1
|
Maus J, Pestana IA. Patient-Reported Abdominal Morbidity Following Abdomen-Based Breast Reconstruction. J Reconstr Microsurg 2024; 40:363-370. [PMID: 37884059 DOI: 10.1055/a-2199-4151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
BACKGROUND Abdominal wall morbidity occurs with increased frequency following flap harvest in the obese abdomen. Its impact on patient-reported outcomes (PROs) in breast reconstruction has been poorly characterized. METHODS A retrospective review of obese patients undergoing abdominal-based free autologous breast reconstruction was conducted over 15 years. Patient operative characteristics were recorded and outcomes were analyzed. PROs were assessed using the BREAST-Q abdominal survey. RESULTS In total, 75 women (108 flaps) with the mean body mass index (BMI) of 33.2 were included. Flaps included deep inferior epigastric artery perforator (24%), muscle-sparing (43%), and free transverse rectus abdominis myocutaneous flaps (f-TRAM; 33%). World Health Organization (WHO) obesity class, BMI, and flap type did not affect flap failure (1%) or complication rates. Hernia developed in 7%; all necessitated repair. Eight percent developed abdominal bulge; one was repaired. Hernia formation was associated with increased patient age (p < 0.05). Bulge formation occurred more often in f-TRAM donor sites (p = 0.005). BMI, WHO class, flap type, and mesh use were not related to hernia or bulge occurrence in either univariate or multivariate analysis. The survey response rate was 63%. Abdominal Physical Well-Being (proxy for abdominal wall function) and Satisfaction with Abdomen (patient-perceived cosmesis) were similar across flap types, age, and WHO classification groups. Patients with postoperative bulge reported higher abdominal physical well-being scores, regardless of flap type (p < 0.01). Bulge was correlated with lower satisfaction (p < 0.05). CONCLUSION The incidence of abdominal wall morbidity following abdominal free-tissue transfer for breast reconstruction was acceptably low in our population of obese patients. Hernia was a clinically significant complication, warranting surgical repair. Bulge was primarily a cosmetic concern and did not detract from patient-reported abdominal wall function. Age may represent an independent risk factor for hernia formation in this population.
Collapse
Affiliation(s)
- Jacob Maus
- Department of Plastic and Reconstructive Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ivo A Pestana
- Department of Plastic and Reconstructive Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
2
|
Choi JY, Kim JN, Lee CR, Choi J, Moon SH, Jun YJ, Oh DY. Transverse division of the rectus abdominis muscle in deep inferior epigastric perforator flap elevation: A rescue technique to include more than one perforator. Microsurgery 2024; 44:e31169. [PMID: 38549425 DOI: 10.1002/micr.31169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/23/2024] [Accepted: 02/28/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND It is important to include as many perforators as possible in order to enhance the vascularity of a deep inferior epigastric perforator (DIEP) flap. However, the rectus muscle must be transected transversely, which prevents suturing and can cause a defect along the same line as the muscle-sparing procedure. When harvesting the DIEP flap, no specific method was suggested to solve these muscle defects. We found that by transecting the rectus muscle transversely, the muscle could be sutured in the tendinous area more easily while maintaining muscle function. The purpose of this study is to confirm the long-term recovery of the rectus abdominis muscle through the volume change after DIEP flap using this tendinous transection and suture method. PATIENTS AND METHODS A retrospective review of 28 patients who underwent unilateral breast reconstruction using a DIEP flap and the tendinous transection method for multiple perforators between May 2018 and April 2020 was conducted. The preoperative and postoperative volumes of the rectus abdominis muscle were estimated both the harvest and opposite sides. RESULTS The preoperative and postoperative muscle volumes from the harvest side were 50.08 ± 8.71 cm3 and 48.56 ± 8.61 cm3, respectively. The volume difference was 1.522 cm3 decrease, which was not statistically significant (p = .070). The preoperative and postoperative muscle volumes from the opposite side were 50.50 ± 8.15 cm3 and 50.08 ± 8.18 cm3, respectively. The volume difference was 0.434 cm3 increase and was not statistically significant (p = .064). Postoperative volume changes in the rectus muscle were not statistically significant on either side. CONCLUSION The tendinous transection method in the DIEP flap procedure did not significantly affect postoperative rectus muscle volume. Therefore, we expect this harvest method to allow DIEP flap reconstruction that includes multiple perforators and complete donor muscle recovery.
Collapse
Affiliation(s)
- Jong Yun Choi
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Nyeon Kim
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chae Rim Lee
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jangyoun Choi
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Suk-Ho Moon
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Joon Jun
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Deuk Young Oh
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
3
|
Shah JK, Amakiri UO, Cevallos P, Yesantharao P, Ayyala H, Sheckter CC, Nazerali R. Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016-2019. Ann Plast Surg 2024; 92:e1-e13. [PMID: 38320006 DOI: 10.1097/sap.0000000000003764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
INTRODUCTION Autologous breast reconstruction (ABR) has increased in recent decades, although concerns for access remain. As such, our goal is to trend national demographics and operative characteristics of ABR in the United States. METHODS Using the National Inpatient Sample, 2016-2019, the International Classification of Disease , Tenth Edition codes identified adult female encounters undergoing ABR. Demographics and procedure-related characteristics were recorded. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate regression modeling. RESULTS A total of 52,910 weighted encounters met the criteria (mean age, 51.5 ± 10.0 years). Autologous breast reconstruction utilization increased (Δ = +5%), 2016-2019, primarily driven by a rise in deep inferior epigastric perforator (DIEP) reconstructions (Δ = +28%; incidence rate ratio [IRR], 1.070; P < 0.001), which were predominant throughout the study period (69%). More recent surgery year, bilateral reconstruction, higher income levels, commercial insurance, and care in the South US region increased the odds of DIEP-based ABR ( P ≤ 0.036). Transverse rectus abdominis myocutaneous flaps, bilateral reconstructions, higher comorbidity levels, and experiencing complications increased the length of stay ( P ≤ 0.038). Most ABRs (75%) were privately insured. The rates of immediate reconstructions increased over the study period (from 26% to 46%; IRR, 1.223; P < 0.001), as did the rates of bilateral reconstructions (from 54% to 57%; IRR, 1.026; P = 0.030). The rates of ABRs performed at teaching hospitals remained high (90% to 93%; P = 0.242). CONCLUSIONS As of 2019, ABR has become more prevalent, with the DIEP flap constituting the most common modality. With the increasing ABR popularity, efforts should be made to ensure geographic and financial accessibility.
Collapse
Affiliation(s)
- Jennifer K Shah
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | | | | | - Pooja Yesantharao
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Haripriya Ayyala
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Clifford C Sheckter
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Rahim Nazerali
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
4
|
Foppiani JA, Kim E, Weidman AA, Alvarez AH, Escobar-Domingo MJ, Valentine L, Lee TC, Mathes DW, Lee BT, Lin SJ. Continuing Insurance Coverage for Flap-Based Breast Reconstruction: Is There a Reservation Cost Related to a Woman's Abdominal Flap Choice? Ann Plast Surg 2024; 92:S228-S233. [PMID: 38556679 DOI: 10.1097/sap.0000000000003804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
BACKGROUND The recent proposed alterations to the Centers for Medicare and Medicaid Services regulations, although subsequently reversed on August 21, 2023, have engendered persistent concerns regarding the impact of insurance policies on breast reconstruction procedures coverage. This study aimed to identify factors that would influence women's preferences regarding autologous breast reconstruction to better understand the possible consequences of these coverage changes. METHODS A survey of adult women in the United States was conducted via Amazon Mechanical Turk to assess patient preferences for breast reconstruction options, specifically deep inferior epigastric perforator (DIEP) and transverse rectus abdominis myocutaneous (TRAM) flap surgery. The Cochrane-Armitage test evaluated trends in flap preferences concerning incremental out-of-pocket payment increases. RESULTS Of 500 total responses, 485 were completed and correctly answered a verification question to ensure adequate attention to the survey, with respondents having a median (interquartile range) age of 26 (25-39) years. When presented with the advantages and disadvantages of DIEP versus TRAM flaps, 78% of respondents preferred DIEP; however, as DIEP's out-of-pocket price incrementally rose, more respondents favored the cheaper TRAM option, with $3804 being the "indifference point" where preferences for both procedures converged (P < 0.001). Notably, respondents with a personal history of breast reconstruction showed a higher preference for DIEP, even at a $10,000 out-of-pocket cost (P = 0.04). CONCLUSIONS Out-of-pocket cost can significantly influence women's choices for breast reconstruction. These findings encourage a reevaluation of emergent insurance practices that could potentially increase out-of-pocket costs associated with DIEP flaps, to prevent cost from decreasing equitable patient access to most current reconstructive options.
Collapse
Affiliation(s)
- Jose A Foppiani
- From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Erin Kim
- From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Allan A Weidman
- From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Angelica Hernandez Alvarez
- From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Maria J Escobar-Domingo
- From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Lauren Valentine
- From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - David W Mathes
- Division of Plastic and Reconstructive Surgery, University of Colorado Hospital, Aurora, CO
| | - Bernard T Lee
- From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Samuel J Lin
- From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| |
Collapse
|
5
|
Huang W, Hu X, Cai W, Cheng M, Fang M, Sun Z, Hu T, Yan W. Soft-tissue reconstruction with pedicled vertical rectus abdominis myocutaneous flap after total or high sacrectomy for giant sacral tumor. J Plast Reconstr Aesthet Surg 2024; 91:173-180. [PMID: 38417394 DOI: 10.1016/j.bjps.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/23/2023] [Accepted: 02/01/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND The large soft-tissue defect after total or high sacrectomy for giant sacral tumor induces high incidence of wound complications. It remains a huge challenge to reconstruct the soft-tissue defect and achieve the preferred clinical outcome. METHODS A total of 27 patients undergoing one-stage total or high sacrectomy for giant sacral tumors between 2016 and 2021 in a tertiary university hospital were retrospectively reviewed. Participants were divided into two groups. Thirteen patients underwent a pedicled vertical rectus abdominis myocutaneous (VRAM) flap reconstruction, whereas 14 patients underwent a conventional wound closure. Patient's clinical characteristics, surgical duration, postoperative complications, and outcomes were compared between the two groups. RESULTS Patients in VRAM and non-VRAM groups were similar in baseline characteristics. The mean tumor size was 12.85 cm (range: 10-17 cm) in VRAM group and 11.79 cm (range: 10-14.5 cm) in non-VRAM group (P = 0.139). The most common giant sacral tumor is chordoma. Patients in VRAM group had a shorter length of drainage (9.85 vs 17.14 days), postoperative time in bed (5.54 vs 17.14 days), and total length of stay (19.46 vs 33.36 days) compared with patients in non-VRAM group. Patients in the VRAM group had less wound infection and debridement than patients in non-VRAM group (15.4% vs 57.1%, P < 0.001). CONCLUSIONS This study demonstrates the advantages of pedicled VRAM flap reconstruction of large soft-tissue defects after high or total sacrectomy using the anterior-posterior approach. This choice of reconstruction is better than direct wound closure in terms of wound infection, length of drainage, and total length of stay.
Collapse
Affiliation(s)
- Wending Huang
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Xianglin Hu
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Weiluo Cai
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Mo Cheng
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Meng Fang
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Zhengwang Sun
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Tu Hu
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Wangjun Yan
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.
| |
Collapse
|
6
|
Ishida K, Hirayama H, Nukami M, Kodama H, Kishi K, Akutsu T, Miyawaki T. Comparison of complications and functional outcomes following total or subtotal glossectomy with laryngeal preservation using a deep inferior epigastric artery perforator free flap versus a rectus abdominis musculocutaneous free flap. J Plast Reconstr Aesthet Surg 2024; 90:249-258. [PMID: 38387422 DOI: 10.1016/j.bjps.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/14/2023] [Accepted: 01/29/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE Wide defects resulting from subtotal or total glossectomy are commonly reconstructed using a bulk flap to maintain oral and speech functions. The flap, including muscle tissue, diminishes with time. This study aimed to compare the surgical outcomes of deep inferior epigastric artery perforator and rectus abdominis musculocutaneous free flap reconstructions after glossectomy with laryngeal preservation. METHODS Medical records of 13 and 26 patients who underwent deep inferior epigastric artery perforator and rectus abdominis musculocutaneous free flap reconstructions, respectively, from 2014 to 2022 at our institution were reviewed. Patients who underwent middle pharynx resection except for the base of the tongue, mandibular bone resection, and sensory reinnervation were excluded. RESULTS The rectus abdominis musculocutaneous groups showed a higher number of lymph node dissection and shorter operative time than the deep inferior epigastric artery perforator groups. No significant differences in postoperative complications or functional oral intake scale scores at 6 months were observed. Volumetric changes on computed tomography images at 6 and 12 months were significantly lower in the deep inferior epigastric artery perforator group. Cancer recurrence was significantly associated with reduced oral function. CONCLUSIONS Oral function in patients with cancer is influenced by various other factors. However, the deep inferior epigastric artery perforator flap may be suitable for tongue reconstruction because of the minimal postoperative changes in flap volume, easy adjustment of flap thickness, elevation of multiple flaps, and minimal complications at the donor site.
