insured, and 83% of patients were treated in an academic teaching hospital setting. No mortalities were recorded. The DIEP cohort was more likely to be obese (P = 0.001). Free TRAM cohort was more likely to suffer pneumonia (P < 0.001; odds ratio [OR], 3.7), wound infection (P = 0.001; OR, 1.7), and wound dehiscence (P < 0.001; OR, 4.3). Type of reconstruction did not appear to affect risk of revision, hemorrhage, hematoma, seroma, or flap loss. Total charges were higher in the DIEP group (P < 0.001). Multivariate analysis demonstrated that fTRAM was an independent risk factor for increased length of stay (P < 0.001; OR, 1.6), and DIEP was an independent risk factor for increased TCs (P < 0.01; OR, 1.5). There was no significant difference in postoperative complications.

CONCLUSIONS

The fTRAM cohort was more likely to develop surgical site complications and have an increased length of stay, but TCs were higher for the DIEP group.

Breast reconstruction with anatomical implants: A review of indications and techniques based on current literature

One important modality of breast cancer therapy is surgical treatment, which has become increasingly less mutilating over the last century. Breast reconstruction has become an integrated part of breast cancer treatment due to long-term psychosexual health factors and its importance for breast cancer survivors. Both autogenous tissue-based and implant-based reconstruction provides satisfactory reconstructive options due to better surgeon awareness of "the ideal breast size", although each has its own advantages and disadvantages. An overview of the current options in breast reconstruction is presented in this article.

Free Versus Pedicled TRAM Flaps: Cost Utilization and Complications

INTRODUCTION

Conventionally, free transverse rectus abdominis myocutaneous (fTRAM) flap breast reconstruction has been associated with decreased donor site morbidity and improved flap inset. However, clinical success depends upon more sophisticated technical expertise and facilities. This study aims to characterize postoperative outcomes undergoing free versus pedicled TRAM (pTRAM) flap breast reconstruction.

METHODS

Nationwide inpatient sample database (2008-2011) was reviewed for cases of fTRAM (ICD-9-CM 85.73) and pTRAM (85.72) breast reconstruction. Inclusion criteria were females undergoing pTRAM or fTRAM breast reconstruction; males were excluded. We examined demographics, hospital setting, insurance information, patient income, and comorbidities. Clinical endpoints included postoperative complications, length-of-stay (LOS), and total charges (TC). Bivariate/multivariate analyses were performed to identify independent risk factors associated with increased complications and resource utilization.

RESULTS

Overall, 21,655 cases were captured. Seventy-percent were Caucasian, 95 % insured, and 72 % treated in an urban teaching hospital. There were 9 pTRAM and 6 fTRAM in-hospital mortalities. On bivariate analysis, the fTRAM cohort was more likely to be obese (OR 1.2), undergo revision (OR 5.9), require hemorrhage control (OR 5.7), suffer hematoma complications (OR 1.9), or wound infection (OR 1.8) (p < 0.003). The pTRAM cohort was more likely to suffer pneumonia (OR 1.6) and pulmonary embolism (OR 2.0) (p < 0.004). Reconstruction type did not affect risk of flap loss or seroma occurrence. TC were higher with fTRAM (p < 0.001). LOS was not affected by procedure type. On risk-adjusted multivariate analysis, fTRAM was an independent risk factor for increased LOS (OR 1.6), TC (OR 1.8), and postoperative complications (OR 1.3) (p < 0.001).

CONCLUSION

Free TRAM has an increased risk of postoperative complications and resource utilization versus pTRAM on the current largest risk-adjusted analysis. Further analyses are required to elucidate additional factors influencing outcomes following these procedures.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the A3 online Instructions to Authors. www.springer.com/00266 .

