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Aristizábal A, Ciudad P, Chen HC, Maruccia M, Nazerali R, Manrique OJ. Is immediate lymphatic reconstruction the future of lymphedema prevention? Gland Surg 2024; 13:600-602. [PMID: 38720677 PMCID: PMC11074654 DOI: 10.21037/gs-23-536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/01/2024] [Indexed: 05/12/2024]
Affiliation(s)
- Alejandra Aristizábal
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Hung Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Rahim Nazerali
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA, USA
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
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Gaxiola-García MA, Escandón JM, Manrique OJ, Skinner KA, Kushida-Contreras BH. Surgical Treatment for Primary Lymphedema: A Systematic Review of the Literature. Arch Plast Surg 2024; 51:212-233. [PMID: 38596145 PMCID: PMC11001464 DOI: 10.1055/a-2253-9859] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/30/2023] [Indexed: 04/11/2024] Open
Abstract
This is a retrospective review of surgical management for primary lymphedema. Data were extracted from 55 articles from PubMed MEDLINE, Web of Science, SCOPUS, and Cochrane Central Register of Controlled Trials between the database inception and December 2022 to evaluate the outcomes of lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), and outcomes of soft tissue extirpative procedures such as suction-assisted lipectomy (SAL) and extensive soft tissue excision. Data from 485 patients were compiled; these were treated with LVA ( n = 177), VLNT ( n = 82), SAL ( n = 102), and excisional procedures ( n = 124). Improvement of the lower extremity lymphedema index, the quality of life (QoL), and lymphedema symptoms were reported in most studies. LVA and VLNT led to symptomatic relief and improved QoL, reaching up to 90 and 61% average circumference reduction, respectively. Cellulitis reduction was reported in 25 and 40% of LVA and VLNT papers, respectively. The extirpative procedures, used mainly in patients with advanced disease, also led to clinical improvement from the volume reduction, as well as reduced incidence of cellulitis, although with poor cosmetic results; 87.5% of these reports recommended postoperative compression garments. The overall complication rates were 1% for LVA, 13% for VLNT, 11% for SAL, and 46% for extirpative procedures. Altogether, only one paper lacked some kind of improvement. Primary lymphedema is amenable to surgical treatment; the currently performed procedures have effectively improved symptoms and QoL in this population. Complication rates are related to the invasiveness of the chosen procedure.
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Affiliation(s)
- Miguel Angel Gaxiola-García
- Plastic and Reconstructive Surgery Department, Mexico's Children's Hospital (Hospital Infantil de México “Federico Gómez”), Mexico City, Mexico
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Kristin A. Skinner
- Department of Surgical Oncology, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
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Escandón JM, Langstein HN, Christiano JG, Aristizábal A, Gooch JC, Weiss A, Manrique OJ. Latissimus dorsi flap with immediate fat transfer (LIFT) for autologous breast reconstruction: Single institution experience. Am J Surg 2024; 228:185-191. [PMID: 37743213 DOI: 10.1016/j.amjsurg.2023.09.023] [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: 05/17/2023] [Revised: 08/15/2023] [Accepted: 09/13/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Few studies have reported the outcomes of LDF and immediate fat transfer (LIFT) during breast reconstruction. The aim of this study was to compare the perioperative outcomes and complications of LIFT and standard LDF (without immediate fat transfer) for breast reconstruction. METHODS We retrospectively reviewed charts from patients undergoing autologous breast reconstruction after total mastectomy between 2011 and 2021. We compared intraoperative and postoperative outcomes between groups. RESULTS One hundred nineteen reconstructions (61.02%) were performed with LIFT, while seventy-six (38.98%) were performed with standard LDF. The median volume of total fat transferred during LIFT was 125-cc [110-170 cc]. The rates of donor site wound disruption (23.7% versus 12.6%, p = 0.044) were higher using the standard LDF compared to LIFT. Reconstructions performed with LIFT (HR 4.01, p < 0.001) were found to be associated with secondary fat grafting procedures. CONCLUSION LIFT is a safe procedure to enhance the volume of LDF in patients desiring autologous reconstruction without increasing recipient-site morbidity. On a time-to-event analysis, LIFT was associated with the requirement of further revision procedures using secondary fat grafting.
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Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Jose G Christiano
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Alejandra Aristizábal
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Jessica C Gooch
- Division of Surgical Oncology, Department of Surgery, Pluta Cancer Center, Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
| | - Anna Weiss
- Division of Surgical Oncology, Department of Surgery, Pluta Cancer Center, Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA.
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Escandón JM, Christiano JG, Gooch JC, Olzinski AT, Prieto PA, Skinner KA, Langstein HN, Manrique OJ. Two-Stage Implant-Based Breast Reconstruction Using Intraoperative Fluorescence Imaging: A Propensity Score-Matched Analysis. Plast Reconstr Surg 2024; 153:291-303. [PMID: 37104496 DOI: 10.1097/prs.0000000000010602] [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: 04/28/2023]
Abstract
BACKGROUND Limited comparability between study groups can generate significant selection and observer bias when evaluating the efficacy of the SPY system and fluorescence imaging for implant-based breast reconstruction. In this study, the authors compared the surgical outcomes and complications during the first stage of reconstruction between reconstructions evaluated intraoperatively with fluorescence imaging using the SPY system and clinical assessment using a matched analysis. METHODS The authors conducted a retrospective review of patients undergoing total mastectomy and immediate two-stage implant-based breast reconstruction with TEs from January of 2011 to December of 2020. The rate of complication, time for TE-to-implant exchange, and time to start radiotherapy were compared between groups (intraoperative fluorescence imaging versus clinical assessment) using a propensity score-matched analysis. RESULTS After propensity score matching, 198 reconstructions were evaluated. There were 99 reconstructions in each group. The median time for TE-to-implant exchange (140 days versus 185 days; P = 0.476) and time to initiate adjuvant radiotherapy (144 days versus 98 days; P = 0.199) were comparable between groups. The 30-day rate of wound-related complications (21% versus 9%; P = 0.017) and 30-day rate of wound-related unplanned interventions were significantly higher in reconstructions evaluated with clinical assessment when compared with the SPY system (16% versus 5%; P = 0.011). A higher 30-day rate of seroma (19% versus 14%; P = 0.041) and hematoma (8% versus 0%; P = 0.004) were found in reconstructions assessed intraoperatively with the SPY system. CONCLUSIONS After matching, reconstructions evaluated with fluorescence imaging exhibited a lower incidence of early wound-related complications when compared with clinical evaluation alone. Nonetheless, the Wise pattern for mastectomy was found to be the only independent predictor associated with early wound-related complications. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Joseph M Escandón