Collapse
Affiliation(s)
- Katsuhiro Ishida
- Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan.
| | - Haruyuki Hirayama
- Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan.
| | - Masaki Nukami
- Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan.
| | - Hiroki Kodama
- Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan.
| | - Keita Kishi
- Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan.
| | - Taisuke Akutsu
- Department of Otolaryngology Head and Neck Surgery, Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan.
| | - Takeshi Miyawaki
- Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan.
| |
Collapse
|
7
|
Arcieri M, Restaino S, Rosati A, Granese R, Martinelli C, Caretto AA, Cianci S, Driul L, Gentileschi S, Scambia G, Vizzielli G, Ercoli A. Primary flap closure of perineal defects to avoid empty pelvis syndrome after pelvic exenteration in gynecologic malignancies: An old question to explore a new answer. Eur J Surg Oncol 2024; 50:107278. [PMID: 38134482 DOI: 10.1016/j.ejso.2023.107278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 11/05/2023] [Accepted: 11/14/2023] [Indexed: 12/24/2023]
Abstract
Pelvic exenteration (PE) is a radical oncological surgical procedure proposed in patients with recurrent or persistent gynecological cancers. The radical alteration of pelvic anatomy and of pelvic floor integrity can cause major postoperative complications. Fortunately, PE can be combined with reconstructive procedures to decrease complications and functional and support problems of pelvic floor, reducing morbility and mortality and increasing quality of life. Many options for reconstructive surgery have been described, especially a wide spectrum of surgical flaps. Different selection criteria have been proposed to select patients for primary perineal defect flap closure without achieving any strict indication of the best option. The aim of this review is to focus on technical aspects and the advantages and disadvantages of each technique, providing an overview of those most frequently used for the treatment of pelvic floor defects after PE. Flaps based on the deep inferior epigastric artery, especially vertical rectus abdominis musculocutaneous (VRAM) flaps, and gracilis flaps, based on the gracilis muscle, are the most common reconstructive techniques used for pelvic floor and vaginal reconstruction. In our opinion, reconstructive surgery may be considered in case of total PE or type II/III PE and in patients submitted to prior pelvic irradiation. VRAM could be used to close extended defects at the time of PE, while gracilis flaps can be used in case of VRAM complications. Fortunately, numerous choices for reconstructive surgery have been devised. As these techniques continue to evolve, it is advisable to adopt an integrated, multi-disciplinary approach within a tertiary medical center.
Collapse
Affiliation(s)
- M Arcieri
- Department of Biomedical, Dental, Morphological and Functional Imaging Science, University of Messina, Messina, Italy; Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy.
| | - S Restaino
- Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy
| | - A Rosati
- Department of Woman, Child, and Public Health, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - R Granese
- Department of Biomedical, Dental, Morphological and Functional Imaging Science, University of Messina, Messina, Italy
| | - C Martinelli
- Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
| | - A A Caretto
- Department of Plastic Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - S Cianci
- Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
| | - L Driul
- Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy; Medical Area Department (DAME), University of Udine, Udine, Italy
| | - S Gentileschi
- Plastic Surgery, Lymphedema Center Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - G Scambia
- Department of Woman, Child, and Public Health, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy; Department of Woman, Child and Public Health, Catholic University of Sacred Heart, Rome, Italy
| | - G Vizzielli
- Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy; Medical Area Department (DAME), University of Udine, Udine, Italy
| | - A Ercoli
- Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
| |
Collapse
|
8
|
Khalil AA, ElSharkawy OA, Alsharkawy K, Youssif S, Khalil HH. Supra-arcuate free fascial MS-TRAM, a modified technique to reduce donor site morbidity in obese population-comparative study. Microsurgery 2024; 44:e31124. [PMID: 37846651 DOI: 10.1002/micr.31124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 09/08/2023] [Accepted: 09/28/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Abdomen-based free flaps represent the gold standard option in the armamentarium of breast reconstruction. The natural evolution to more preservation with less invasive forms of these flaps has been driven by both patient and surgeon satisfaction. Nevertheless, obese patients are challenging due to the increased risk of compromised flap perfusion and donor site morbidity. This challenge is compounded by the prevalence of obesity worldwide, resulting in more free abdominal flaps being performed for breast reconstruction in obese patients. The authors present the outcomes of a modified supra-arcuate fascial muscle-sparing transverse rectus abdominus myocutaneous (FMS-TRAM) technique compared to standard muscle-sparing transverse rectus abdominus myocutaneous (MS-TRAM) technique to reduce the donor site morbidity while providing a well-vascularized large volume of autologous tissue. METHODS A retrospective comparative data analysis was conducted at two centers: Cairo University Hospitals, Egypt, and University Hospitals Birmingham, United Kingdom. Standard MS-TRAM was performed in 65 patients between 2008 and 2011 (Group 1) versus 275 patients between 2011 and 2020 (Group 2) who underwent FMS-TRAM. The modified technique involved limiting the fascial incision to above or at the level of the arcuate line to preserve the integrity of the anterior rectus sheath caudally. All patients included were of the obese population (BMI≥30 kg/m2 ) and underwent unilateral post-mastectomy reconstruction. Patient demographics, comorbidities, operative details, and outcomes focusing on donor site morbidity and flap complications were recorded and compared between the two groups. RESULTS The median age and BMI for Group 1 were 43 and 32, respectively. While for Group 2, they were 47 and 33, respectively. Flap weight ranged from 560 to 1470 g (Mean 705) for Group 1, while Group 2 ranged from 510 to 1560 (mean 715). The majority (280/340 [82%]) of the patients in both groups received radiotherapy. 7.7% of Group 1 were smokers, while in Group 2 it was 4.7%. The percentage of delayed versus immediate reconstruction in Group 1 was 60%/40%, while in Group 2, it was 43%/56%. The incidence of fat necrosis, partial necrosis, and total necrosis was 7.6%.1.5%, and 3%, respectively, for Group 1 and 8%, 1.4%, and 2.6%, respectively, for Group 2. The two-tailed p-value demonstrated a significant statistical difference (p < 0.00001) in donor site morbidity between both groups, with more bulge 20% (13/65) and hernia 1.5% (2/65) occurrence in Group 1 versus 1.9% (5/275) and 0.7% (2/275) in Group 2 respectively, over a follow-up period ranging from 24 to 60 months (mean 32). CONCLUSION FMS-TRAM flaps are safe, robust, and reliable with less donor site morbidity while maintaining optimal flap perfusion for large volume flaps in obese patients with excellent, durable outcomes. It should be considered a valuable tool in the reconstructive armamentarium of breast reconstruction.
Collapse
Affiliation(s)
- Ashraf A Khalil
- Plastic and Reconstructive Surgery Division, General Surgery Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Omar A ElSharkawy
- Plastic and Reconstructive Surgery Division, General Surgery Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Kareem Alsharkawy
- Plastic and Reconstructive Surgery Department, University Hospitals, Birmingham, UK
| | - Sherif Youssif
- Plastic and Reconstructive Surgery Department, University Hospitals, Birmingham, UK
| | - Haitham H Khalil
- Plastic and Reconstructive Surgery Department, University Hospitals, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
9
|
Liu J, Fu C, Chen Z, Li G. Perineal wound complications after vertical rectus abdominis myocutaneous flap and mesh closure following abdominoperineal surgery and pelvic exenteration of anal and rectal cancers: A meta-analysis. Int Wound J 2023; 20:3963-3973. [PMID: 37539486 PMCID: PMC10681467 DOI: 10.1111/iwj.14284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 08/05/2023] Open
Abstract
A meta-analysis research was implemented to appraise the perineal wound complications (PWCs) after vertical rectus abdominis myocutaneous (VRAM) flap and mesh closure (MC) following abdominoperineal surgery (AS) and pelvic exenteration (PE) of anal and rectal cancers. Inclusive literature research till April 2023 was done and 2008 interconnected researches were revised. Of the 20 picked researches, enclosed 2972 AS and PE of anal and rectal cancers persons were in the utilized researchers' starting point, 1216 of them were utilizing VRAM flap, and 1756 were primary closure (PC). Odds ratio (OR) and 95% confidence intervals (CIs) were utilized to appraise the consequence of VRAM flap in treating AS and PE of anal and rectal cancers by the dichotomous approach and a fixed or random model. VRAM flap had significantly lower PWCs (OR, 0.64; 95% CI, 0.42-0.98, p < 0.001), and major PWCs (OR, 0.50; 95% CI, 0.32-0.80, p = 0.004) compared to PC in AS and PE of anal and rectal cancers persons. However, VRAM flap and PC had no significant difference in minor PWCs (OR, 1; 95% CI, 0.54-1.85, p = 1.00) in AS and PE of anal and rectal cancer persons. VRAM flap had significantly lower PWCs, and major PWCs, however, no significant difference was found in minor PWCs compared to PC in AS and PE of anal and rectal cancers persons. However, caution needs to be taken when interacting with its values since there was a low sample size of most of the chosen research found for the comparisons in the meta-analysis.
Collapse
Affiliation(s)
- Jiang Liu
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
| | - Chao Fu
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
| | - Zhiliang Chen
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
| | - Gang Li
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
| |
Collapse
|
10
|
Galbraith NJ, McCollum C, Di Mascio L, Lowrie J, Hinckley M, Lo S, Watson S, Telfer JR, Roxburgh CS, Horgan PG, Chong PS, Quinn M, Steele CW. Effect of differing flap reconstruction strategies in perineal closure following advanced pelvic oncological resection: a retrospective cohort study. Int J Surg 2023; 109:3375-3382. [PMID: 37678294 PMCID: PMC10651229 DOI: 10.1097/js9.0000000000000617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 07/09/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Advancing approaches to locally invasive pelvic malignancy creates a large tissue defect resulting in perineal wound complications, dehiscence, and perineal hernia. Use of reconstructive flaps such as vertical rectus abdominus myocutaneous (VRAM) flap, gracilis, anterolateral thigh and gluteal flaps have been utilised in our institution to address perineal closure. The authors compared outcomes using different flap techniques along with primary perineal closure in advanced pelvic oncological resection. METHODS A prospectively maintained database of patients undergoing advanced pelvic oncological resection in a single tertiary hospital was retrospectively analysed. This study included consecutive patients between 2014 and 2021 according to the Strengthening The Reporting of Cohort Studies in Surgery (STROCSS) criteria. Primary outcome measures were the frequency of postoperative perineal complications between primary closure, VRAM, gluteal and thigh (anterolateral thigh and gracilis) reconstruction. RESULTS One hundred twenty-two patients underwent advanced pelvic resection with perineal closure. Of these, 40 patients underwent extra-levator abdominoperineal resection, and 70 patients underwent pelvic exenteration. Sixty-four patients received reconstructive flap closure, which included VRAM (22), gluteal (21) and thigh flaps (19). Perineal infection and dehiscence rates were low. Infection rates were lower in the flap group despite a higher rate of radiotherapy ( P <0.050). Reoperation rates were infrequent (<10%) but specific for each flap, such as donor-site hernia following VRAM and flap dehiscence after thigh flap reconstruction. CONCLUSIONS In patients who are at high risk of postoperative perineal infections, reconstructive flap closure offers acceptable outcomes. VRAM, gluteal and thigh flaps offer comparable outcomes and can be tailored to the individual patient.