Complications and oncologic outcomes of pedicled transverse rectus abdominis myocutaneous flap in breast cancer patients

BACKGROUND

There are several techniques for harvesting the pedicled transverse rectus abdominis myocutaneous (TRAM) flap after mastectomy in breast cancer patients. We examined the whole muscle with partial sheath sparing technique and determined factors associated with its complications and oncological outcomes.

METHODS

We retrospectively reviewed the results of 168 TRAM flaps performed between January 2003 and December 2010, focusing on complications and oncologic outcomes.

RESULTS

Among the 168 pedicled TRAM flap procedures in 158 patients, flap complications occurred in 34%. Most of the flap complications included some degree of fat necrosis. There was no total flap loss. Flap complications were associated with elderly patients and the presence of major donor site complications. Abdominal bulging and hernia occurred in 12% of patients. The bi-pedicled TRAM flap and higher body mass index (BMI) were significant factors associated with increased donor site complications. Seven patients (4%) developed loco-regional recurrence. Within a median follow-up of 27 months, distant metastasis and death occurred in 6% and 4% of patients, respectively.

CONCLUSIONS

The pedicled TRAM flap using the whole muscle with partial sheath sparing technique in the present study is consistent with the results from previous studies in flap complication rates and oncological outcomes.

NSQIP Analysis: Increased Immediate Reconstruction in the Treatment of Breast Cancer

Immediate reconstruction after the surgical treatment of breast cancer has increased in the last decade. The purpose of this study is to use the National Surgical Quality Improvement Program database to analyze long-term trends in breast reconstruction. Women who underwent mastectomy for invasive or in situ breast cancer or prophylaxis between 2005 and 2011 were selected from the National Surgical Quality Improvement Program database. Trends and predictors for reconstruction were explored. In 44,410 women identified, immediate reconstruction increased from 30.0 to 39.6 per cent from 2005 to 2011 ( P < 0.001). This trend persisted after adjustment for patient characteristics using multivariate logistic regression [odds ratio (OR) 1.09/year, 95% confidence interval (CI) 1.07–1.10]. Reconstruction type was 77.9 per cent implant, 13.3 per cent pedicle flap, 5.5 per cent free flap, and 3.3 per cent other. Pedicle flaps decreased from 27.1 to 9.2 per cent ( P < 0.001), implant-based reconstruction increased from 66.3 to 81.3 per cent ( P < 0.001), and free flaps remained stable between 4 and 7 per cent. Independent predictors for reconstruction were young age (stepwise decrease in OR from 1 to 0.02 by decade as age increased from 40 to 80, all P < 0.001), carcinoma in situ (OR 1.51, 95% CI 1.42–1.61), prophylaxis (OR 1.89, 95% CI 1.63–2.19), bilateral resection (OR 2.55, 95% CI 2.42–2.69), and non-Hispanic white race (OR 0.67 for other races, 95% CI 0.64–0.70). Immediate breast reconstruction has steadily increased since 2005 with an associated rise in implant-based reconstruction. Based on these trends, discussion with a reconstructive surgeon should be an early part of the newly diagnosed breast cancer patient's treatment algorithm.

Breast reconstruction following conservative mastectomies: predictors of complications and outcomes

Breast reconstruction can be performed using a variety of techniques, most commonly categorized into an alloplastic approach or an autologous tissue method. Both strategies have certain risk factors that influence reconstructive outcomes and complication rates. In alloplastic breast reconstruction, surgical outcomes and complication rates are negatively impacted by radiation, smoking, increased body mass index (BMI), hypertension, and prior breast conserving therapy. Surgical factors such as the type of implant material, undergoing immediate breast reconstruction, and the use of fat grafting can improve patient satisfaction and aesthetic outcomes. In autologous breast reconstruction, radiation, increased BMI, certain previous abdominal surgery, smoking, and delayed reconstruction are associated with higher complication rates. Though a pedicled transverse rectus abdominis myocutaneous (TRAM) flap is the most common type of flap used for autologous breast reconstruction, pedicled TRAMs are more likely to be associated with fat necrosis than a free TRAM or deep inferior epigastric perforator (DIEP) flap. Fat grafting can also be used to improve aesthetic outcomes in autologous reconstruction. This article focuses on factors, both patient and surgical, that are predictors of complications and outcomes in breast reconstruction.