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital
| | - Jose G Christiano
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital
| | - Jessica C Gooch
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center
| | - Ann Therese Olzinski
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center
| | - Peter A Prieto
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center
| | - Kristin A Skinner
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center
| | - Howard N Langstein
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital
| | - Oscar J Manrique
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital
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Escandón JM, Mascaro-Pankova A, DellaCroce FJ, Escandón L, Christiano JG, Langstein HN, Ciudad P, Manrique OJ. The Value of a Co-surgeon in Microvascular Breast Reconstruction: A Systematic Review and Meta-analysis. Plast Reconstr Surg Glob Open 2024; 12:e5624. [PMID: 38317657 PMCID: PMC10843485 DOI: 10.1097/gox.0000000000005624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 12/06/2023] [Indexed: 02/07/2024]
Abstract
Using a co-surgeon model has been suggested to improve perioperative outcomes and reduce the risk of complications. Therefore, we evaluated if a co-surgeon model compared with a single microsurgeon model could decrease the surgical time, length of stay, rate of complications, and healthcare-associated costs in adult patients undergoing microvascular breast reconstruction (MBR). A comprehensive search was performed across PubMed MEDLINE, Embase, and Web of Science. Studies evaluating the perioperative outcomes and complications of MBR using a single-surgeon model and co-surgeon model were included. A random-effects model was fitted to the data. Seven retrospective comparative studies were included. Ultimately, 1411 patients (48.23%) underwent MBR using a single-surgeon model, representing 2339 flaps (48.42%). On the other hand, 1514 patients (51.77%) underwent MBR using a co-surgeon model, representing 2492 flaps (51.58%). The surgical time was significantly reduced using a co-surgeon model in all studies compared with a single-surgeon model. The length of stay was reduced using a co-surgeon model compared with a single-surgeon model in all but one study. The log odds ratio (log-OR) of recipient site infection (log-OR = -0.227; P = 0.6509), wound disruption (log-OR = -0.012; P = 0.9735), hematoma (log-OR = 0.061; P = 0.8683), and seroma (log-OR = -0.742; P = 0.1106) did not significantly decrease with the incorporation of a co-surgeon compared with a single-surgeon model. Incorporating a co-surgeon model for MBR has minimal impact on the rates of surgical site complications compared with a single-surgeon model. However, a co-surgeon optimized efficacy and reduced the surgical time and length of stay.
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Affiliation(s)
- Joseph M. Escandón
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, N.Y
| | | | - Frank J. DellaCroce
- Center for Restorative Breast Surgery and the Tulane School of Public Health and Tropical Medicine, New Orleans, La
| | - Lauren Escandón
- Universidad El Bosque, School of Medicine, Bogotá D.C., Colombia
| | - Jose G. Christiano
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, N.Y
| | - Howard N. Langstein
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, N.Y
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Oscar J. Manrique
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, N.Y
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Escandón JM, Aristizábal A, Langstein HN, Christiano JG, Gooch JC, Prieto PA, Skinner KA, Weiss A, Manrique OJ. Single versus Double Drainage for Immediate Two-Stage Implant-Based Breast Reconstruction: A Propensity Score-Matched Analysis. Aesthetic Plast Surg 2024:10.1007/s00266-023-03800-6. [PMID: 38216789 DOI: 10.1007/s00266-023-03800-6] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 12/06/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Reports evaluating plastic surgeons' practices indicate there are conflicting trends regarding the use of one or two drains for implant-based breast reconstruction (IBBR). Our study aimed to perform a matched cohort analysis to examine the postoperative outcomes and complications of immediate IBBR with tissue expander (TE) using two drains versus a single drain. METHODS A propensity score-matched analysis (nearest neighbor, 1:1 matching) of immediate reconstructions using two versus one drain was conducted. Female patients undergoing immediate two-stage IBBR with TEs between January 2011 and May 2021 were included. The covariables were as follows: BMI, mastectomy weight, lymph node surgery, TE surface, plane of reconstruction, use of acellular dermal matrix products, fluorescence imaging use, and intraoperative TE volume. RESULTS After matching using propensity scores, 192 reconstructions were included in the final analysis: 96 in each group. The rate of 30-day complications and overall complications during the first phase of IBBR were comparable between groups. The time for drain removal, time to initiate and finalize expansions, and time for TE-to-implant exchange were comparable between groups. Diabetes (OR 3.74, p = 0.025) and an increased estimated blood loss (OR 1.004, p = 0.01) were the only independent predictors for seroma formation. CONCLUSION In this matched cohort analysis evaluating the role of one versus two drains for two-stage IBBR, we found a comparable rate of complications and surgical outcomes between the two cohorts. Using two drains for immediate IBBR needs to be tailored depending on intraoperative findings. 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 .
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Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Alejandra Aristizábal
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Jose G Christiano
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Jessica C Gooch
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Peter A Prieto
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Kristin A Skinner
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Anna Weiss
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA.
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Gaxiola-García MA, Kushida-Contreras BH, Albornoz CR, Manrique OJ. Quality of life assessment after microvascular head and neck reconstruction: a systematic review of available tools. Br J Oral Maxillofac Surg 2024; 62:23-29. [PMID: 38042715 DOI: 10.1016/j.bjoms.2023.10.022] [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: 08/03/2023] [Revised: 10/13/2023] [Accepted: 10/26/2023] [Indexed: 12/04/2023]
Abstract
In this study, we aimed to appraise the quality and psychometric properties of quality of life (QOL) assessment tools used after microsurgical reconstruction for head and neck cancers. A systematic review of QOL assessment tools used in head and neck cancer patients after microsurgical reconstruction was performed; emphasis was placed on psychometric properties and validity. Fifty-four studies published between January 2010 and February 2023 fulfilled the criteria; in these, twenty-three different QOL assessment tools were identified. The most commonly used instrument was the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck version (EORTC-H&N). No assessment tool fulfilled all the quality criteria; no single tool presented evidence from all the components of validity. Almost all reported reliability coefficients were above 0.7; most papers reported an internal consistency coefficient (Cronbach's alpha) for the global score. The array of available tools allows for the choice of the most appropriate one depending on the context faced by the clinician or researcher.