Collapse
Affiliation(s)
- Norman J. Galbraith
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Catherine McCollum
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Lucia Di Mascio
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Joanna Lowrie
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Matthew Hinckley
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Steven Lo
- Canniesburn Department of Plastic and Reconstructive Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Stuart Watson
- Canniesburn Department of Plastic and Reconstructive Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - John R.C. Telfer
- Canniesburn Department of Plastic and Reconstructive Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Paul G. Horgan
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Peter S. Chong
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Martha Quinn
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Colin. W. Steele
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| |
Collapse
|
11
|
Murphy RNA, Reid AJ, Columb MO, O'Ceallaigh S, Duncan J, Holt R. Breast-Q sensory outcomes of non-neurotized, autologous, unilateral breast reconstruction with a minimum of 3-year follow-up. J Plast Reconstr Aesthet Surg 2023; 85:86-91. [PMID: 37473644 DOI: 10.1016/j.bjps.2023.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/18/2023] [Accepted: 06/22/2023] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Sensory reinnervation of autologous breast tissue after free flap reconstruction is highly variable. There is no long-term follow-up data exploring spontaneous reinnervation and how this affects patients' quality of life nor the nerve-related symptoms they experience. To address this issue, we invited patients with a minimum of 3 years after non-neurotized, free flap breast reconstruction to complete patient-reported outcome measures exploring sensation, quality of life and breast-related symptoms. METHODS We performed a retrospective cohort study of patients undergoing unilateral Muscle-Sparing Transverse Rectus Abdominus Muscle (MS-TRAM) or deep inferior epigastric artery perforator (DIEP) flap breast reconstruction between 01-01-2015 and 31-12-2019 in the Department of Plastic and Reconstructive Surgery at Manchester University NHS Foundation Trust. We invited participants to complete the recently developed Breast-Q© Breast Sensation Module. RESULTS All patients had undergone unilateral immediate (n = 85) or delayed (n = 82) breast reconstruction after mastectomy using either a free DIEP (n = 150) or TRAM (n = 17) flap reconstruction a minimum of 3 years prior. The median age at operation was 48. Sensation after reconstruction was significantly reduced in the reconstructed breast compared with the contralateral breast (P < 0.0001) with a reduction in reported quality of life (immediate (68.0 [54.0, 89.0]) and delayed (68.0 [62.0, 83.8])). The sensation was significantly better in immediate vs delayed procedures (P = 0.024). Sensory scores after reconstruction increased with age (P = 0.036). DISCUSSION Breast sensation after non-neurotized reconstruction with autologous tissue is significantly reduced at long-term follow-up with a reduction in quality of life. A minimum outcome set for quantification of breast sensation is required and future research into the cost-benefit of neurotized, autologous breast reconstruction is needed.
Collapse
Affiliation(s)
- Ralph N A Murphy
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK; Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PT, UK.
| | - Adam J Reid
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK; Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PT, UK
| | - Malachy O Columb
- Department of Anaesthesia and Intensive Care Medicine, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK
| | - Siobhan O'Ceallaigh
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK
| | - Jonathan Duncan
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK
| | - Rachel Holt
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK
| |
Collapse
|
12
|
Tsai CY, Kim BS, Kuo WL, Liu KH, Chang TNJ, Cheong DCF, Huang JJ. Novel Port Placement in Robot-Assisted DIEP Flap Harvest Improves Visibility and Bilateral DIEP Access: Early Controlled Cohort Study. Plast Reconstr Surg 2023; 152:590e-595e. [PMID: 36995211 DOI: 10.1097/prs.0000000000010470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
SUMMARY To minimize donor-site damage, robot-assisted (RA) deep inferior epigastric perforator (DIEP) flap harvest has been suggested. Current robotic approaches favor port placement, which either does not allow a bilateral DIEP flap harvest through the same ports or necessitates additional scars. In this article, the authors propose a modification of port configuration. In a retrospective controlled cohort study, RA-DIEP and conventional DIEP surgery were compared. The perforator and pedicle were visualized conventionally until the level behind the rectus abdominis muscle. Next, the robotic system was installed to dissect the retromuscular pedicle. The authors assessed patient age; body mass index; history of smoking, diabetes mellitus, and hypertension; and additional surgical time. The length of the anterior rectus sheath (ARS) incision was measured. Pain was quantified using the visual analogue scale. Donor-site complications were assessed. Thirteen RA-DIEP flaps (11 unilateral and two bilateral) and 87 conventional DIEP flaps were harvested without flap loss. The bilateral DIEP flaps were raised without readjustments of the ports. The mean time for pedicle dissection was 53.2 ± 13.4 minutes. The length of the ARS incision was significantly shorter in the RA-DIEP group (2.67 ± 1.13 cm versus 8.14 ± 1.69 cm; 304.87% difference; P < 0.0001). There was no statistical difference in postoperative pain (day 1: 1.9 ± 0.9 versus 2.9 ± 1.6, P = 0.094; day 2: 1.8 ± 1.2 versus 2.3 ± 1.5, P = 0.319; day 3: 1.6 ± 0.9 versus 2.0 ± 1.3, P = 0.444). Preliminary results show that the authors' RA-DIEP approach is safe and allows dissection of bilateral RA-DIEP flaps with short ARS incision lengths. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
Collapse
Affiliation(s)
- Chun-Yi Tsai
- From the Department of General Surgery
- College of Medicine, Chang Gung University
| | - Bong-Sung Kim
- Department of Plastic and Reconstructive Surgery
- College of Medicine, Chang Gung University
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich
| | - Wen-Ling Kuo
- From the Department of General Surgery
- College of Medicine, Chang Gung University
- School of Medicine, National Tsing Hua University
| | - Keng-Hao Liu
- From the Department of General Surgery
- College of Medicine, Chang Gung University
| | - Tommy Nai-Jen Chang
- Department of Plastic and Reconstructive Surgery
- College of Medicine, Chang Gung University
| | - David Chon-Fok Cheong
- Department of Plastic and Reconstructive Surgery
- College of Medicine, Chang Gung University
| | - Jung-Ju Huang
- Department of Plastic and Reconstructive Surgery
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou Medical Center
- College of Medicine, Chang Gung University
| |
Collapse
|
13
|
Tokumoto H, Akita S, Kosaka K, Nakamura R, Yamamoto N, Kubota Y, Mitsukawa N. Fascia turnover procedure at breast reconstruction using free TRAM flap for decreasing umbilical migration. J Plast Reconstr Aesthet Surg 2023; 85:120-126. [PMID: 37482025 DOI: 10.1016/j.bjps.2023.06.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/16/2023] [Accepted: 06/29/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND The ideal umbilical position is midway between the two iliac crests. Some patients complained that the umbilicus position shifted from the midline after the breast reconstruction with a free muscle-sparing transverse rectus abdominis musculocutaneous (MS-TRAM) flap. We considered that the fascia of the external oblique muscle could be applied to the rectus abdominis fascia defect. This study aimed to introduce this "fascia turnover procedure" and compare the umbilical position in this procedure with that in primary fascial closure for the MS-TRAM flap of breast reconstruction. METHODS A total of 152 patients were enrolled (80 patients with fascia turnover (+) vs. 72 patients (-)). The patients' demographics were compared. Horizontal distances (right side: a; left side: b) were measured bilaterally from the lateral abdominal wall to the center of the umbilicus. Frontal abdominal photographs were taken preoperatively (a1, b1) and postoperatively (a2, b2). The rate of umbilical migration (= | (a1 - b1) / (a1 + b1) - (a2 - b2) / (a2 + b2) | × 100%) was calculated. Because the aponeurosis of the external oblique muscle is confirmed in front of the lateral side of the anterior rectus sheath, this procedure could be performed in cases with a medial defect. RESULTS No significant differences in the patients' demographics, including abdominal bulging rates and abdominal wall defect widths were observed between the two groups. The rate of umbilical migration showed a significant difference (median 1.78% vs. 3.70%, P < 0.001). CONCLUSIONS This procedure could decrease the rate of umbilical migration.
Collapse
Affiliation(s)
- Hideki Tokumoto
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, Japan.
| | - Shinsuke Akita
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, Japan
| | - Kentaro Kosaka
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, Japan
| | - Rikiya Nakamura
- Department of Breast Surgery, Chiba Cancer Center Hospital, Japan
| | - Naohito Yamamoto
- Department of Breast Surgery, Chiba Cancer Center Hospital, Japan
| | - Yoshitaka Kubota
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, Japan
| |
Collapse
|
14
|
Benedict KC, Songcharoen SJ, Stephens KL, Winter AL, Edwards SR, Campbell CA, Arnold PB. Comparison of inferior gluteal artery perforator flaps versus vertical rectus abdominis musculocutaneous flaps in the reconstruction of perineal wounds. J Plast Reconstr Aesthet Surg 2023; 84:514-520. [PMID: 37418850 DOI: 10.1016/j.bjps.2023.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 03/29/2023] [Accepted: 06/06/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Achieving a healed perineal wound following chemoradiotherapy and abdominoperineal resection (APR) is challenging for surgeons and patients. Prior studies have shown trunk-based flaps, including vertical rectus abdominis myocutaneous (VRAM) flaps, are superior to both primary closure and thigh-based flaps; however, there has been no direct comparison with gluteal fasciocutaneous flaps. This study evaluates postoperative complications after various methods of perineal flap closure of APR and pelvic exenteration defects. METHODS Retrospective review of patients who underwent APR or pelvic exenteration from April 2008 through September 2020 was analyzed for postoperative complications. Flap closure techniques, including VRAM, unilateral (IGAP), and bilateral (BIGAP) inferior gluteal artery perforator fasciocutaneous flaps, were compared. RESULTS Of 116 patients included, the majority underwent fasciocutaneous (BIGAP/IGAP) flap reconstruction (n = 69, 59.6%), followed by VRAM (n = 47, 40.5%). There were no significant differences between group patient demographics, comorbidities, body mass index, or cancer stage. There were no significant differences between BIGAP/IGAP and VRAM groups in minor complications (57% versus 49%, p = 0.426) or major complications (45% versus 36%, p = 0.351), including major/minor perineal wounds. CONCLUSIONS Prior studies have shown flap closure is preferable to primary closure after APR and neoadjuvant radiation but lack consensus on which flap offers superior postoperative morbidity. This study comparing outcomes of perineal flap closure showed no significant difference in postoperative complications. Fasciocutaneous flaps are a viable choice for the reconstruction of these challenging defects.
Collapse
Affiliation(s)
- Katherine C Benedict
- University of Mississippi Medical Center, Division of Plastic and Reconstructive Surgery, 2500 North State Street, Jackson, MS 39216, USA.
| | - Somjade J Songcharoen
- University of Mississippi Medical Center, Division of Plastic and Reconstructive Surgery, 2500 North State Street, Jackson, MS 39216, USA
| | - Kristin L Stephens
- University of Virginia, Department of Plastic Surgery, 200 Jeanette Lancaster Way, Charlottesville, VA 22903, USA
| | - Anna L Winter
- University of Mississippi Medical Center, Division of Plastic and Reconstructive Surgery, 2500 North State Street, Jackson, MS 39216, USA
| | - Shelley R Edwards
- University of Mississippi Medical Center, Division of Plastic and Reconstructive Surgery, 2500 North State Street, Jackson, MS 39216, USA
| | - Christopher A Campbell
- University of Virginia, Department of Plastic Surgery, 200 Jeanette Lancaster Way, Charlottesville, VA 22903, USA
| | - Peter B Arnold
- University of Mississippi Medical Center, Division of Plastic and Reconstructive Surgery, 2500 North State Street, Jackson, MS 39216, USA
| |
Collapse
|
15
|
Tokumoto H, Akita S, Kosaka K, Kubota Y, Mitsukawa N. Correlation between abdominal visceral volume measured by a simple procedure and bulging at the abdominal free flap donor site for breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 84:295-301. [PMID: 37385141 DOI: 10.1016/j.bjps.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 05/10/2023] [Accepted: 06/02/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Breast reconstructions using autologous abdominal tissue result in breasts with a natural shape and consistency. One of the major complications is abdominal bulging. Because of the increased abdominal wall tension, high visceral volume (not visceral fat alone) may increase the occurrence rate of abdominal bulging. A simple procedure involving CT imaging was used to assess this relationship in patients undergoing an abdominal free flap for unilateral breast reconstruction. METHODS A total of 278 patients were enrolled in this study. The patients' demographics, the thicknesses of visceral volume were compared (Bulging (+) vs. Bulging (-)). Visceral volume was investigated based on the horizontal thickness, which was measured at the thickest part at the level of the umbilical fossa between both sides under the transverse abdominis muscles. RESULTS Bulging (+) consisted of 39 patients (14.0%), whereas Bulging (-) included 239 patients. Patients with Bulging (+) were significantly older, had higher gestational history rate, and had thin rectus abdominis muscle. In terms of visceral volume, the Bulging (+) group had significantly higher horizontal thicknesses (median 233 mm vs. 219 mm, P < 0.001). No significant differences were observed with respect to other factors (age, BMI, history of laparotomy, and operative details). The multivariate logistic regression analysis revealed that the thickness of the rectus abdominis muscle, horizontal visceral volume, and gestational history were independently significant predictors. CONCLUSIONS Not only the patients with thin rectus abdominis muscle but also patients with a thick horizontal visceral volume may have a higher risk of abdominal bulging.