Outcomes of Take-Back Operations in Breast Reconstruction with Free Lower Abdominal Flaps

Background

Microvascular complications after free-flap breast reconstructions are potentially devastating problems that can increase patient morbidity and lead to flap loss. To date, no comprehensive study has examined the rates of salvage and the methods of microvascular revision in breast reconstruction. We reviewed the treatment of microvascular complications of free-flap breast reconstruction procedures over a seven-year period.

Methods

A retrospective review of all patients who underwent microvascular breast reconstruction at our institution between April 2006 and December 2013 was conducted. Based on their surgical records, all patients who required emergency re-exploration were identified, the rate of flap salvage was determined, the factors associated with flap salvage were evaluated, and the causes and methods of revision were reviewed.

Results

During the review period, 605 breast reconstruction procedures with a free lower abdominal flap were performed. Seventeen of these flaps were compromised by microvascular complications, and three flaps were lost. The overall salvage rate was 82.35%. No significant differences between the salvaged group and the failed group were observed with regard to age, BMI, axillary dissection, number of anastomotic arteries and veins, recipient vessel types, or use of the superficial inferior epigastric vein in the revision operation. Successful salvage of the flap was associated with a shorter time period between recognizing the signs of flap compromise and the take-back operation.

Conclusions

The salvage rate of compromised lower abdominal flaps was high enough to warrant attempting re-exploration. Immediate intervention after the onset of flap compromise signs is as important as vigilant postoperative monitoring.

Breast reconstruction with a turbocharged transverse rectus abdominis myocutaneous flap on the contralateral perforator

Seventeen patients were submitted to delayed unilateral breast reconstruction using pedicled, muscle-sparing turbocharged transverse rectus abdominis myocutaneous flap based on the contralateral perforator vessels. The lateral portion of the rectus abdominis muscle on the pedicled side was preserved in 12 patients. Zones II and IV were included in the flap in all cases. Mean duration of surgery was 7 hours and 15 minutes. Four complications developed in the abdominal donor site: contralateral abdominal bulging (n=1), minor suture dehiscence (n=2), and epidermolysis at the border of the abdominal flap and umbilical scar (n=1). Three partial losses (10%-30%) occurred in the reconstructed breast (17.64% of cases), whereas 2 cases of fat necrosis were associated with partial losses. One patient developed deep vein thrombosis with pulmonary embolism; however, outcome was favorable. This proved a viable alternative for breast reconstruction, with satisfactory results in most patients and acceptable morbidity and surgical time.

Adjuvant chemotherapy increases the prevalence of fat necrosis in immediate free abdominal flap breast reconstruction

BACKGROUND

Fat necrosis is one of the most common complications following free flap breast reconstruction. Although a minor complication, fat necrosis can compromise esthetic results and confuse with cancer recurrence. Perfusion-related factors and post-operative radiotherapy are the known risks. However, the influence of adjuvant chemotherapy on fat necrosis prevalence remains unknown.

METHODS

Our initial experience of 88 consecutive breast reconstructions with free abdominal flaps was reviewed. The prevalence of fat necrosis was recorded and the risk factors were analyzed using univariate and multivariate logistic regression models.

RESULTS

The overall prevalence of fat necrosis was 36.4% in this series. In a multivariate logistic regression model, adjuvant chemotherapy significantly increased the risk of fat necrosis. The relative risk was 4.762 (95% confidence interval (CI), 1.767-12.831; p = 0.002). There was no evidence of a specific chemotherapeutic agent causing fat necrosis. The first cycle of adjuvant chemotherapy was frequently delivered earlier in patients with fat necrosis than those without fat necrosis, although this tendency was not statistically significant.