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Affiliation(s)
- Miguel Angel Gaxiola-García
- Plastic and Reconstructive Surgery Department, Mexico's Children Hospital (Hospital Infantil de México "Federico Gómez"), Mexico City, Mexico.
| | | | | | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, United States
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Ciudad P, Kirschbaum-Rubin S, Manrique OJ, Chen HC. Technical pearls and pitfalls of the posterior auricular artery free flap in facial reconstruction. Microsurgery 2024; 44:e31132. [PMID: 37953651 DOI: 10.1002/micr.31132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/10/2023] [Accepted: 10/26/2023] [Indexed: 11/14/2023]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | | | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, New York, USA
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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Cevallos P, Berry C, Lipman KJ, Kubiak CA, Mohan AT, Ayyala HS, Manrique OJ, Nazerali R. Breast reconstruction after mastectomy in patients with obesity: a narrative review. Ann Transl Med 2023; 11:413. [PMID: 38213816 PMCID: PMC10777214 DOI: 10.21037/atm-23-1599] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 09/01/2023] [Indexed: 01/13/2024]
Abstract
Background and Objective Breast reconstruction in patients with obesity presents numerous challenges, both in terms of surgical technique and post-operative complication management. As breast reconstruction techniques continue to evolve, the armamentarium of reconstructive options for patients with obesity has vastly expanded. Options now include immediate or delayed, implant-based, autologous, or hybrid reconstruction. Determining the optimal breast reconstruction in this complex population requires nuanced and experienced decision-making. Methods A literature search was conducted to identify studies assessing breast reconstruction considerations in patients with obesity. The search was performed on PubMed and was limited to English language studies published between 1990 and 2023. Primary studies, case reports, chart reviews, and qualitative studies were included. Additional articles were identified for inclusion based on a review of references, as well as a web-based search, to identify additional studies that were not captured with the primary search strategy. Key Content and Findings This narrative review article summarizes the current literature available to guide surgeons in breast reconstruction in patients with obesity. Conclusions The advancements in oncologic surgery and breast reconstruction techniques have expanded available surgical options, including immediate or delayed implant-based, autologous, or hybrid breast reconstruction. Each approach has its unique advantages, disadvantages, and surgical considerations. Despite the challenges, patients with obesity can achieve favorable aesthetic outcomes through careful assessment of comorbidities and expectation management.
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Affiliation(s)
- Priscila Cevallos
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA, USA
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Charlotte Berry
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA, USA
| | - Kelsey Jordan Lipman
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA, USA
| | - Carrie A. Kubiak
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA, USA
| | - Anita T. Mohan
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA, USA
| | - Haripriya S. Ayyala
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Rahim Nazerali
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA, USA
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Ciudad P, Escandón JM, Duarte-Bateman D, Escandón L, Maruccia M, Forte AJ, Mayer HF, Manrique OJ. Surgical management of breast cancer-related lymphedema: a narrative review of contemporary practices. Ann Transl Med 2023; 11:418. [PMID: 38213809 PMCID: PMC10777216 DOI: 10.21037/atm-23-292] [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] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 09/22/2023] [Indexed: 01/13/2024]
Abstract
Background and Objective Breast cancer-related lymphedema (BCRL) represents a colossal burden in terms of health and patient-reported outcomes. Surgical management plays a prominent role in the psychological and physical well-being of women suffering from BCRL. Therefore, we performed a narrative review of the current surgical management of BCRL and analyzed the postoperative results. Methods A literature search was conducted across PubMed MEDLINE, Scopus, and Web of Science from database inception through January 2, 2023. We included English-written studies evaluating postoperative outcomes of lymphatic surgery for the management of BCRL. Key Content and Findings The surgical management of lymphedema can be classified into two approaches: (I) physiologic procedures and (II) debulking or ablative procedures. While ablative procedures are intended to lessen the symptomatic burden of lymphedema via the removal of pathological tissues, physiologic procedures are performed to restore the abnormal lymphatic flow by creating bypasses into the venous or lymphatic circulation, or by creating new lymphatic connections by means of lymphangiogenesis. Physiologic procedures generate better outcomes in the early stages of lymphedema as there is some residual physiologic flow and vessels are less fibrotic, while ablative procedures are regarded to be the best alternative in very advanced lymphedema stages. A combination of physiologic and ablative procedures provides more comprehensive surgical management to BCRL. Conclusions Lymphedema is a common complication of breast cancer treatment with an extensive incidence range. Postoperative outcomes of the surgical management of BCRL are heterogeneous despite most studies indicating favorable results after lymphatic surgery.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive, and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Lauren Escandón
- Los Cobos Medical Center, School of Medicine, Universidad El Bosque, Bogotá DC, Colombia
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, University of Bari, Bari, Italy
| | | | - Horacio F. Mayer
- Department of Plastic Surgery, Hospital Italiano de Buenos Aires, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
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Escandón JM, Weiss A, Christiano JG, Langstein HN, Escandón L, Prieto PA, Gooch JC, Manrique OJ. Prepectoral versus subpectoral two-stage implant-based breast reconstruction: U.S. medical center experience and narrative review. Ann Transl Med 2023; 11:411. [PMID: 38213807 PMCID: PMC10777228 DOI: 10.21037/atm-23-1094] [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] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/02/2023] [Indexed: 01/13/2024]
Abstract
Background and Objective With the incorporation of autologous fat grafting, acellular dermal matrix (ADM) products, and nipple-sparing mastectomy, prepectoral device placement has become more popular in selected patients when compared to partial submuscular (dual plane) or complete submuscular device placement. In this article, we aimed to present a review of the current state-of-the-art for implant-based breast reconstruction (IBBR) using expanders. Additionally, we present a case series of our experience with IBBR evaluating perioperative outcomes, complications, and patient-reported outcomes (PRO). Methods For our series, we retrospectively evaluated adult female patients undergoing 2-stage immediate IBBR after total mastectomy between 2011 and 2021. We performed a systematic search across PubMed MEDLINE for articles evaluating outcomes of prepectoral versus subpectoral two-stage IBBR with expanders published from database inception through February 28th, 2023. Key Content and Findings Both prepectoral and subpectoral are safe alternatives for two-stage IBBR. Due to current advancements in the field of breast reconstruction, prepectoral IBBR has gained popularity and has a comparable rate of complications compared to a subpectoral approach in selected patients according to high-quality articles. In patients with several comorbidities, current tobacco use, history of preoperative radiation, and limited perfusion of the mastectomy flaps, subpectoral device placement should be given special consideration as a layer of vascularized tissue can decrease the risk of major complications or unplanned procedures. As prepectoral device placement does not require dissection of the pectoral muscles, faster recovery, better implant position, decreased pain, and a shorter time to complete expansion is expected. The plane of reconstruction does not seem to significantly affect the time for expander-to-implant exchange or PRO for quality-of-life (QOL) according to most studies. Conclusions Prepectoral and subpectoral IBBR demonstrated a comparable rate of complications in selected patients. Nonetheless, perioperative outcomes seem to be improved using a prepectoral approach in terms of reduced pain, reduced time to conclude outpatient expansions, and less animation deformity.