Collapse
Affiliation(s)
- Hideki Tokumoto
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, 666-2 Nitona, Chuo-ku, Chiba City, Chiba 260-8717, Japan.
| | - Shinsuke Akita
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, 666-2 Nitona, Chuo-ku, Chiba City, Chiba 260-8717, Japan
| | - Kentaro Kosaka
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, 666-2 Nitona, Chuo-ku, Chiba City, Chiba 260-8717, Japan
| | - Yoshitaka Kubota
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, 666-2 Nitona, Chuo-ku, Chiba City, Chiba 260-8717, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, 666-2 Nitona, Chuo-ku, Chiba City, Chiba 260-8717, Japan
| |
Collapse
|
16
|
Lee S, Ju JW, Yoon S, Lee HJ, Ha JH, Hong KY, Jin US, Chang H, Cho YJ. Norepinephrine preserved flap blood flow compared to phenylephrine in free transverse rectus abdominis myocutaneous flap breast reconstruction surgery: A randomized pilot study. J Plast Reconstr Aesthet Surg 2023; 83:438-447. [PMID: 37311286 DOI: 10.1016/j.bjps.2023.04.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 04/13/2023] [Accepted: 04/26/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Vasopressors are used in up to 85% of cases during free flap surgery. However, their use is still debated with concerns of vasoconstriction-related complications, with rates up to 53% in minor cases. We investigated the effects of vasopressors on flap blood flow during free flap breast reconstruction surgery. We hypothesized that norepinephrine may preserve flap perfusion better than phenylephrine during free flap transfer. METHODS A randomized pilot study was performed in patients undergoing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Patients with peripheral artery disease, allergies to study drugs, previous abdominal operations, left ventricular dysfunction, or uncontrolled arrhythmias were excluded. Twenty patients were randomized to receive either norepinephrine (0.03-0.10 µg/kg/min) or phenylephrine (0.42-1.25 µg/kg/min) (each n = 10) to maintain a mean arterial pressure of 65-80 mmHg. The primary outcome was differences in mean blood flow (MBF) and pulsatility index (PI) of flap vessels after anastomosis measured using transit time flowmetry in the two groups. Secondary outcomes included flap loss, necrosis, thrombosis, wound infection, and reoperation within 7 days postoperatively. RESULTS After anastomosis, MBF showed no significant change in the norepinephrine group (mean difference, -9.4 ± 14.2 mL/min; p = 0.082), whereas it was reduced in the phenylephrine group (-7.9 ± 8.2 mL/min; p = 0.021). PI did not change in either group (0.4 ± 1.0 and 1.3 ± 3.1 in the norepinephrine and phenylephrine groups; p = 0.285 and 0.252, respectively). There were no differences in secondary outcomes between the groups. CONCLUSION During free TRAM flap breast reconstruction, norepinephrine seems to preserve flap perfusion compared to phenylephrine. However, further validation studies are required.
Collapse
Affiliation(s)
- Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Susie Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jeong Hyun Ha
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Ki Yong Hong
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Ung Sik Jin
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Hak Chang
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea.
| |
Collapse
|
17
|
Bruce JC, Batchinsky M, Van Spronsen NR, Sinha I, Bharadia D. Analysis of online materials regarding DIEP and TRAM flap autologous breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 82:81-91. [PMID: 37149913 DOI: 10.1016/j.bjps.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/11/2023] [Indexed: 05/09/2023]
Abstract
Online resources have become a mainstay for health information, and it is vital that such resources maintain accessible literacy levels to empower informed decision making. Previous studies have shown that the online resources regarding post-mastectomy breast reconstruction are of low readability; however, none have evaluated specific online resources regarding the most common procedures within autologous breast reconstruction, limiting analysis to the results of generic searches. This study sought to discover the readability of online, patient-directed resources regarding the Deep Inferior Epigastric Perforator (DIEP) and Transverse Rectus Abdominis Muscle (TRAM) flaps, the most utilized autologous flaps in breast reconstruction, using health literacy analysis. We hypothesized that the online materials regarding DIEP and TRAM flaps would yield literacy scores above the 6th-grade reading level, as recommended by the American Medical Association, despite previous literature and readability recommendations. Google searches for "DIEP breast reconstruction" and "TRAM breast reconstruction" were conducted. All patient-directed, non-sponsored websites found within the first three pages of the search underwent analysis using a variety of readability formulae. Both DIEP and TRAM resources were well above the 6th-grade reading level according to every metric used, and there was no significant difference in the reading level between the two procedures. Based on these results, significant work was needed to simplify the online resources to be more understandable for patients; these authors propose one method for such. In addition, the low readability of online resources suggests added emphasis on the need for surgeons to ensure that patients understand the medical information discussed during the presurgical consultations.
Collapse
Affiliation(s)
- J Christian Bruce
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
| | - Maria Batchinsky
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Nicole R Van Spronsen
- Department of Surgery, Division of Plastic & Reconstructive Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Indranil Sinha
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Deepak Bharadia
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| |
Collapse
|
18
|
宋 达, 李 赞, 章 一. [Effectiveness of lobulated pedicled rectus abdominis myocutaneous flap for repairing huge chest wall defect]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2023; 37:473-477. [PMID: 37070317 PMCID: PMC10110752 DOI: 10.7507/1002-1892.202212101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 04/19/2023]
Abstract
Objective To explore the effectiveness of lobulated pedicled rectus abdominis myocutaneous flap to repair huge chest wall defect. Methods Between June 2021 and June 2022, 14 patients with huge chest wall defects were treated with radical resection of the lesion and lobulated pedicled rectus abdominis myocutaneous flap transplantation for reconstruction of chest wall defects. The patients included 5 males and 9 females with an average age of 44.2 years (range, 32-57 years). The size of skin and soft tissue defect ranged from 20 cm×16 cm to 22 cm×22 cm. The bilateral pedicled rectus abdominis myocutaneous flaps in size of 26 cm×8 cm to 35 cm×14 cm were prepaired and cut into two skin paddles with basically equal area according to the actual defect size of the chest wall. After the lobulated pedicled rectus abdominis myocutaneous flap was transferred to the defect, there were two reshaping methods. The first method was that the skin paddle at the lower position and opposite side was unchanged, and the skin paddle at the effected side was rotated by 90° (7 cases). The second method was that the two skin paddles were rotated 90° respectively (7 cases). The donor site was sutured directly. Results All 14 flaps survived successfully and the wound healed by first intention. The incisions at donor site healed by first intention. All patients were followed up 6-12 months (mean, 8.7 months). The appearance and texture of the flaps were satisfactory. Only linear scar was left at the donor site, and the appearance and activity of the abdominal wall were not affected. No local recurrence was found in all tumor patients, and distant metastasis occurred in 2 breast cancer patients (1 liver metastasis and 1 lung metastasis). Conclusion The lobulated pedicled rectus abdominis myocutaneous flap in repair of huge chest wall defect can ensure the safety of blood supply of the flap to the greatest extent, ensure the effective and full use of the flap tissue, and reduce postoperative complications.
Collapse
Affiliation(s)
- 达疆 宋
- 湖南省肿瘤医院肿瘤整形外科(长沙 410008)Department of Oncology Plastic Surgery, Hunan Cancer Hospital, Changsha Hunan, 410008, P. R. China
| | - 赞 李
- 湖南省肿瘤医院肿瘤整形外科(长沙 410008)Department of Oncology Plastic Surgery, Hunan Cancer Hospital, Changsha Hunan, 410008, P. R. China
| | - 一新 章
- 湖南省肿瘤医院肿瘤整形外科(长沙 410008)Department of Oncology Plastic Surgery, Hunan Cancer Hospital, Changsha Hunan, 410008, P. R. China
| |
Collapse
|
19
|
Lange M, Hage JJ, Aalbers A, Wit EMK, Amant F, Hoornweg MJ. Surgical flap delay to allow primary transabdominal transplantation of extended rectus abdominis myocutaneous flaps in increasingly complex pelvic wound reconstructions. J Plast Surg Hand Surg 2023; 57:393-398. [PMID: 36344212 DOI: 10.1080/2000656x.2022.2142600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 09/12/2022] [Accepted: 10/28/2022] [Indexed: 11/09/2022]
Abstract
Primary intra- or transabdominal transplantation of an extended rectus abdominis myocutaneous (ERAM) flap may help prevent surgical complications of pelvic resections. Surgical delay of the ERAM flap may help prevent intra-abdominal (partial) flap loss after transplantation in highly complex situations including previous irradiation. We report on the outcome of this approach and the risk-factors associated with an eventful outcome. From 2012 to 2020, 105 delayed ERAM flaps were consecutively applied immediately following extended pelvic resections after chemoradiation or hyperthermic intraperitoneal chemotherapy. We addressed the increased reconstructive demands by designing the flap in line with the 10th rib and delaying the flap's skin island. All post-operative complications were assessed in light of patient-related or procedure-related potential risk-factors. Major complications occurred in 39 patients. These were correlated with surgery for residual or recurrent malignancy (p < 0.01), with tip necrosis after flap delay (p = 0.02), and with the use of a mesh to close the abdominal donor site (p < 0.01). (Partial) flap loss occurred in 4 cases. We observed a comparably high rate of major complications after ERAM transplantations for increasingly extending indications of perineal-pelvic resections. We consider this to be attributable to poorer patients' conditions and disease processes, rather than to flap viability. Delay of the flap allowed for the use of large and voluminous flaps with comparably little (partial) flap loss.
Collapse
Affiliation(s)
- Maurits Lange
- Department of Plastic and Reconstructive Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - J Joris Hage
- Department of Plastic and Reconstructive Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Arend Aalbers
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Esther M K Wit
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Frédéric Amant
- Department of Gynecology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Gynecology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
- Department of Oncology, Katholieke Universiteit, Leuven, Belgium
| | - Marije J Hoornweg
- Department of Plastic and Reconstructive Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| |
Collapse
|
20
|
Abstract
BACKGROUND Abdominoperineal resection is used to treat a variety of colorectal pathologies. Traditionally, the vertical rectus abdominis myocutaneous flap has been most commonly used for reconstruction. Here, we explore the role of the profunda artery perforator (PAP) flap for perineal reconstruction. METHODS A prospectively maintained database was retrospectively analyzed to identify patients who had undergone perineal reconstruction with a pedicled PAP flap. Parameters of interest included age, sex, body mass index, primary diagnosis, comorbidities, and history of radiation, and postoperative complications. RESULTS Fifteen patients (5 men and 10 women) with a median age of 52 years (interquartile range, 48.5-61.5 years) were included in the study. Median body mass index was 26.3 kg/m2 (interquartile range, 24.0-29.3 kg/m2). Patients underwent abdominoperineal resection for treatment of rectal cancer (n = 9, 60.0%), recurrent anal squamous cell carcinoma (n = 3, 20.0%), and Crohn's disease (n = 3, 20.0%). Twelve patients (80.0%) underwent neoadjuvant radiotherapy. Eight patients (53.3%) experienced a total of 10 complications (2 major and 8 minor). The most common complication was donor (n = 3, 20.0%)/recipient (n = 3, 20.0%) site wound dehiscence. Stable soft tissue coverage was achieved in all patients. CONCLUSIONS The PAP flap provides stable soft tissue coverage of perineal defects with a low donor-site morbidity. This flap should be strongly considered in the reconstructive algorithm when approaching perineal defects.
Collapse
Affiliation(s)
- Connor Arquette
- From the Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA
| | | | | |
Collapse
|
21
|
Hayashi K, Nakagawa T, Oda G, Sato Y, Tokunaga M, Uemura N, Mori H. [A Case of Laparoscopic Total Gastrectomy for Gastric Cancer after Rectus Abdominis Flap Reconstruction for Breast Cancer]. Gan To Kagaku Ryoho 2021; 48:1652-1654. [PMID: 35046286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
A 60-year-old woman underwent laparoscopic total gastrectomy for gastric cancer with a good postoperative course. At the age of 45, she had underwent skin-sparing total mastectomy, sentinel node biopsy, and right rectus abdominis flap reconstruction for left breast cancer. Since there is a certain risk of abdominal wall hernia after the abdominal flap reconstruction, laparoscopic surgery with less abdominal wall damage might be useful. Although the umbilicus is hollowed out and sutured to a small hole in the cranial skin after abdominal flap reconstruction, there seems to be no problem in using the umbilicus for the port. The abdominal wall is scarred after the abdominal flap reconstruction, but normal insufflation pressure was sufficient to perform the operation in our case. Additionally, we must be careful not to damage the flap pedicle, and it would be useful to check its location by ultrasonography before starting the operation.