CONCLUSIONS

Our initial experience with free flap breast reconstruction seems to suggest that chemotherapy may increase the risk of fat necrosis following immediate breast reconstruction. Patients should be fully informed, and the initiation of post-operative chemotherapy may be adjusted accordingly.

Evidence-based medicine: breast reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Differentiate among the various techniques available to reconstructive breast surgeons. 2. Perform a comprehensive assessment of the breast reconstruction candidate. 3. Gain knowledge about the indications and contraindications for different breast reconstructive procedures. 4. Understand the complications inherent in different reconstructive breast procedures. 5. Summarize the long-term objective and subjective implications of surgery.

SUMMARY

This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

Increased Flap Weight and Decreased Perforator Number Predict Fat Necrosis in DIEP Breast Reconstruction

Background:

Compromised perfusion in autologous breast reconstruction results in fat necrosis and flap loss. Increased flap weight with fewer perforator vessels may exacerbate imbalances in flap perfusion. We studied deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps to assess this concept.

Methods:

Data from patients who underwent reconstruction with DIEP and/or MS-TRAM flaps between January 1, 2010 and December 31, 2011 (n = 123) were retrospectively reviewed. Patient demographics, comorbidities, intraoperative parameters, and postoperative outcomes were collected, including flap fat necrosis and donor/recipient site complications. Logistic regression analysis was used to examine effects of flap weight and perforator number on breast flap fat necrosis.

Results:

One hundred twenty-three patients who underwent 179 total flap reconstructions (166 DIEP, 13 MS-TRAM) were included. Mean flap weight was 658 ± 289 g; 132 (73.7%) were single perforator flaps. Thirteen flaps (7.5%) developed fat necrosis. African American patients had increased odds of fat necrosis (odds ratio, 11.58; P < 0.001). Odds of developing fat necrosis significantly increased with flap weight (odds ratio, 1.5 per 100 g increase; P < 0.001). In single perforator flaps weighing more than 1000 g, six (42.9%) developed fat necrosis, compared to 14.3% of large multiple perforator flaps.

Conclusions:

Flaps with increasing weight have increased risk of fat necrosis. These data suggest that inclusion of more than 1 perforator may decrease odds of fat necrosis in large flaps. Perforator flap breast reconstruction can be performed safely; however, considerations concerning race, body mass index, staging with tissue expanders, perforator number, and flap weight may optimize outcomes.

The role of hydroxyethyl starch in preventing surgical-site infections and nipple necrosis in patients undergoing reduction mammaplasty: a prospective case-control study of 334 patients

BACKGROUND

Surgical-site infections after reduction mammaplasty are associated with poor cosmetic results. This study investigated the postoperative antiinflammatory influence of hydroxyethyl starch and its effect on surgical-site infections after breast reduction.

METHODS

In this prospective case-control study, 334 patients undergoing reduction mammaplasty were prospectively assigned in a 2:1 ratio to receive either 2 × 250 ml of hydroxyethyl starch 6 % or saline solution 0.9 % for 3 days postoperatively. Patient follow-up evaluation was at least 1 month. Using uni- and multivariate analyses, this study aimed to identify risk factors for surgical-site infections and nipple necrosis.

RESULTS

Surgical-site infections occurred in 6.6 % of the hydroxyethyl starch group and in 3.6 % of the control group (p = 0.704). Hydroxyethyl starch had no effect of reducing surgical-site infections [p = 0.212; odds ratio (OR), 0.317; confidence interval (CI), 0.052-1.925]. According to univariate analyses, hydroxyethyl starch reduced the occurrence of postoperative fever (p = 0.085; OR 0.608; CI 0.345-1.072), and fever was associated with increased infection rates (p = 0.033; OR 2.335; CI 1.071-5.089). Additional risk factors for postoperative infections were diabetes (p = 0.051; OR 4.051; CI 0.997-16.463) and obesity (normal weight vs grade ≥2: p = 0.003; OR 7.612; CI 2.031-28.529). Multivariate analysis showed no independent predictors for surgical-site infections. Nipple necrosis were equally observed in the two groups (p = 0.458; OR 1.643; CI 0.443-6.097).