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Affiliation(s)
- Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Anna Weiss
- Division of Surgical Oncology, Department of Surgery, Pluta Cancer Center, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Jose G. Christiano
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Howard N. Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Lauren Escandón
- School of Medicine, Universidad El Bosque, Bogotá DC, Colombia
| | - Peter A. Prieto
- Division of Surgical Oncology, Department of Surgery, Pluta Cancer Center, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Jessica C. Gooch
- Division of Surgical Oncology, Department of Surgery, Pluta Cancer Center, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
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Maruccia M, Giudice G, Ciudad P, Manrique OJ, Cazzato G, Chen HC, Elia R. Lymph Node Transfer and Neolymphangiogenesis: From Theory to Evidence. Plast Reconstr Surg 2023; 152:904e-912e. [PMID: 36940155 DOI: 10.1097/prs.0000000000010434] [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: 03/21/2023]
Abstract
BACKGROUND Vascularized lymph node transfer (VLNT) has proven to be a valuable treatment for patients with advanced stages of lymphedema. Although spontaneous neolymphangiogenesis has been advocated to explain the positive effects of VLNT, there is still a lack of supportive biological evidence. The aim of this study was to demonstrate the postoperative formation of new lymphatic vessels using histologic skin sections from the lymphedematous limb. METHODS Patients with lymphedema of the extremities who had undergone gastroepiploic vascularized lymph node flap surgery between January of 2016 and December of 2018 were identified. Full-thickness 6-mm skin-punch biopsy specimens were obtained from patients at identical sites of the lymphedematous limb during the VLNT surgical procedure (T0) and 1 year later (T1). The histologic samples were immunostained with anti-podoplanin/gp36 antibody. RESULTS A total of 14 patients with lymph node transfer were included. At the 12-month follow-up, the mean circumference reduction rate was 44.3 ± 4.4 at the above-elbow/above-knee level and 60.9 ± 7 at the below-elbow/below-knee level. Podoplanin expression values were, on average, 7.92 ± 1.77 vessels/mm 2 at T0 and 11.79 ± 3.38 vessels/mm 2 at T1. The difference between preoperative and postoperative values was statistically significant ( P = 0.0008). CONCLUSION This study provides anatomic evidence that a neolymphangiogenic process is induced by the VLNT procedure because new functional lymphatic vessels can be detected in close proximity to the transferred lymph nodes. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Michele Maruccia
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
| | - Giuseppe Giudice
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
| | - Pedro Ciudad
- Department of Plastic, Reconstructive, and Burn Surgery, Arzobispo Loayza National Hospital
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center
| | - Gerardo Cazzato
- Section of Pathology, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro"
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital
| | - Rossella Elia
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
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Ciudad P, Escandón JM, Manrique OJ, Escobar H, Pejerrey Mago B, Arredondo Malca A. Efficacy of Combined Spinal-Epidural Anesthesia for Lower Extremity Microvascular Reconstruction. J Surg Res 2023; 291:700-710. [PMID: 37562232 DOI: 10.1016/j.jss.2023.07.026] [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: 04/22/2022] [Revised: 06/13/2023] [Accepted: 07/12/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION Some surgeons have raised concerns regarding the sympathectomy-like effect of epidural anesthesia during lower limb microvascular reconstruction. The combined spinal-epidural (CSE) anesthetic technique incorporates several benefits of spinal and epidural techniques in a single approach. The aim of this study was to analyze the postoperative outcomes of patients undergoing soft-tissue reconstruction of the lower limb by implementing the CSE anesthesia approach. METHODS We reviewed medical records from patients who underwent lower limb reconstructive procedures under CSE anesthesia with free tissue transfer from January 2017 to December 2020. We evaluated the postoperative outcomes. RESULTS Thirty-eight patients underwent microvascular reconstructive procedures of the lower extremity over the study period. The average age and BMI were 38.4-year and 28 kg/m2. All patients only had one postoperative rescue dose with epidural anesthesia. The most common type of flap used was the anterolateral thigh flap (53%). The average splinting time and length of stay (LoS) were 8.4 days and 18.4 days, respectively. Donor-site complications included wound dehiscence (3%) and surgical site infection (3%). Recipient-site complications included partial flap loss (8%) and total flap loss (10%). No pro re nata morphine analgesia was used. Tramadol and/or ketoprofen were administered for postoperative analgesia. The average time to start physiotherapy and to resume daily activities were 10 days and 29 days, respectively. CONCLUSIONS The CSE anesthesia for microvascular reconstruction of the lower limb demonstrated a similar success rate compared to historical records. CSE provided adequate pain management and none of the patients required postoperative monitoring in the ICU.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru.