Collapse
Affiliation(s)
- Kumiko Hayashi
- Dept. of Specialized Surgery, Tokyo Medical and Dental University
| | | | | | | | | | | | | |
Collapse
|
22
|
Henn D, Sivaraj D, Barrera JA, Lin JQ, Chattopadhyay A, Maan ZN, Chen K, Nguyen A, Cheesborough J, Gurtner GC, Lee GK, Nazerali R. The Plane of Mesh Placement Does Not Impact Abdominal Donor Site Complications in Microsurgical Breast Reconstruction. Ann Plast Surg 2021; 87:542-546. [PMID: 34699433 DOI: 10.1097/sap.0000000000002897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reinforcement of the abdominal wall with synthetic mesh in autologous breast reconstruction using abdominal free tissue transfer decreases the risk of bulging and herniation. However, the impact of the plane of mesh placement on donor site complications has not yet been investigated. METHODS We performed a retrospective analysis of 312 patients who had undergone autologous breast reconstruction with muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps or deep inferior epigastric perforator (DIEP) flaps as well as polypropylene mesh implantation at the donor site. Donor site complications were compared among patients with different flap types and different mesh positions including overlay (n = 90), inlay and overlay (I-O; n = 134), and sublay (n = 88). RESULTS Abdominal hernias occurred in 2.86% of patients who had undergone MS-TRAM reconstructions and in 2.63% of patients who had undergone DIEP reconstructions. When comparing patients with different mesh positions, donor site complications occurred in 14.4% of patients with overlay mesh, 13.4% of patients with I-O mesh, and 10.2% of patients with sublay mesh (P = 0.68). Abdominal hernias occurred in 4.44% of patients with overlay mesh, 2.24% of patients with I-O mesh, and 2.27% of patients with sublay mesh (P = 0.69). Multivariable logistic regression analysis did not identify a significant association between mesh position and hernia rates as well as wound complications. CONCLUSIONS Our data indicate that the plane of synthetic mesh placement in relation to the rectus abdominis muscle does not impact the rate of postoperative donor site complications in patients undergoing breast reconstruction with MS-TRAM or DIEP flaps.
Collapse
Affiliation(s)
| | - Dharshan Sivaraj
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Janos A Barrera
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - John Q Lin
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Arhana Chattopadhyay
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Zeshaan N Maan
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Kellen Chen
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Alan Nguyen
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Jennifer Cheesborough
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Geoffrey C Gurtner
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Gordon K Lee
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Rahim Nazerali
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| |
Collapse
|
23
|
Siegwart LC, Sieber L, Fischer S, Diehm Y, Hirche C, Kneser U, Kotsougiani-Fischer D. The Use of Semi-Absorbable Mesh and its Impact on Donor-Site Morbidity and Patient-Reported Outcomes in DIEP Flap Breast Reconstruction. Aesthetic Plast Surg 2021; 45:907-916. [PMID: 33469702 DOI: 10.1007/s00266-020-02096-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/10/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to evaluate the impact of semi-absorbable mesh on donor-site morbidity and patient-reported outcomes in deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS We conducted a retrospective cohort study of all patients who had DIEP flap breast reconstruction in our department from July 2007 to March 2019. Patients were invited to a comparative follow-up visit and grouped according to donor-site closure: primary fascial closure (the no-mesh group) and fascial reinforcement with semi-absorbable mesh in a subfascial position (the mesh group). The primary outcome of interest was donor-site morbidity, including bulging, hernia formation and rectus abdominis muscle strength. We also surveyed, surgical site complications and patient-reported outcomes using Patient and Observer Scar Assessment Scale v2.0 and BREAST-Q© version 2.0. RESULTS A total of 191 patients had received DIEP flap breast reconstruction. Eighty-five patients (44.5%) with 108 DIEP flaps (53 patients in the mesh group and 32 patients in the no-mesh group) were included in the study. The mean BMI of the patients was significantly higher in the mesh group (mesh group, 26.9 vs. no-mesh group, 25.0, with p = 0.03). The incidence of hernia was significantly reduced in the mesh group (mesh group, 2.8% vs. no-mesh group, 13.5%, with p = 0.03). The incidence of bulging and the extent of rectus abdominis muscle strength were similar for both groups. Operative surgical site complications were reduced in the mesh group (mesh group, 7.5% vs. no-mesh group, 18.8%). There was no difference in patients' physical well-being and satisfaction with the donor site between groups. Patient-reported scar outcome was significantly better in the no-mesh group (p < 0.001). CONCLUSION Our novel method of donor-site closure with semi-absorbable mesh in a subfascial position for reinforcement of the anterior rectus fascia on the DIEP donor site is safe. It has no negative impact on surgical site complications and patient-reported outcomes, while reducing the incidence of hernias on the donor-site in DIEP flap breast reconstruction. LEVEL OF EVIDENCE IV 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 .
Collapse
Affiliation(s)
- L C Siegwart
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - L Sieber
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - S Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Y Diehm
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - C Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - U Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - D Kotsougiani-Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany.
| |
Collapse
|
24
|
Lasso JM, Pinilla C, Vasquez W, Asencio JM. The Effect of Intraoperative Radiotherapy on Healing and Complications After Sacrectomy and Immediate Reconstruction. Ann Plast Surg 2021; 86:688-694. [PMID: 33346550 DOI: 10.1097/sap.0000000000002571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Sacropelvic resection is the treatment of choice for pelvic bone tumors and can be associated with intraoperative electron radiotherapy (IOERT) to optimize local control of the disease. Reconstruction with flaps also is essential to avoid pelvic complications. There is scarcity of publications evaluating outcomes of reconstructive procedures associated with IOERT. METHODS A prospective study in 53 patients between 2005 and 2018 was performed. Thirty-four patients received IOERT (group I [GI]) and 19 did not (GII). We examined demographic characteristics, tumor pathology, type of resection and volume of surgical specimen, timing of surgery, IOERT doses, postoperative stay, and complications. We used it for reconstruction rectus abdominis, gluteal, omental and gracilis, superior gluteal artery perforator flap, and free flaps. RESULTS Colonic adenocarcinoma and chordoma were the most frequent tumors. The median (interquartile range) IOERT dose was 1250 (1000-1250) cGy; operating time was 10.15 (8.6-14.0) hours versus 6.0 (5.0-13.0) hours, hospital stay was 37 (21.2-63.0) days versus 26.0 (12.0-60.0) days, and volume of surgical specimen was 480.5 (88.7-1488.0) mL versus 400 (220.0-6700.0) mL in GI and GII, respectively. Operating time was significantly longer in GI (P < 0.03). There were significant positive correlations between operating time, hospital stay, and volume of surgical specimen. Main complications were exudative wounds (50% vs 31.5%), wound dehiscence (41.1% vs 31.5%), and seroma (29.4% vs 26.3%) in GI and GII, respectively. Complications were similar to previous studies with or without radiotherapy. CONCLUSIONS Under a reconstructive approach, IOERT did not harm flap survival nor increased pelvic complications when compared with similar cases without IOERT.
Collapse
Affiliation(s)
- Jose M Lasso
- From the Department of Plastic and Reconstructive Surgery
| | - Carmen Pinilla
- From the Department of Plastic and Reconstructive Surgery
| | - Wenceslao Vasquez
- Department of General Surgery, Hospital Gregorio Marañón, Madrid, Spain
| | - J M Asencio
- Department of General Surgery, Hospital Gregorio Marañón, Madrid, Spain
| |
Collapse
|
25
|
Van Vliet A, Girardot A, Bouchez J, Bigness A, Wang K, Moino D, Theodotou A, Pothuraju T, Felder S, Smith P, Kumar A, Dayicioglu D. How Big Is Too Big?: The Effect of Defect Size on Postoperative Complications of Vertical Rectus Abdominis Flap Reconstruction. Ann Plast Surg 2021; 86:S571-S574. [PMID: 34100815 DOI: 10.1097/sap.0000000000002875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The vertical rectus abdominis myocutaneous (VRAM) flap has been frequently used for perineal reconstruction given the high potential for wound complications associated with direct closure of this area. However, the relationship between defect size and postoperative complications remains undefined. METHODS A retrospective chart review of the last 20 years for VRAM flaps was performed. Defect size, age, body mass index (BMI), cause of defect, sex, radiation, and flap donor laterality were recorded. Complications of infection, partial flap loss, total flap loss, minor wounds, treated nonoperatively, and major wound, which required reoperation, were analyzed with respect to defect size. Descriptive statistics were used to summarize the demographic and clinical characteristics of the included patients. Associations were assessed using binary logistic regression analysis, and difference in means for compared groups was assessed using the independent samples t test. P values were set at 5% for all comparisons. RESULTS There were 65 patients with VRAM flaps identified during the review period. Mean defect size was 204.71 cm2. Mean age was 63.97, and mean BMI was 27.18. History of prior radiation was noted in 90.77% of patients (n = 59). When adjusted for age and BMI, mean defect area was significantly different for patients with minor or major wounds. Larger perineal defects were associated with increased risk of major wound complications (odds ratio, 1.012; 95% confidence interval, 1.003-1.022). CONCLUSIONS The vertical rectus abdominis flap has been a workhorse flap for perineal reconstruction. Defect size does not affect risk of partial flap necrosis, complete flap loss, infection, abdominal fascial dehiscence, ventral hernia, or seroma, which supports the utility of VRAM flap for perineal reconstruction. Larger perineal defects are associated with increased risk for major wound complications, which required reoperation, regardless of age or BMI. Future studies should be performed to determine if there is a maximum defect size cutoff that limits the utility of VRAM flap reconstruction or to develop a predictive model to assess the risk of major wound complications based on defect size.
Collapse
|
26
|
Song D, Li Z, Zhou X, Zhang Y, Feng G, Zhou B, Lü C, Wu P, Tang Y, Yi L, Luo Z. [Muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator for breast reconstruction]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2021; 35:605-610. [PMID: 33998215 PMCID: PMC8175202 DOI: 10.7507/1002-1892.202011020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To explore the surgical technique, effectiveness, and safety of muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator for breast reconstruction. METHODS Between December 2016 and February 2019, 6 cases of early breast cancer received modified radical surgery, lower abdominal flap was applied for one- or two-staged breast reconstruction. The average age of the patients was 34.6 years (range, 29-56 years). The disease duration ranged from 2 to 16 months, with an average of 9.5 months. The tumor was located in the upper outer quadrant in 4 cases and the lower outer quadrant in 2 cases. Pathological examination showed that they were all invasive ductal carcinoma. Four cases of breast cancer were in stage Ⅰ and 2 cases was in stage Ⅱ. During operation, the inferior epigastric artery perforators were found to be close to the upper edge of the flap and/or near the umbilical cord in 4 cases, the inferior epigastric artery perforator vessels were relatively small (<0.3 mm) in 2 cases; and the breast was reconstructed with muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator. The length, width, and thickness of the flap were (28.9±0.2), (12.1±0.4), and (4.4±0.3) cm, respectively. The length of the vascular pedicle was (11.5±0.2) cm and the weight of the flap was (420.5±32.7) g. RESULTS All 6 muscle-sparing rectus abdominis myocutaneous flaps were successful, and the breast incisions healed by first intention. There was no vascular crisis, donor site effusion, hematoma, or infection. All 6 patients were followed up 12-36 months (mean, 26.8 months). The reconstructed breast had a good shape, good elasticity, and no flap contracture or deformation; only linear scars left at the donor site of the flap, and the abdominal wall function was not affected. During follow-up, there was no breast cancer recurrence and metastasis. CONCLUSION When the inferior epigastric artery perforators are too close to the upper edge of the flap and/or near the umbilical cord, the vascularity of lower abdominal flap can be ruined, harvested in form of muscle-sparing rectus abdominis myocutaneous flap vascularized with intercostal artery perforator and inferior epigastric artery perforator can efficiently ensure blood supply safety.
Collapse
Affiliation(s)
- Dajiang Song
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Zan Li
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Xiao Zhou
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200000, P.R.China
| | - Guang Feng
- Department of Burn and Plastic Surgery, the Fourth Affiliated Hospital of Chinese PLA General Hospital, Beijing, 100048, P.R.China
| | - Bo Zhou
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Chunliu Lü
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Peng Wu
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Yuanyuan Tang
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Liang Yi
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Zhenhua Luo
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| |
Collapse
|
27
|
Yi KH, Lee HJ, Lee JH, Seo KK, Kim HJ. Application of Botulinum Neurotoxin Injections in TRAM Flap for Breast Reconstruction: Intramuscular Neural Arborization of the Rectus Abdominis Muscle. Toxins (Basel) 2021; 13:toxins13040269. [PMID: 33918558 PMCID: PMC8070362 DOI: 10.3390/toxins13040269] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 02/06/2023] Open
Abstract
Breast reconstruction after mastectomy is commonly performed using transverse rectus abdominis myocutaneous (TRAM) flap. Previous studies have demonstrated that botulinum neurotoxin injections in TRAM flap surgeries lower the risk of necrosis and allow further expansion of arterial cross-sectional diameters. The study was designed to determine the ideal injection points for botulinum neurotoxin injection by exploring the arborization patterns of the intramuscular nerves of the rectus abdominis muscle. A modified Sihler's method was performed on 16 rectus abdominis muscle specimens. Arborization of the intramuscular nerves was determined based on the most prominent point of the xyphoid process to the pubic crest. All 16 rectus abdominis muscle specimens were divided into four muscle bellies by the tendinous portion. The arborized portions of the muscles were located on the 5-15%, 25-35%, 45-55%, and 70-80% sections of the 1st, 2nd, 3rd, and 4th muscle bellies, respectively. The tendinous portion was located at the 15-20%, 35-40%, 55-60%, and 90-100% sections. These results suggest that botulinum neurotoxin injections into the rectus abdominis muscles should be performed in specific sections.