CONCLUSION

The antiinflammatory approach of hydroxyethyl starch did not lead to a decrease in infections or nipple necrosis. No difference in surgical-site infections was observed between aesthetic and oncologic procedures.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Fat necrosis in autologous abdomen-based breast reconstruction: a systematic review

BACKGROUND

Fat necrosis is a common and potentially exasperating complication of autologous breast reconstruction. The authors performed a systematic review of the English literature on autologous breast reconstruction to determine significant patient and surgical factors that are predictors of postoperative fat necrosis.

METHODS

A PubMed search using the terms "fat necrosis" and "breast reconstruction" was conducted. Articles were screened using predetermined inclusion and exclusion criteria. Data collected included patient characteristics, reconstructive techniques used, and the specific postoperative morbidity of interest. Patient cohorts were pooled, and the incidence of fat necrosis was calculated in the presence and absence of each risk factor. Chi-square analysis was applied, and p < 0.05 was considered statistically significant.

RESULTS

Of 172 articles found, 70 met the inclusion criteria. The mean rate of fat necrosis was 11.3 percent. Deep inferior epigastric artery perforator flaps had the highest rate of fat necrosis (14.4 percent), followed by pedicled transverse rectus abdominis musculocutaneous (12.3 percent), superficial inferior epigastric artery (8.1 percent), and free transverse rectus abdominis musculocutaneous flaps (6.9 percent). Significant predictors of fat necrosis included obesity (p = 0.035), prereconstruction irradiation (p = 0.022), postreconstruction irradiation (p < 0.001), active smoking (p < 0.001), and abdominal scars (p = 0.05). Protective factors included supercharging (p < 0.001) and bilateral reconstruction (p = 0.01).

CONCLUSIONS

Although there is little agreement in the literature regarding risk factors for fat necrosis, the authors were able to demonstrate several significant predictors by systematically analyzing 70 articles. Improved knowledge of the risk factors for fat necrosis can help surgeons provide improved preoperative counseling and take measures to minimize the risk of this complication.

The nonhematopoietic effects of erythropoietin in skin regeneration and repair: from basic research to clinical use

Erythropoietin (EPO) is the main regulator of red blood cell production but there exists also a variety of nonhematopoietic properties. More recent data show that EPO is also associated with the protection of tissues suffering from ischemia and reperfusion injury as well as with improved regeneration in various organ systems, in particular the skin. This review highlights the mechanisms of EPO in the different stages of wound healing and the reparative processes in the skin emphasizing pathophysiological mechanisms and potential clinical applications. There is clear evidence that EPO effectively influences all wound-healing phases in a dose-dependent manner. This includes inflammation, tissue, and blood vessel formation as well as the remodeling of the wound. The molecular mechanism is predominantly based on an increased expression of the endothelial and inducible nitric oxide (NO) synthase with a consecutive rapid supply of NO as well as an increased content of vascular endothelial growth factor (VEGF) in the wound. The improved understanding of the functions and regulatory mechanisms of EPO in the context of wound-healing problems and ischemia/reperfusion injury, especially during flap surgery, may lead to new considerations of this growth hormone for its regular clinical application in patients.

An Investigation of the Application of Laser-Assisted Indocyanine Green Fluorescent Dye Angiography in Pedicle Transverse Rectus Abdominus Myocutaneous Breast Reconstruction

BACKGROUND

Pedicle transverse rectus abdominus myocutaneous (pTRAM) flaps remain the most common method of autologous tissue breast reconstruction. Using pTRAM flaps, complications often arise postoperatively, secondary to inadequate circulation. Tissues from distant angiosomes are associated with poorer perfusion, but this differs among patients. Many modalities have been used to reduce the risk of complications, but none have achieved widespread application. The authors believe that laser-assisted indocyanine green fluorescent dye angiography (LA-ICGA) can potentially reduce the risk of complications.