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Hugo Escobar
- Department of Anesthesiology and Perioperative Medicine, Arzobispo Loayza National Hospital, Lima, Peru
| | - Bertha Pejerrey Mago
- Department of Anesthesiology and Perioperative Medicine, Arzobispo Loayza National Hospital, Lima, Peru
| | - Aida Arredondo Malca
- Department of Anesthesiology and Perioperative Medicine, Arzobispo Loayza National Hospital, Lima, Peru
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Escandón JM, Butterfield JA, Christiano JG, Gooch JC, Olzinski AT, Prieto PA, Skinner KA, Langstein HN, Manrique OJ. Wise Pattern versus Transverse Pattern Mastectomy in Two-Stage Implant-Based Breast Reconstruction: A Propensity Score-Matched Analysis. Plast Reconstr Surg 2023; 152:69S-80S. [PMID: 37220238 DOI: 10.1097/prs.0000000000010703] [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: 05/25/2023]
Abstract
BACKGROUND The Wise pattern adapted to mastectomy incisions has become a valuable asset for breast reconstruction in patients with large and ptotic breasts. The authors compared the time for exchange, time to initiate postmastectomy radiotherapy, and complication rates between Wise pattern and transverse incision pattern reconstructions. METHODS Records of patients who underwent immediate, two-stage, implant-based breast reconstruction (IBBR) between January of 2011 and December of 2020 were retrospectively reviewed. Two cohorts were compared according to the incision pattern: Wise pattern versus transverse incision pattern. Complications were compared after propensity score matching. RESULTS The authors initially analyzed 393 two-stage immediate IBBRs in 239 patients [91 IBBRs (23.2%) in the Wise pattern group and 302 (76.8%) in the transverse pattern group]. Expansion time (53 days versus 50 days, P = 0.9), time for tissue expander-to-implant exchange (154 versus 175 days, P = 0.547), and time to initiate postmastectomy radiotherapy (144 days versus 126 days, P = 0.616) were not different between groups. Before propensity score matching, the 30-day rate of wound-related complications (32% versus 10%, P < 0.001) and the 30-day rate of wound complications requiring excision/débridement and closure procedures (20% versus 7%, P < 0.001) were significantly higher in the Wise pattern group. After propensity score matching, the 30-day rate of wound complications was persistently higher (25% versus 10%, P = 0.03) in the Wise pattern group. CONCLUSIONS The Wise pattern mastectomy independently increases the incidence of wound-related complications versus only transverse patterns during two-stage IBBR, even after propensity score matching. Delayed tissue expander placement may improve the safety profile of this procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Joseph M Escandón
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center
| | - James A Butterfield
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center
| | - Jose G Christiano
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center
| | - Jessica C Gooch
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center
| | - Ann Therese Olzinski
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center
| | - Peter A Prieto
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center
| | - Kristin A Skinner
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center
| | - Howard N Langstein
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center
| | - Oscar J Manrique
- From the Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center
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Ciudad P, Espinoza Díaz R, Mello De la Cruz P, Aucasi I, Llanca L, Manrique OJ, Escandón JM, Aristizábal A. Reducing postoperative intensive care unit admission after lower limb microvascular reconstruction using sequential general and epidural anesthesia in low-resource settings. Microsurgery 2023; 43:748-749. [PMID: 37434561 DOI: 10.1002/micr.31087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 06/28/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Academic Department of Surgery Faculty of Medicine, Federico Villarreal National University, Lima, Peru
| | | | | | - Isabel Aucasi
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Lilyan Llanca
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, USA
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, USA
| | - Alejandra Aristizábal
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, USA
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Escandón JM, Ali-Khan S, Christiano JG, Gooch JC, Olzinski AT, Prieto PA, Skinner KA, Langstein HN, Manrique OJ. Simultaneous Fat Grafting During Tissue Expander-to-Implant Exchange: A Propensity Score-Matched Analysis. Aesthetic Plast Surg 2023; 47:1695-1706. [PMID: 36271157 DOI: 10.1007/s00266-022-03152-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 07/01/2022] [Accepted: 10/13/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Implant-based breast reconstruction (IBBR) is the most common technique for breast reconstruction. The primary resource for correcting deformities, once patients have achieved an adequate volume with two-stage IBBR, is autologous fat grafting. We compared the surgical outcomes of simultaneous fat grafting during TE-to-implant exchange (SFG + TtIE) versus no fat grafting during TE-to-implant exchange (No-FGX). METHODS A retrospective review was performed of all consecutive patients undergoing two-stage implant-based breast reconstruction with TE from January 2011 to December 2020. Propensity score matching was implemented to optimize comparability. The control group did not receive fat grafting at the time of TE-to-implant exchange. RESULTS After propensity score matching, 196 reconstructions were evaluated, 98 in each group. Reconstructions in the SFG + TtIE received larger implants during exchange in comparison with the No-FGX group (539 ± 135.1-cc versus 495.97 ± 148-cc, p=0.035). The mean volume of fat lipoinjected during TE-to-implant exchange in the SFG + TtIE group was 88.79 ± 41-ml. A higher proportion of reconstructions in the SFG + TtIE group underwent additional fat grafting after exchange versus the No-FGX group (19% versus 9%, p = 0.041). After propensity score matching, only the rate of fat necrosis after exchange was significantly higher in the SFG + TtIE group (10% versus 2%, p = 0.017). The rate of breast cancer recurrence (3% versus 5%, p = 1.00) was comparable between the groups. CONCLUSION SFG + TtIE is a safe procedure to improve the envelope of reconstructed breasts during two-stage IBBR. SFG + TtIE does not increase the rate of periprosthetic infection or wound-related complication versus no fat grafting during TE-to-implant exchange, but increases the rate of fat necrosis. LEVEL OF EVIDENCE III Therapeutic study. 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.
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Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Safi Ali-Khan
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Jose G Christiano
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Jessica C Gooch
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Ann Therese Olzinski
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Peter A Prieto
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Kristin A Skinner
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA.
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Escandón JM, Aristizábal A, Christiano JG, Langstein HN, Manrique OJ. Sentinel lymph node biopsy and immediate two-stage implant-based breast reconstruction: A propensity score-matched analysis. J Plast Reconstr Aesthet Surg 2023; 84:447-458. [PMID: 37413737 DOI: 10.1016/j.bjps.2023.06.003] [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: 05/02/2023] [Revised: 05/27/2023] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND There are important differences between patients requiring sentinel lymph node biopsy (SLNB) and those who do not require axillary surgery at the time of breast reconstruction. We aimed to perform a propensity score-matched analysis to evaluate the impact of SLNB at the time of immediate implant-based breast reconstruction (IBBR) with tissue expanders compared with IBBR alone. METHODS Consecutive female patients undergoing total mastectomy and immediate two-stage IBBR between January 2011 and May 2021 were included. A 1:1 nearest-neighbor matching method without replacement was implemented with a caliper width of 0.01. Patients were matched for age, diabetes, hypertension, hyperlipidemia, premastectomy radiotherapy, neoadjuvant chemotherapy, the plane of prosthesis placement, mastectomy specimen weight, number of drains, and radiation of the expander. RESULTS We included 320 two-stage immediate IBBRs after propensity score matching, 160 reconstructions per group. Relevant surgical variables were comparable between groups. A higher rate of 30-day seroma formation was reported in immediate reconstructions that had SLNB at the time of mastectomy compared with reconstructions that did not have axillary surgery (16.3% versus 8.1%, p = 0.039). The time to complete outpatient expansions and time for expander-to-implant exchange were comparable between patients who underwent IBBRs with SLNB and those who did not. CONCLUSION SLNB performed at the time of mastectomy and IBBR with tissue expander increased the risk of seroma formation compared with reconstructions that did not have axillary surgery. The rate of infection, hematoma, and unplanned procedures to manage complications did not differ between groups.