Collapse
Affiliation(s)
- Kyu-Ho Yi
- Wonju City Public Health Center, Wonju-Si, Kangwondo 26417, Korea;
- Department of Oral Biology, Division in Anatomy and Developmental Biology, Human Identification Research Institute, BK 21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (H.-J.L.); (J.-H.L.)
| | - Hyung-Jin Lee
- Department of Oral Biology, Division in Anatomy and Developmental Biology, Human Identification Research Institute, BK 21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (H.-J.L.); (J.-H.L.)
| | - Ji-Hyun Lee
- Department of Oral Biology, Division in Anatomy and Developmental Biology, Human Identification Research Institute, BK 21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (H.-J.L.); (J.-H.L.)
| | | | - Hee-Jin Kim
- Department of Oral Biology, Division in Anatomy and Developmental Biology, Human Identification Research Institute, BK 21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (H.-J.L.); (J.-H.L.)
- Department of Materials Science & Engineering, College of Engineering, Yonsei University, Seoul 03722, Korea
- Correspondence:
| |
Collapse
|
28
|
Espinosa-de-Los-Monteros A, Frias-Frias R, Alvarez-Tostado-Rivera A, Caralampio-Castro A, Llanes S, Saldivar A. Postoperative Abdominal Bulge and Hernia Rates in Patients Undergoing Abdominally Based Autologous Breast Reconstruction: Systematic Review and Meta-Analysis. Ann Plast Surg 2021; 86:476-484. [PMID: 33720921 DOI: 10.1097/sap.0000000000002538] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
ABSTRACT Bulge and hernia may occur after abdominally based breast reconstruction. The purpose of this study is to provide an estimate of the effects that the type of flap used for breast reconstruction (ie, transverse rectus abdominis muscle [TRAM] vs muscle-sparing [MS]-2 TRAM vs DIEP) has on the postoperative development of both abdominal bulge and abdominal hernia, taking into consideration the method of donor site closure (ie, with mesh vs without mesh), based on the available literature. Twenty-eight studies met the inclusion criteria and were included in the systematic review. From these, 9 studies were comparative and suitable for meta-analysis. The results showed that, for unilateral breast reconstructions, there was no statistically significant difference in hernia/bulge rates in the following techniques: MS-2 TRAM flap without mesh, MS-2 TRAM flap with mesh, and DIEP flap without mesh, and they showed significantly lower hernia/bulge rates compared with TRAM flap without mesh, and TRAM flap with mesh, whereas for bilateral reconstructions, there was no statistically significant difference in hernia/bulge rates in the following techniques: MS-2 TRAM flaps with mesh and DIEP flaps without mesh, and they showed significantly lower hernia/bulge rates compared with TRAM flaps without mesh, TRAM flaps with mesh, and MS-2 TRAM flaps without mesh.
Collapse
|
29
|
Tieman JT, Nourian MM, Agbenorku P, Hoyte-Williams PE, Farhat B, Goodwin IA, Swistun L, Foreman KB, Rockwell WB. Developing a Breast Reconstruction Program in a Resource-Constrained Ghanaian Teaching Hospital: Needs Assessment and Implementation. Ann Plast Surg 2021; 86:129-131. [PMID: 33449461 DOI: 10.1097/sap.0000000000002683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT As the detection of breast cancer in Ghana improves, the incidence of mastectomy has increased and the outcomes have improved. As a secondary result, the need for breast reconstruction is increasing. The cultural hesitation to undergo a mastectomy and live without a breast can be decreased by making breast reconstruction available, cost-effective, and acceptable. Cultural, economic, and technical factors were considered in choosing the best method of breast reconstruction. Discussions, lectures, and cadaver dissections investigated the various reconstructive options. Operative cases were performed using a latissimus musculocutaneous flap, a lower abdominal transverse rectus abdominis myocutaneous (TRAM) flap, and a midabdominal TRAM flap. The midabdominal TRAM was found to be the best choice at Komfo Anokye Teaching Hospital. It is a reliable, robust, well-perfused, single-stage flap that produced excellent patient satisfaction.
Collapse
Affiliation(s)
- Joshua T Tieman
- From the Division of Plastic Surgery, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Maziar Mohsen Nourian
- From the Division of Plastic Surgery, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Pius Agbenorku
- Reconstructive Plastic Surgery and Burns Unit, Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, School of Medical Sciences, Kumasi, Ghana, Africa
| | - Paa Ekow Hoyte-Williams
- Reconstructive Plastic Surgery and Burns Unit, Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, School of Medical Sciences, Kumasi, Ghana, Africa
| | - Boutros Farhat
- Reconstructive Plastic Surgery and Burns Unit, Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, School of Medical Sciences, Kumasi, Ghana, Africa
| | - Isak A Goodwin
- From the Division of Plastic Surgery, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Lukasz Swistun
- From the Division of Plastic Surgery, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Kenneth Bo Foreman
- Department of Neurobiology and Anatomy, University of Utah Health Sciences Center, Salt Lake City, UT
| | | |
Collapse
|
30
|
Lei C, Xu L, Xu F, Li J, Jiang H, Guan S, Wang X, Wen B, Li J, Li X, Geng C, Yin J. Patient satisfaction in one-stage immediate breast reconstruction after mastectomy: A multi-center comparative patient evaluation of prosthesis, LDMF, and TRAM techniques. Medicine (Baltimore) 2020; 99:e19991. [PMID: 32481367 DOI: 10.1097/md.0000000000019991] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To analyze patient satisfaction and the predictive factors characterizing three types of one-stage immediate breast reconstruction (IBR) after mastectomy, including prosthesis, latissimus dorsi myocutaneous flap (LDMF), transverse rectus abdominis myocutaneous (TRAM) flap techniques.Data were collected via face-to-face or telephone interviews from eight breast centers in China from January 2012 to December 2016. A standardized questionnaire that evaluated the general satisfaction and aesthetic satisfaction was sent to patients who had undergone IBR. Logistic regression analysis was performed to identify risk factors associated with patient satisfaction among the three types of breast reconstruction.A total of 412 questionnaires were sent out, and 309 copies were collected including 226 prosthesis, 46 LDMF, and 37 pedicle TRAM reconstruction. Logistic regression analysis showed that general satisfaction and aesthetic satisfaction were significantly correlated with radiotherapy (P < .001, P = .018), respectively. Besides, the aesthetic satisfaction was also associated with nipple-areola complex (NAC) preservation (P < .001).Our multi-center study identified factors of higher patient satisfaction, like NAC preservation and absence of radiotherapy, in order to help breast surgeons make better decisions about individualized reconstruction plan.
Collapse
Affiliation(s)
| | - Lijie Xu
- Department of General Surgery, Beijing Chao-Yang Hospital
| | - Feng Xu
- Department of Breast Surgery
| | - Jie Li
- Department of Breast Surgery
| | | | - Shan Guan
- Department of General Surgery, Beijing Tongren Hospital
| | - Xiang Wang
- Department of Breast Surgery, Cancer Hospital, Chinese Academy of Medical Sciences
| | - Bing Wen
- Department of Plastic and Reconstructive Surgery, The First Hospital of Peking University
| | - Jinfeng Li
- Department of Breast Center, Peking University Cancer Hospital
| | - Xiru Li
- Department of General Surgery, General Hospital of People's Liberation Army, Beijing
| | - Cuizhi Geng
- Breast Center, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei
| | - Jian Yin
- Department of Breast Surgery, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| |
Collapse
|
31
|
Díaz-Plasencia JA, Guzmán-Gavidia CR, Valencia-Mariñas HD, Yan-Quiroz EF, Díaz-Villazon MS. Rectus abdominis muscle flap for repair of the gastrojejunal leakage afterdistal gastrectomy with Billroth II anastomosis for gastric cancer. Rev Gastroenterol Peru 2019; 39:187-192. [PMID: 31333239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Anastomotic leakages at the gastrojejunostomy site are difficult to repair, due to complex gastrointestinal anatomy. This is the first study reporting clinical use of rectus abdominis muscle (RAM) flap for repair of gastrojejunostomy leakage. A patient with leakage of gastrojejunostomy after distal gastrectomy with Billrroth II anastomosis for gastric cancer underwent repair using left RAM flap, based on superior epigastric artery. Rectus abdominis muscle flap, after being harvested was then anchored to the edges of the leak of gastrojejunostomy with few interrupted 2-0 vicryl sutures. Gastrojejunostomy leak sealed in the two cases. Rectus abdominis muscle flap for closure of gastrointestinal defect is a simple, technically easy and dependable procedure, which can be performed, quickly in critically ill patients. It can be used for repair of a large gastrointestinal defect with friable edges when omentum is not available or when other conventional methods are impractical.
Collapse
Affiliation(s)
- Juan A Díaz-Plasencia
- Department of Abdomen, Regional Institute of Neoplastic Diseases "Luis Pinillos Ganoza". Trujillo, Peru; Private University Antenor Orrego. Trujillo, Peru
| | - Carlos R Guzmán-Gavidia
- Department of Abdomen, Regional Institute of Neoplastic Diseases "Luis Pinillos Ganoza". Trujillo, Peru; Private University Antenor Orrego. Trujillo, Peru
| | - Hugo D Valencia-Mariñas
- Department of Abdomen, Regional Institute of Neoplastic Diseases "Luis Pinillos Ganoza". Trujillo, Peru; Private University Antenor Orrego. Trujillo, Peru
| | - Edgar F Yan-Quiroz
- Private University Antenor Orrego. Trujillo, Peru; Oncologic Surgery Service, Hospital of High Complexity "Virgen de la Puerta". Trujillo, Peru
| | | |
Collapse
|
32
|
Grinsell D, Lonie S, Wilson KC, Choong PFM. The innervated rectus abdominis flap for quadriceps reconstruction. J Plast Reconstr Aesthet Surg 2019; 72:941-945. [PMID: 30926411 DOI: 10.1016/j.bjps.2019.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 02/20/2019] [Accepted: 03/10/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The vertical rectus abdominis myocutaneous (VRAM) and transverse rectus abdominis myocutaneous (TRAM) flaps have traditionally been excluded from consideration of reconstructions with functional potential, because of their segmental innervation. We present a case series that aimed to demonstrate that segmental innervation does not preclude successful neural anastomoses and can deliver a functional reconstruction of a total compartment in the anterior thigh. METHODS This review included all patients who required total anterior thigh compartmentectomy and reconstruction between December 2009 and February 2016 were included from the first author's prospective database. RESULTS Eleven cases were identified, with innervated rectus abdominis flaps used for anterior thigh reconstruction. During the median follow up period of 12 months, all patients had reinnervation of the rectus with six reaching M5, one M4+, one M4, two M3 and one M2, according to Medical Research Council power grades. CONCLUSION All patients had successful functional reconstruction in the thigh using the rectus abdominis myocutaneous flap.
Collapse
Affiliation(s)
- Damien Grinsell
- Department of Plastic and Reconstructive Surgery, St.Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia; Horizon Plastic Surgery, 19 Winifred Street, Essendon, Victoria 3040, Australia
| | - Sarah Lonie
- Department of Plastic and Reconstructive Surgery, St.Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia.
| | - K Clare Wilson
- Department of Plastic and Reconstructive Surgery, St.Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia
| | - Peter F M Choong
- Department of Surgery, The University of Melbourne, Grattan Street, Parkville Victoria 3052, Australia; Department of Orthopaedic Surgery, St.Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia
| |
Collapse
|
33
|
Baus A, Culie D, Duong LT, Ben Lakhdar A, Schaff JB, Janot F, Kolb F. Primary clear cell sarcoma of the tongue and surgical reconstruction: About a rare case report. ANN CHIR PLAST ESTH 2018; 64:98-105. [PMID: 30262251 DOI: 10.1016/j.anplas.2018.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 09/03/2018] [Indexed: 01/03/2023]
Abstract
Clear cell sarcomas (SCC), also called "soft-tissue melanoma", are rare and aggressive tumors that preferentially affect the lower limbs (tendons and fasciae) and which have also been described in head and neck localizations. Their clinical and immunohistochemical mimicry with melanoma makes it difficult to diagnose sarcomas. SCC treatment is mainly focused on large-scale resection surgery with adjuvant radiotherapy because of their low chemo-sensitivity and extreme lymphophilia. In case of head and neck localization, these treatments may lead to function and aesthetic sequelae thus requiring the use of modern techniques of reconstructive surgery. The authors describe the diagnosis, treatment and follow-up of large lingual SCC case using a DIEP free flap reconstruction according to an original technique developed in the department. Given the characteristics of patients with SCC (a high proportion of women between 20 and 40 years old) and its inherent qualities (low morbidity of the donor site, volume delivered and excellent plasticity), the fascio-cutaneous free flap type "DIEP" "taken according to the design of the" Cathedral triptych seems to be a viable choice among the range of reconstruction solutions.