METHODS

In two routine, single-pedicle, ipsilateral pTRAM flaps, LA-ICGA imaging was performed following the division of the distal rectus muscle and deep inferior epigastric pedicle. The resulting images were used to guide design of the flap and debridement.

RESULTS

In case 1, good perfusion was observed in zone 1 and part of zone 2. In case 2, good perfusion was observed in zone 1 and 50% of zone 3, with little perfusion in zone 2. In both cases, tissues with poor perfusion were debrided before transfer and inset. In both patients, there were no issues with wound healing, tissue necrosis or fat necrosis.

CONCLUSIONS

The variability of perfusion of the pTRAM flap among individuals is well appreciated. LA-ICGA helped to determine the limits of good perfusion and, therefore, the limits of tissue to be preserved for transfer and inset. This helped to avoid harvesting poorly perfused tissue that would have almost certainly experienced necrosis and, ultimately, would have reduced the risk of postoperative complications.

Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction

BACKGROUND

Immediate breast reconstruction results in a superior cosmetic outcome. However, immediate breast reconstruction using both prosthetic and autologous techniques is associated with significantly higher complication rates than delayed procedures. These early postoperative complications are usually related to unrecognized ischemia of mastectomy skin and/or inadequate perfusion of autologous tissue used for reconstruction. Aside from clinical experience, there are no reliable tools to assist the novice surgeon with intraoperative assessment of tissue viability.

METHODS

Laser-assisted indocyanine green imaging was applied to determine and map tissue perfusion. Indocyanine green perfusion mapping was used in 24 consecutive breast reconstructions to define the perfusion of both mastectomy skin and autologous tissue. Areas of inadequate perfusion were then removed at the time of surgery. Postoperative complications occurring within 90 days after surgery were reviewed.

RESULTS

In 24 consecutive breast reconstruction (16 tissue expanders, two latissimus dorsi flaps, and six deep inferior epigastric perforator/superficial inferior epigastric arteries), there was a 4 percent complication rate. Intraoperatively, the use of indocyanine green imaging allowed all poorly perfused skin to be removed completely in each case, minimizing the incidence of mastectomy flap necrosis, partial necrosis of autologous tissue, and impaired healing. For autologous reconstruction, patency of anastomoses could also be confirmed. This complication rate was significantly less than the 15.1 percent complication rate observed in 206 reconstructions in the previous consecutive 148 patients (p < 0.01) with similar demographics and risk factors.

CONCLUSIONS

This early experience demonstrates an increased accuracy in predicting tissue necrosis (mastectomy flap, autologous tissue) as guided by indocyanine green imaging. Further prospective studies are warranted to quantify whether this technology can reduce health care costs by preventing complications in immediate breast reconstruction.

Outcomes and patient satisfaction following breast reconstruction with bilateral pedicled TRAM flaps in 105 consecutive patients

BACKGROUND

Breast reconstruction using pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps has come under increasing scrutiny secondary to presumed abdominal wall morbidity. This study analyzes morbidity and patient satisfaction in a consecutive series of breast reconstructions performed using bilateral pedicled TRAM flaps.

METHODS

Between 1991 and 2007, 105 women underwent bilateral pedicled TRAM flap breast reconstruction performed by the senior author (J.J.P.). Charts were reviewed for postoperative complications and demographic data. Minimum 11-month follow-up survey data were obtained through the Michigan Breast Satisfaction Questionnaire, the Qualitative Assessment of Back Pain Questionnaire, and the Short Form-36 questionnaire.