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Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Alejandra Aristizábal
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Jose G Christiano
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA.
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Escandón JM, Catanzaro M, Christiano JG, Gooch JC, Weiss A, Langstein HN, Manrique OJ. Autologous breast reconstruction with latissimus dorsi flap in obese patients: Time-to-event analysis. J Plast Reconstr Aesthet Surg 2023; 84:605-617. [PMID: 37453148 DOI: 10.1016/j.bjps.2023.06.035] [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: 01/09/2023] [Revised: 04/26/2023] [Accepted: 06/05/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Obesity is a multisystem disease process that confers increased surgical risk. In patients who are not surgical candidates for breast reconstruction with implants/tissue expanders or abdomen-based flaps, the latissimus dorsi flap (LDF) remains a versatile alternative due to its safety profile. We conducted an analysis of patients who underwent reconstruction with LDFs and compared outcomes between two groups: obese and nonobese patients. METHODS We reviewed records from patients undergoing total mastectomy and breast reconstruction with LDFs between January 2011 and December 2021. We compared the surgical outcomes between obese and nonobese patients. Associations between risk factors and the presence of wound-related complications were analyzed using multivariable Cox proportional-hazards models. RESULTS One-hundred ten reconstructions were performed in obese patients (67.5%) and fifty-three in nonobese patients (32.5%). The median body mass index was 34.96 kg/m2 [32.6-39.2] in the obese patients' group and 26.8 kg/m2 [25.7-28.9] in the nonobese group (P < 0.001). The mean age was comparable between groups (54 years; P = 0.632). The rate of donor-site and recipient-site complications was similar between groups. The rate of revision procedures for secondary fat grafting and donor- or recipient-site revisions was comparable between obese and nonobese patients. Preoperative radiotherapy (hazard ratio [HR], 2.44), nipple-sparing mastectomy (HR, 3.26), and vertical pattern mastectomy (HR, 2.86) were associated with an increased risk of wound disruption. CONCLUSION The LDF is a reliable and safe alternative for autologous breast reconstruction in obese patients. The rates of surgical site complications were comparable between obese and nonobese patients.
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Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Michael Catanzaro
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Jose G Christiano
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Jessica C Gooch
- Division of Surgical Oncology, Department of Surgery, Pluta Cancer Center, Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
| | - Anna Weiss
- Division of Surgical Oncology, Department of Surgery, Pluta Cancer Center, Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA.
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Maruccia M, Elia R, De Cosmo A, Cigna E, Tedeschi P, Bolletta A, Manrique OJ, Ciudad P, Di Summa PG, Cherubino M, Giudice G. The medial sural artery perforator flap for retromolar trigone reconstruction: A multicenter case series. Microsurgery 2023; 43:546-554. [PMID: 36805669 DOI: 10.1002/micr.31026] [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: 01/26/2022] [Revised: 01/07/2023] [Accepted: 02/02/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Retromolar trigone (RMT) cancer is a rare malignancy, which develops in a narrow area of the oral cavity. Surgical intervention requires wide excision and appropriate reconstruction usually with a free tissue transfer. Little has been published regarding the ideal microvascular reconstruction, mainly focusing on radial forearm and anterolateral thigh free flap. The medial sural artery perforator flap (MSAP) is not new for head and neck reconstruction but its use for RMT reconstruction has not been previously explored. The purpose of the study is to present a multicentric case series investigating the reliability of MSAP flap for RMT reconstruction. METHODS The study is designed as a retrospective case series. All patients diagnosed with RMT cancer and undergone surgical resection and immediate reconstruction with a MSAP flap between February 2016 and March 2020 were identified. Patients' demographics and surgical details were collected. Functional results were evaluated using the Head and Neck Module of the European Organization for Research and Treatment of Cancer at 12 months of follow-up. A total of 34 patients with a mean age of 58 years were included in the study. An average defect size of 31.5 cm2 was observed after RMT tumor resection. RESULTS The MSAP flaps' average dimensions were 11 ± 3.1 cm in length and 4.7 ± 1.6 cm in width with a mean thickness of 1.4 ± 0.8 cm. No flap complications were observed in 28 cases; four patients developed an orocutaneous fistula. One patient needed surgical revision for venous congestion while only one case of flap failure was observed. At 12 months of follow-up, 87% of the patient cohort had normal, understandable speech. No patient experienced complete loss of swallowing. Results of the H&N35 module showed a significative postoperative improvement in mouth soreness, mouth opening and social (p < .05*). No patient complained difficulty in motility at the donor site. CONCLUSIONS The MSAP flap appears to be appropriate for RMT reconstruction and could be considered the workhorse for small to medium size defect of RTM region. It has a long pedicle of matching caliber and provides adequate tissue volume with minimal donor site morbidity.