Collapse
Affiliation(s)
- A Baus
- Institut Gustave-Roussy, department of plastic surgery, Gustave-Roussy, 114 rue Édouard-Vaillant, 94805 Villejuif, France.
| | - D Culie
- Institut Gustave-Roussy, department of head and neck oncology, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - L T Duong
- Institut Gustave-Roussy, department of head and neck oncology, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - A Ben Lakhdar
- Institut Gustave-Roussy, department of biopathology, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - J-B Schaff
- Institut Gustave-Roussy, department of plastic surgery, Gustave-Roussy, 114 rue Édouard-Vaillant, 94805 Villejuif, France
| | - F Janot
- Institut Gustave-Roussy, department of head and neck oncology, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - F Kolb
- Institut Gustave-Roussy, department of plastic surgery, Gustave-Roussy, 114 rue Édouard-Vaillant, 94805 Villejuif, France
| |
Collapse
|
34
|
Erdmann-Sager J, Wilkins EG, Pusic AL, Qi J, Hamill JB, Kim HM, Guldbrandsen GE, Chun YS. Complications and Patient-Reported Outcomes after Abdominally Based Breast Reconstruction: Results of the Mastectomy Reconstruction Outcomes Consortium Study. Plast Reconstr Surg 2018; 141:271-281. [PMID: 29019862 PMCID: PMC5785552 DOI: 10.1097/prs.0000000000004016] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Abdominal flap reconstruction is the most popular form of autologous breast reconstruction. The current study compared complications and patient-reported outcomes after pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps. METHODS Patients undergoing abdominally based breast reconstruction at 11 centers were prospectively evaluated for abdominal donor-site and breast complications. Patient-reported outcomes were measured by the BREAST-Q and Patient-Reported Outcomes Measurement Information System surveys. Mixed-effects regression models were used to assess the effects of procedure type on outcomes. RESULTS Seven hundred twenty patients had 1-year follow-up and 587 had 2-year follow-up. Two years after reconstruction, SIEA compared with DIEP flaps were associated with a higher rate of donor-site complications (OR, 2.7; p = 0.001); however, SIEA flaps were associated with higher BREAST-Q abdominal physical well-being scores compared with DIEP flaps at 1 year (mean difference, 4.72, on a scale from 0 to 100; p = 0.053). This difference was not significant at 2 years. Abdominal physical well-being scores at 2 years postoperatively were lower in the pedicled TRAM flap group by 7.2 points (p = 0.006) compared with DIEP flaps and by 7.8 points (p = 0.03) compared with SIEA flaps, and in the free TRAM flap group, scores were lower by 4.9 points (p = 0.04) compared with DIEP flaps. Bilateral reconstruction had significantly lower abdominal physical well-being scores compared with unilateral reconstruction. CONCLUSIONS Although all abdominally based flaps are viable breast reconstruction options, DIEP and SIEA flaps are associated with higher abdominal physical well-being than pedicled and free TRAM flaps. Although SIEA flaps offer the advantage of not violating the fascia, higher rates of donor-site complications may diminish patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
Collapse
Affiliation(s)
| | - Edwin G. Wilkins
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI
| | | | - Ji Qi
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Jennifer B. Hamill
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Hyungjin Myra Kim
- Department of Biostatistics, University of Michigan Medical School, Ann Arbor, MI
| | | | - Yoon S. Chun
- Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, MA
| |
Collapse
|
35
|
Jeong W, Lee S, Kim J. Meta-analysis of flap perfusion and donor site complications for breast reconstruction using pedicled versus free TRAM and DIEP flaps. Breast 2017; 38:45-51. [PMID: 29227815 DOI: 10.1016/j.breast.2017.12.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/27/2017] [Accepted: 12/04/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The transverse rectus abdominis musculocutaneous (TRAM) flap is an important option for breast reconstruction. Several studies have recently evaluated whether a greater number of complications result from the use of pedicled TRAM (pTRAM) flaps versus either free TRAM (fTRAM) flaps or deep inferior epigastric artery perforator (DIEP) flaps. To clarify the evidence regarding this issue, we performed an objective meta-analysis of published studies. MATERIALS AND METHODS A literature search of articles published between January 1, 1990, to January 1, 2017 was performed using the PubMed, EMBASE, Scopus, and Cochrane databases. Heterogeneity was statistically analyzed, and fixed effects and random effects models were used as appropriate. RESULTS Eleven articles comparing pedicled TRAM (pTRAM) flaps with either free TRAM (fTRAM) or DIEP flaps were included. The articles evaluated a total of 3968 flaps, including 1891 pTRAM flaps, 866 fTRAM flaps, and 1211 DIEP flaps. Patients with fTRAM flaps had a significantly lower risk of fat necrosis and partial flap necrosis than those with pTRAM flaps. No difference was observed in total flap necrosis and hernia or bulge between fTRAM and pTRAM flaps. No difference was noted in flap complications between DIEP and pTRAM flaps except for hernia or bulge.. CONCLUSION Although pTRAM flaps are being replaced by fTRAM and DIEP flaps, which exhibit fewer complications related to flap ischemia and donor site morbidity, it was unclear from the literature which flap type was most beneficial regarding flap vascularity and donor site morbidity. Hence, surgeons should choose the appropriate option based on their preferences and on patient factors..
Collapse
Affiliation(s)
- Woonhyeok Jeong
- Department of Plastic and Reconstructive Surgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, South Korea.
| | - Seongwon Lee
- Department of Plastic and Reconstructive Surgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, South Korea
| | - Junhyung Kim
- Department of Plastic and Reconstructive Surgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, South Korea
| |
Collapse
|
36
|
Suzuki Y, Yokoyama K, Terao M, Morioka T, Tsuda B, Niikura N, Okamura T, Yamada E, Imagawa K, Akamatsu T, Tokuda Y, Kumaki N. Pyoderma Gangrenosum after Breast Mastectomy and Primary Rectus Abdominis Flap Reconstruction. Tokai J Exp Clin Med 2017; 42:133-138. [PMID: 28871582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 07/05/2017] [Indexed: 06/07/2023]
Abstract
Pyoderma gangrenosum is an intractable disease of unknown cause involving recurrent ulcerative lesions on the skin, and may accompany ulcerative colitis, rheumatoid arthritis, leukemia, systemic lupus erythematosus, and other conditions. Here, we report a rare case of pyoderma gangrenosum in the thoracic abdomen following post-mastectomy reconstructive surgery. A 39-year-old presented at the hospital with a complaint of left papilla erosion. Skin biopsy at the site revealed invasive skin cancer, with Paget-like progression in the cancerous nipple and suspected malignancy of skin appendages. After partial mastectomy including the areola, invasive ductal breast carcinoma was diagnosed. The patient underwent a subsequent full mastectomy with simultaneous sentinel lymph node biopsy and primary breast reconstructive surgery using a rectus abdominis myocutaneous flap. Two weeks post-surgery, healing of the abdominal surgical wound was found to be delayed, and suture abscess was suspected. Despite localized treatment, an ulcerative lesion developed in the thoracic region, and pyoderma gangrenosum was diagnosed following skin biopsy. After the introduction of steroid pulse therapy, no progression of the lesion was observed. This report describes the disease characteristics, diagnosis, and treatment of post-surgical pyoderma gangrenosum and discusses the case in the context of previous literature.
Collapse
Affiliation(s)
- Yasuhiro Suzuki
- Division of Breast and Endocrine Surgery, Department of Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Chung E, Kapenhas E, Badia D, Spektor M, Gluck BS, Secola S. Management of Recurrent Invasive Ductal Carcinoma in Transrectus Abdominis Myocutaneous Flap and Lymphatic Remodeling to the Contralateral Axilla. Am Surg 2017; 83:e113-e114. [PMID: 28424111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
|
38
|
Chen J, Song B, Chen C, Zhang D, Wang N, Ma X, Guo S. [Thinning of the free muscle flaps for the treatment of hand and foot defects]. Zhonghua Zheng Xing Wai Ke Za Zhi 2017; 33:112-115. [PMID: 30070809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To investigate the feasibility of one-stage thinning of latissimus dorsi muscle, rectus abdominis muscle and gracilis flap in reconstruction of the hand and foot defects. METHODS From June 2009 to April 2015,24 free muscle flaps were thinned during transfer operation by removing their superficial muscle layers on the basis of their vessel pedicles running in the deep surface of flaps. The surface of the muscle flaps were covered by split-thickness skin grafts. There were 16 latissimus dorsi muscle flaps,4 gracilis flaps and 4 rectus abdominis muscle flaps. Flap size ranged from 6 cm × 4 cm to 20 cm × 12 cm. Thinned muscle flaps were used to resurface 7 hand defects and 17 foot defects. RESULTS All muscle flaps survived the thinning procedures without any circulation problems except for one case which suffered total flap necrosis due to venous thrombosis. Skins grafts on muscle flaps also took well. One patient experienced partial skin loss. Two patients underwent secondary debridement and thinning procedure for infection and bulkiness. During the 0.3-20 months follow-up, the contour of thinned muscle flaps matched well with the recipient areas. Reconstructed feet are able to wear regular shoes. CONCLUSIONS Intraoperative immediate thinning of free muscle flaps can be safely accomplished during the primary reconstruction procedure. This procedure prevents the limitations of muscle flap bulkiness and may provide an alternative for surface coverage.
Collapse
|
39
|
Pang JH, Patel SA, King SA, Curcillo PG, Weiss ES, Buchanan DR. Reduced-port approach to laparoscopic flap harvest (RALFH): An anterior sheath sparing rectus abdominis flap. J Plast Reconstr Aesthet Surg 2017; 70:710-712. [PMID: 28238721 DOI: 10.1016/j.bjps.2017.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/20/2017] [Accepted: 01/31/2017] [Indexed: 01/05/2023]
Affiliation(s)
- John H Pang
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sameer A Patel
- Department of Surgical Oncology, Division of Plastic & Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Stephanie A King
- Department of Surgical Oncology, Division of Plastic & Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Paul G Curcillo
- Department of Surgical Oncology, Division of Plastic & Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Eric S Weiss
- Department of Surgery, Einstein Healthcare Network, Philadelphia, PA, USA.
| | - Dallas R Buchanan
- Department of Surgery, Division of Plastic & Reconstructive Surgery, Temple University Hospital, Philadelphia, PA, USA
| |
Collapse
|
40
|
Roslan EJ, Kelly EG, Zain MA, Basiron NH, Imran FH. Immediate simultaneous bilateral breast reconstruction with deep inferior epigastric (DIEP) free flap and transverse rectus abdominis musculocutaneous (TRAM) pedicled flap. Med J Malaysia 2017; 72:85-87. [PMID: 28255154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Breast reconstructive surgery has evolved tremendously since its inception. Following tumour clearance surgery, physical restoration with breast reconstruction is an important aspect of physical and emotional rehabilitation. Various methods have been described to suit patients demand for the best aesthetic outcome. Surgeon's preference, experience and practicality of differing procedures must be considered. We describe a simultaneous bilateral breast reconstruction with free deep inferior epigastric (DIEP) flap and pedicled transverse rectus abdominis musculocutaneous (TRAM) flap immediately post mastectomies for bilateral breast cancers. The surgery described has resulted in a reasonable technical ease, acceptable flap and abdominal morbidity and good aesthetic outcome.
Collapse
Affiliation(s)
- E J Roslan
- Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Department of Surgery, 56000 Cheras, Kuala Lumpur, Malaysia.
| | - E G Kelly
- Royal College of Surgeons in Ireland, Ireland
| | - M A Zain
- Hospital Kuala Lumpur, Department of Plastic and Reconstructive Surgery, Kuala Lumpur, Malaysia
| | - N H Basiron
- Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Department of Surgery, Plastics and Reconstructive Unit, 56000 Cheras, Kuala Lumpur, Malaysia
| | - F H Imran
- University College Dublin, School of Medicine & Medical Science, Dublin, Ireland
| |
Collapse
|
41
|
Jeong WS, Han W, Eom JS. Comparison of Aesthetic Outcomes Between Vertical and Horizontal Flap Insets in Breast Reconstruction with the TRAM or DIEP Flaps. Aesthetic Plast Surg 2017; 41:19-25. [PMID: 28032178 DOI: 10.1007/s00266-016-0757-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 11/30/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Tissue transfer, such as use of the transverse rectus abdominis myocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) free flaps, is considered a standard method. However, outcomes may vary among inset methods. Here we compared the aesthetic outcomes of breast reconstructions using vertical and horizontal flap inset methods. METHODS We, respectively, reviewed 274 patients who underwent unilateral post-mastectomy breast reconstruction using TRAM or DIEP free flaps between April 2006 and December 2013. Photographs (frontal and bilateral oblique views) obtained 6 months post-operatively were evaluated. Symmetry scores and regional volume discrepancy scores were compared between the vertical and horizontal inset groups. Symmetry scores were adjusted for 11 potential confounding factors on multivariate regression analysis. RESULTS The vertical inset method was associated with higher total symmetry scores, projection, and ptotic naturalness scores. On multivariate regression analysis, the inset method was an independent predictor of outcomes. Regional volume discrepancy score analysis showed a greater tendency for more symmetrical volumes in the upper, medial, and lateral poles with the vertical inset. CONCLUSION The flap inset method is one of the key determinants of aesthetic breast reconstruction outcomes. The vertical inset method was associated with superior aesthetic outcomes and enabled balanced distribution of flap volume to the four poles of the breast. 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 .