RESULTS

The mean follow-up interval was 6 years. Abdominal wall complications included three abdominal hernias (2.9 percent), three abdominal wall bulges (2.9 percent), and four partial donor-site skin dehiscences (3.8 percent). Fat necrosis was the most common flap complication, present in 24 flaps (11.4 percent). The survey response rate was 61.9 percent. Short Form-36 data demonstrated no significant difference from a mean age-matched female population in general well-being, although patients with a body mass index greater than or equal to 30 reported significantly lower emotional well-being (p = 0.01), social functioning (p = 0.03), and overall energy scores (p = 0.03) in comparison with patients with a body mass index less than 30. Thirteen of the 65 patients who completed the survey (20 percent) complained of postoperative back pain, although most of these patients reported their symptoms to be mild in nature.

CONCLUSIONS

Low complication rates were demonstrated and patients were generally satisfied in this series of 105 consecutive bilateral pedicled TRAM flaps. This suggests that the bilateral pedicled TRAM flap remains a viable option for breast reconstruction.

Principles of surgical treatment of congenital, developmental and acquired female breast asymmetries

Background/Aim. There is a natural asymmetry in normal female brests. When the difference in the shape, size or position of the breast and nipple-areola complex is visible, surgical correction is the only treatment option and presents one of the greatest challenges for a plastic surgeon. Based on the Nahai classification presented in details, the aim of the study was to present the possibilities of plastic surgery to correct primary (congenital), secondary (developmental) and tertiary (acquired) brest asymmetries. Methods. We conducted a retrospective analysis of female breast asymmetry surgeries performed in the Clinic for Plastic Surgery and Burns, Military Medical Academy (MMA), Belgrade over the last seven years (January 2002 - January 2009). Results. During the above mentioned period, 82 female patients, 18 - 65 years of age, underwent surgery for breast asymmetry. The most frequent asymmetries were developmental, 'pubertal' (n = 43); acquired asymmetries as a consequence of tumor surgery were found in the other 22 patients, while 7 patients were diagnosed with primary asymmetries such as congenital chest-wall asymmetry (Sy. Poland), accessory and tuberous breasts. All patients underwent preoperative ultrasound examination, while hormone status was determined in those with developmental, 'pubertal' asymmetries. The selection of surgical procedure for correction of breast asymmetry depended upon clinical examination findings and patient's wish relating to the shape and size of the breasts. The most of breast asymmetries were corrected by a combination of surgical procedures including primary and secondary reconstruction, reduction, suspension or augmentation mammoplasty. Having combined different surgical procedures, we managed to achieve satisfactory results. The hypertrophic scar formation after reduction mamoplasty was seen in some cases, however, they caused no significant patient's discomfort. Conclusion. Application of plastic, reconstructive and aesthetic surgical principles can considerably contribute to achieving excellent results in corrective surgery for breast asymmetries. In addition to most suitable breast asymmetry surgical procedures choice, motivation of a patient is also very important for achieving satisfactory results.

[Ischemic preconditioning in a rat adipocutaneous flap model]

INTRODUCTION

Flap necrosis in ear, nose, and throat surgery, especially in high-risk groups, is not rare, but not all of the individual pathophysiological processes are known. The objective of this study was to establish an animal model to determine whether acute ischemic preconditioning, which has been reported to be successful in organ transplantation, will result in enhanced flap survival.

METHODS AND MATERIALS

Forty-two Wistar rats were divided into three experimental groups. An epigastric adipocutaneous flap, based on both superficial epigastric arteries and veins, was raised. The flap was either raised (control), clamped for 2 h (ischemic), or subjected to ischemia of 30 min, followed by 30 min of reperfusion and another 2 h of induced ischemia (IP). The mean flap necrosis area was assessed in all groups on the 5th postoperative day.

RESULTS

All animals were doing well on the final day. The average necrosis in the ischemic group was significantly greater than in the control group. No significant superiority in the IP group was demonstrated.

CONCLUSION

The data show that the experimental animal model is practicable and that additional approaches to ischemic preconditioning should be verified.