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Affiliation(s)
- Michele Maruccia
- Unit of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | - Rossella Elia
- Unit of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | - Alessio De Cosmo
- Unit of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | - Emanuele Cigna
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Pasquale Tedeschi
- Unit of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | - Alberto Bolletta
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Oscar J Manrique
- Division of Plastic Surgery, Department of Surgery, University of Rochester, Rochester, New York, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Pietro G Di Summa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Mario Cherubino
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Giuseppe Giudice
- Unit of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
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Manrique OJ, Escandón JM. Breast reconstruction in the era of evidence-based medicine. Ann Transl Med 2023; 11:341. [PMID: 37675303 PMCID: PMC10477617 DOI: 10.21037/atm-2022-79] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 01/06/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
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Escandón JM, Manrique OJ, Christiano JG, Mroueh V, Prieto PA, Gooch JC, Weiss A, Langstein HN. Breast reconstruction with latissimus dorsi flap: a comprehensive review and case series. Ann Transl Med 2023; 11:355. [PMID: 37675333 PMCID: PMC10477619 DOI: 10.21037/atm-23-469] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/05/2023] [Indexed: 09/08/2023]
Abstract
The latissimus dorsi flap (LDF) has gained popularity given its versatile nature and broad applicability in breast reconstruction. Its resurgence has been attributed to its ability to be enhanced using implant or high-volume fat grafting, rendering it a primary option for selected patients. The aim of this review is to tackle current indications and subjects of controversy regarding use of complete-autologous and implant-enhanced LDF in breast reconstruction. Also, a case-series showcasing the authors' experience with this versatile reconstructive option is presented. A search across Web of Science and PubMed MEDLINE from inception through January 3, 2023, was conducted. Articles reporting postoperative outcomes of autologous breast reconstruction with LDF were included. Regarding the case series, electronic medical records of patients who underwent total mastectomy and autologous breast reconstruction with LDF from January 2011 to December 2021 were retrospectively reviewed. Data on demographic and oncologic characteristics, and surgical characteristics and outcomes were extracted. Our review suggests that LDF is suitable for patients who lack alternative donor site, have a history of abdominoplasty or no access to microsurgery, smokers or obese. Latissimus dorsi (LD) harvesting has almost complete shoulder function recovery in the long-term. Thoracodorsal nerve division does not cause volume loss or animation deformity. Multisite multilayer fat grafting, beveling the edges of the skin paddle and fat, folding the LD muscle and plicating the paddle allow adequate projection and contour achievement. Our case-series included 234 reconstructions. Almost half of the patients had immediate fat transfer during reconstruction (51.3%). The rate of recipient site hematoma was 3.0%, seroma was 7.7%, wound disruption 32.1%, wound disruption events requiring unplanned procedures was 13.7%, and surgical site infection (SSI) was 12.4%. The LDF is reliable and safe for immediate or delayed breast reconstruction or salvage after reconstruction failure. Its versatility, reliable anatomy, easy dissection, and relative low complication rate have revived this modality as valuable opportunity for breast reconstruction in this era.
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Affiliation(s)
- Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Jose G. Christiano
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Vanessa Mroueh
- American University of Beirut Faculty of Medicine, Beirut, Lebanon
| | - Peter A. Prieto
- Division of Surgical Oncology, Department of Surgery, Pluta Cancer Center, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Jessica C. Gooch
- Division of Surgical Oncology, Department of Surgery, Pluta Cancer Center, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Anna Weiss
- Division of Surgical Oncology, Department of Surgery, Pluta Cancer Center, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Howard N. Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
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Aristizábal A, Escandón JM, Ciudad P, Manrique OJ. The Limited Coverage of Facial Feminization Surgery in the United States: A Literature Review of Policy Constraints and Implications. J Clin Med 2023; 12:5308. [PMID: 37629353 PMCID: PMC10455106 DOI: 10.3390/jcm12165308] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/25/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
There is a literature gap regarding facial feminization surgery (FFS) access and coverage. Our goal is to compile information from previous studies and assess the current policy landscape for these surgeries in the US. We also explored why some policies do not cover them, identify states with better coverage, and determine the most covered procedures. PubMed, Medline, Embase, and Scopus were searched for studies that reviewed policies on FFS coverage. Studies on surgical techniques or other gender-affirming surgeries (GASs) that did not involve FFS were excluded. Seven studies were included for analysis. In 2014, the Department of Human Health Services (HHS) lifted the transgender exclusion policy, leading to an increase in policies regarding GASs for both private and state insurance. However, there are differences in medical necessity requirements among policies, which may not align with the World Professional Association for Transgender Health (WPATH) criteria. States that prohibit exclusion tend to offer better coverage for FFS. These states are mainly located in the western and northeast regions, whereas states in the southern and middle east regions have less coverage. Among the procedures, chondrolaryngoplasty is the most covered, while facial and cervical rhytidectomy are the least covered. To enhance transgender care, it is crucial to reach a consensus on how to offer coverage for facial feminization surgery. However, there is a lack of adequate research on this topic, and there is a need for resources and tools to assess the results of FFS procedures. One significant constraint of this study is that it does not provide a systematic review of the literature.
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Affiliation(s)
- Alejandra Aristizábal
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, NY 14642, USA
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, NY 14642, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima 15082, Peru
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, NY 14642, USA
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Escandón JM, Langstein HN, Christiano JG, Gooch JC, Prieto PA, Aristizábal A, Weiss A, Manrique OJ. Predictors for Prolonged TE-to-Implant Exchange During Implant-Based Breast Reconstruction: A Single Institution Experience. Aesthetic Plast Surg 2023:10.1007/s00266-023-03536-3. [PMID: 37563435 DOI: 10.1007/s00266-023-03536-3] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/19/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND There is limited evidence regarding the factors causing a prolonged time for tissue expander (TE) exchange into a definitive implant using two-stage implant-based breast reconstruction (IBBR). This study aimed to review our experience with IBBR, focusing on the time for TE-to-implant exchange and determining which factors cause a prolonged time for exchange. METHODS A retrospective review was performed to include women undergoing immediate two-stage IBBR with TEs after total mastectomy between January 2011 and May 2021. Reconstructions with irradiated TEs were excluded. Cases that had a prolonged time for TE-to-implant exchange were defined as those undergoing exchange longer than 232 days, which corresponds to the 75th percentile of the overall study group. RESULTS We included 442 reconstructions in our analysis. The median age for our series was 51 years and the median body mass index was 26.43-kg/m2. The median time for TE-to-implant exchange was 155 days [IQR, 107-232]. Cases that had a prolonged time for TE-to-implant exchange were defined as those undergoing exchange on postoperative day 232 or afterward. Diabetes (OR 4.05, p = 0.006), neoadjuvant chemotherapy (OR 2.76, p = 0.006), an increased length of stay (OR 1.54, p = 0.013), and a lengthier time to complete outpatient expansions (OR 1.018, p < 0.001) were independently associated with a prolonged time for exchange. CONCLUSION As evident from our analysis, the time for exchange is highly heterogeneous among patients. Although several factors affect the timing for TE-to-implant exchange, efforts must be directed to finalize outpatient expansions as soon as possible to expedite the transition into a definitive implant. 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 .
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Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Jose G Christiano
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Jessica C Gooch
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Peter A Prieto
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Alejandra Aristizábal
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Anna Weiss
- Division of Surgical Oncology, Department of Surgery, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA.