Collapse
Affiliation(s)
- Woo Shik Jeong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Wooyeon Han
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Jin Sup Eom
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
| |
Collapse
|
42
|
Seymour NC, Rathinaezhil R. A rare case of umbilical metastasis after delayed transverse rectus abdominis myocutaneous flap reconstruction for invasive breast cancer. Breast Dis 2016; 37:33-35. [PMID: 28035905 DOI: 10.3233/bd-160249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 46-year-old female presented with an inflamed and painful umbilicus. Past medical history included breast cancer, followed by metastatic sternal cancer two years after the initial breast cancer diagnosis.The painful umbilicus was confirmed metastasis from a primary breast cancer she had treated eleven years previously.Metastases to the umbilicus are rare, and are usually gastrointestinal in origin. To our knowledge this is the first report of a metastasis from any primary cancer to the umbilicus after transverse rectus abdominis myocutaneous flap (TRAM). Any lesion at any stage after treatment for breast cancer should be viewed with suspicion of recurrence and investigated and treated appropriately.
Collapse
|
43
|
Golpanian S, Gerth DJ, Tashiro J, Thaller SR. Free Versus Pedicled TRAM Flaps: Cost Utilization and Complications. Aesthetic Plast Surg 2016; 40:869-876. [PMID: 27743083 DOI: 10.1007/s00266-016-0704-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 09/13/2016] [Indexed: 11/26/2022]
Abstract
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 .
Collapse
Affiliation(s)
- Samuel Golpanian
- Division of Plastic, Aesthetic & Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami, Clinical Research Building, 1120 N.W. 14th Street, 4th Floor, Miami, FL, 33136, USA
| | - David J Gerth
- Division of Plastic, Aesthetic & Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami, Clinical Research Building, 1120 N.W. 14th Street, 4th Floor, Miami, FL, 33136, USA
| | - Jun Tashiro
- Division of Plastic, Aesthetic & Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami, Clinical Research Building, 1120 N.W. 14th Street, 4th Floor, Miami, FL, 33136, USA
| | - Seth R Thaller
- Division of Plastic, Aesthetic & Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami, Clinical Research Building, 1120 N.W. 14th Street, 4th Floor, Miami, FL, 33136, USA.
| |
Collapse
|
44
|
Michaud JE, Ko JS, Lue K, Di Carlo HN, Redett RJ, Gearhart JP. Use of muscle pedicle flaps for failed bladder neck closure in the exstrophy spectrum. J Pediatr Urol 2016; 12:289.e1-289.e5. [PMID: 27086261 DOI: 10.1016/j.jpurol.2016.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 03/22/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE The authors have reviewed the use of muscle pedicle flaps for the treatment of failed bladder neck closure in exstrophy spectrum patients. METHODS A retrospective review of all exstrophy spectrum patients who underwent continence procedures with the use of muscle pedicle flaps at our institution during the last 15 years was performed. Patient characteristics, surgical history, and outcomes, including complications, continence, morbidity, and infection, were assessed. The authors utilized muscle pedicle flaps in eight exstrophy patients, including four patients with classic bladder exstrophy and four patients with cloacal exstrophy. Seven of eight patients had failed at least one prior bladder neck closure, and they had undergone a median of three prior urologic procedures. To achieve continence, five rectus muscle flaps and three gracilis muscle flaps were utilized in combination with bladder neck closure. RESULTS There were no major intraoperative or postoperative complications. All patients were initially continent, and after a median follow-up of 18.7 months seven of eight patients were continent. One patient required continent urinary stoma revision and one patient developed perineal incontinence after perineal trauma. No patients required revision of, or additional, continence procedures at the bladder neck. DISCUSSION The use of pedicle muscle flaps appears to be a safe and feasible option for exstrophy spectrum patients with failed bladder neck closure. Although achieving continence can be difficult in this population, use of muscle flaps and bladder neck closure is a viable and effective option in this challenging subset of patients.
Collapse
Affiliation(s)
- Jason E Michaud
- Division of Pediatric Urology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Joan S Ko
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kathy Lue
- Division of Pediatric Urology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Heather N Di Carlo
- Division of Pediatric Urology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Richard J Redett
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - John P Gearhart
- Division of Pediatric Urology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| |
Collapse
|
45
|
Tigga SR, Goswami P, Khanna J. Congenital Partial Absence of Trapezius with Variant Pattern of Rectus Sheath. Acta Med Iran 2016; 54:280-282. [PMID: 27309271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2016] [Indexed: 06/06/2023] Open
Abstract
Musculocutaneous pedicled/free flaps are an essential prerequisite for reconstructive surgery. Amongst the trunk muscles commonly harvested for flaps, the trapezius and rectus abdominis provide satisfactory coverage for cranial and trunk defects. unilateral/bilateral or partial congenital absence of trapezius muscle is well documented and may result in muscular imbalances compromising posture and limb movements. During routine cadaveric dissection, we encountered a case of bilateral partial absence of occipital part of the trapezius muscle. Concurrently, the ventral abdominal musculature displayed the aponeurosis of transversus abdominis muscle solely forming the posterior wall of the rectus sheath. These conjointly occurring anomalies advocate a compensatory strengthening of the anterior wall of rectus sheath in response to the congenital absence of occipital part of the trapezius, probably to counteract the postural instability. The present study focuses on recognition of compensatory mechanisms resulting from congenital variations as identification of such processes may prevent chronic debilitating conditions.
Collapse
Affiliation(s)
- Sarika Rachel Tigga
- Department of Anatomy, Esic Medical College and Hospital, Rohtak University, Delhi, India
| | - Preeti Goswami
- Department of Anatomy, Azad Medical College, Delhi University, New Delhi, India
| | - Jugesh Khanna
- Department of Anatomy, University College of Medical Sciences, Delhi, India
| |
Collapse
|
46
|
Bocková M, Hoch J, Frajer L. [Perineal hernia - hernia repair using rectus abdominis muscle flap]. Rozhl Chir 2016; 95:206-209. [PMID: 27336750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
UNLABELLED Perineal hernia is defined as a protrusion of intra-abdominal viscera through a defect in the pelvic floor. Primary hernias are extremely rare; secondary (postoperative) hernias following pelvic surgery, especially abdominoperineal resection or pelvic exenteration, are more common. Impaired perineal wound healing and neoadjuvant chemoradiotherapy in cancer patients are defined as main risk factors. A growing incidence of this complication is expected in connection with an increasing use of laparoscopic approaches and ELAPE. Despite the considerable time since the first described secondary perineal hernia in literature, patient series, prospective studies and treatment guidelines are still missing. The authors present a case of a 66-year-old man with secondary perineal hernia following a previous laparoscopic abdominoperineal resection for rectal cancer undergoing a surgical intervention. This was performed through an abdominal approach using a rectus abdominis muscle flap to repair the pelvic floor defect. KEY WORDS perineal hernia - hedrocele - RAM - abdominoperineal resection.
Collapse
|
47
|
Affiliation(s)
- Paddy Dewan
- Department of General Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
48
|
Gupta R, Singh H, Talukder S, Verma GR. A new technique of closing a gastroatmospheric fistula with a rectus abdominis muscle flap. BMJ Case Rep 2015; 2015:bcr2015209309. [PMID: 25819831 PMCID: PMC4386304 DOI: 10.1136/bcr-2015-209309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2015] [Indexed: 11/04/2022] Open
Abstract
Proximal enteroatmospheric fistulae are difficult to manage and carry high mortality from sepsis and electrolyte imbalances. Conservative management with total parenteral nutrition, exclusion of fistula, resection and anastomosis are conventional methods of treatment with low success rate. Providing muscle cover to manage an enteroatmospheric fistula is a noble concept. A postoperative high-output gastroatmospheric fistula (GAF) was repaired by superior epigastric artery-based rectus abdominis muscle flap (RAMF). Postoperative recovery was uneventful. This technique may be useful for closure of proximal enteroatmospheric fistulae that fail to heal through medical and conventional surgical management.
Collapse
Affiliation(s)
- Rahul Gupta
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shibojit Talukder
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ganga Ram Verma
- Surgical Gastroenterology Division, Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
49
|
Zhang J, Zhang J, Liang W, Ji C, Pan S, Chen Y, Gao S, Yao Y. [Lengthened pedicle of rectus abdominis flap to repair defect on neck and chest]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2014; 28:1372-1375. [PMID: 25639053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To explore the feasibility to repair defect on the neck and chest with the rectus abdominis flap which pedicle is lengthened by measuring the width, thickness, and the intercostal space of the inferior costicartilage using CT angiography (CTA). METHODS Thirty cases receiving CTA and three-dimensional reconstruction between July and December 2013 were included in the study. Of 30 cases, 17 were male and 13 were female, aged 44-70 years (mean, 56 years). The width and thickness of the 3rd to 7th costicartilages and the distance of the 3rd to 6th intercostal spaces were measured, and the lengthened pedicle was calculated after the 4th to 7th costicartilage was cut off. Between July 2012 and November 2013, the lengthened pedicle of the rectus abdominis flap was clinically used to repair the defect on the neck and chest in 4 cases. RESULTS The pedicle of the rectus abdominis flap was about 6 cm in length. When the left 7th, 6th, 5th, and 4th costicartilages were cut off, the average pedicle was lengthened by 4.07, 7.99, 12.50, and 17.48 cm respectively; when the right 7th, 6th, 5th, and 4th costicartilages were cut off, the average pedicle was lengthened by 4.63, 10.82, 16.64, and 22.05 cm respectively. In 4 flaps which were clinically used to repair defects, 3 flap completely survived, 1 flap had partial necrosis. Three patients were followed up 6 months, and the appearance and texture of the flap were satisfactory; 1 patient failed to be followed up. CONCLUSION Resecting the inferior costicartilage can prolong the pedicle of the rectus abdominis flap, therefore it can be used to repair defect on the upper chest and the neck.
Collapse
|
50
|
Liu E, Smalldridge J, Scott B. Unipedicle TRAM flap procedures are associated with symptoms of pelvic floor dysfunction in women: a case control study. N Z Med J 2014; 127:41-46. [PMID: 24997700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
HYPOTHESIS Chronic conditions that cause raised intra-abdominal pressure, such as obesity, chronic cough and constipation are risk factors for pelvic floor dysfunction (PFD). We hypothesise that unipedicle transverse rectus abdominis musculocutaneous flap (UTRAM flap) for reconstruction following mastectomy for breast cancer increases the risk of PFD. AIM The aim of this study is to assess if there is increased risk of pelvic floor dysfunction associated with UTRAM flap reconstruction compared to controls. METHOD 39 patients who had UTRAM flaps for breast reconstruction following mastectomy for breast cancer between year 1997 to 2004 were recruited as cases. They were matched by age with 36 controls, who have had breast cancer but not U TRAM flap reconstruction as part of their treatment. Validated questionnaires (Pelvic floor distress inventory PFDI-20) were completed by study participants, and demographic data were also collected. Mixed effect analysis of variance was used to assess for statistical difference in the mean PFDI-20 scores, adjusted by age, parity, BMI and history of gynaecological surgery. RESULTS The case group has significantly higher mean PFDI-20 score than the control group, 13 (3-29) vs 5.5 (1-11), MH odds ratio 1.8 (1.1-2.8), p value=0.02. CONCLUSION Women who have undergone U TRAM flap reconstruction appeared to have more symptoms of PFD, compared to women who did not have the procedure. It is likely that the reduction in volume of abdomen, following surgery leads to an increase in intra-abdominal pressure (IAP) which predisposes these women to PFD. Future work to assess changes in IAP is proposed.
Collapse
Affiliation(s)
- Emily Liu
- Auckland City Hospital, 2 Park Road, Grafton, Auckland 1023, New Zealand.
| | | | | |
Collapse
|