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Ciudad P, Bolletta A, Kaciulyte J, Losco L, Manrique OJ, Cigna E, Mayer HF, Escandón JM. The breast cancer-related lymphedema multidisciplinary approach: Algorithm for conservative and multimodal surgical treatment. Microsurgery 2023; 43:427-436. [PMID: 36433802 DOI: 10.1002/micr.30990] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 04/15/2022] [Revised: 10/17/2022] [Accepted: 11/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Multiple surgical alternatives are available to treat breast cancer-related lymphedema (BCRL) providing a variable spectrum of outcomes. This study aimed to present the breast cancer-related lymphedema multidisciplinary approach (B-LYMA) to systematically treat BCRL. METHODS Seventy-eight patients presenting with BCRL between 2017 and 2021 were included. The average age and BMI were 49.4 ± 7.8 years and 28.1 ± 3.5 kg/m2 , respectively. Forty patients had lymphedema ISL stage II (51.3%) and 38 had stage III (48.7%). The mean follow-up was 26.4 months. Treatment was selected according to the B-LYMA algorithm, which aims to combine physiologic and excisional procedures according to the preoperative evaluation of patients. All patients had pre- and postoperative complex decongestive therapy (CDT). RESULTS Stage II patients were treated with lymphaticovenous anastomosis (LVA) (n = 18), vascularized lymph node transfer (VLNT) (n = 12), and combined DIEP flap and VLNT (n = 10). Stage III patients underwent combined suction-assisted lipectomy (SAL) and LVA (n = 36) or combined SAL and VLNT (n = 2). Circumferential reduction rates (CRR) were comparable between patients treated with LVA (56.5 ± 8.4%), VLNT (54.4 ± 10.2%), and combined VLNT-DIEP flap (56.5 ± 3.9%) (p > .05). In comparison to LVA, VLNT, and combined VLNT-DIEP flap, combined SAL-LVA exhibited higher CRRs (85 ± 10.5%, p < .001). The CRR for combined SAL-VLNT was 75 ± 8.5%. One VLNT failed and minor complications occurred in the combined DIEP-VLNT group. CONCLUSION The B-LYMA protocol directs the treatment of BCRL according to the lymphatic system's condition. In advanced stages where a single physiologic procedure is not sufficient, additional excisional surgery is implemented. Preoperative and postoperative CDT is mandatory to improve the outcomes.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Alberto Bolletta
- Department of Translational Research and New Technologies in Medicine and Surgery, Plastic Surgery Unit, University of Pisa, Pisa, Italy
| | - Juste Kaciulyte
- Department of Surgery "P.Valdoni", Unit of Plastic and Reconstructive Surgery, Sapienza University of Rome, Rome, Italy
| | - Luigi Losco
- Department of Translational Research and New Technologies in Medicine and Surgery, Plastic Surgery Unit, University of Pisa, Pisa, Italy
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Emanuele Cigna
- Department of Translational Research and New Technologies in Medicine and Surgery, Plastic Surgery Unit, University of Pisa, Pisa, Italy
| | - Horacio F Mayer
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Buenos Aires, Argentina
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
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Ciudad P, Reynaga C, Aucasi I, Ludeña J, Manrique OJ, Castro J, Rojas D, Llanca L, Escandón JM. Maximizing the use of the distal descending branch of the lateral circumflex femoral artery during donor site closure: An opportunity for learning. J Plast Reconstr Aesthet Surg 2023; 80:165-167. [PMID: 37028243 DOI: 10.1016/j.bjps.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 03/15/2023] [Indexed: 04/08/2023]
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26
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Ciudad P, Escandón JM, Bravo LL, Manrique OJ. Management of Facial Second-Degree Burns with Nanocellulose-Based Dressing: A Case Series and Systematic Review. Facial Plast Surg 2023; 39:130-141. [PMID: 35609875 DOI: 10.1055/a-1860-8504] [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: 10/18/2022] Open
Abstract
Previous studies have evaluated the effectiveness of bacterial nanocellulose (BNC) for the treatment of thermal injuries, but the synergic effect of platelet-rich plasma (PRP) with BNC-based dressing for burns still requires further investigation. Herein, we evaluated the effectiveness of BNC dressings in the management of facial burns using PRP. Patients with second-degree facial burns were treated with BNC-based wound dressings after debridement. The burn's depth and epithelialization were evaluated by clinical assessment. Besides using the dressings, we injected PRP subcutaneously into the left-hemifacial burns. The right hemiface was only treated with the dressings. Scar quality was assessed using the Patient and Observer Scar Assessment Scale (POSAS). Eight patients were included with superficial second-degree burns in 75% of the cases and deep second-degree burns in 25%. Overall, dressings were placed 3.25 days after the initial insult. None of the patients presented with complications after dressing placement. Dressing changes were not required, and no further surgical management was necessary. The mean time for epithelialization was 11.4 days. During subgroup analysis, we did not find a significant difference in the epithelialization time when comparing BNC-based dressings (11.8 days) to BNC-based dressings + PRP (11 days, p = 0.429). The mean POSAS scores from a patient (17 vs. 12.3, p = 0.242) and surgeon (13.5 vs. 11.3, p = 0.26) standpoint were not significantly different using BNC-based dressings versus BNC-based dressings + PRP. Nanocellulose-based dressings are effective to treat second-degree facial burns. It enhances reepithelialization with optimal esthetic outcomes with or without PRP.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Academic Department of Surgery, Hipolito Unanue School of Medicine, Federico Villarreal National University, Lima, Peru
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Strong Memorial Hospital, New York, New York
| | - Lilyan L Bravo
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Strong Memorial Hospital, New York, New York
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Ciudad P, Escandón JM, Manrique OJ, Llanca L, Reynaga C, Mayer HF. Cross-leg free flaps and cross-leg vascular cable bridge flaps for lower limb salvage: experience before and after COVID-19. Eur J Plast Surg 2023; 46:1-11. [PMID: 37363691 PMCID: PMC10020769 DOI: 10.1007/s00238-023-02052-6] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 01/23/2023] [Indexed: 03/19/2023]
Abstract
Background Previous reports have evidenced the disruptive effect of the COVID-19 in microsurgical and reconstructive departments. We report our experience with cross-leg free flaps and (CLFF) and cross-leg vascular cable bridge flaps (CLVCBF) for lower limb salvage, technical consideration to decrease morbidity, and some structural modifications to our protocols for standard of care adapted to the COVID-19. Methods We retrospectively included consecutive patients undergoing reconstruction with CLFFs and CLVCBFs for lower limb salvage from January 2003 to May 2022. We extracted data on baseline demographic characteristics, mechanism of trauma, and surgical outcomes. Results Twenty-four patients were included, 11 (45.8%) underwent reconstruction with CLFF while 13 had CLVCBFs (54.2%). Fifteen patients (62.5%) underwent lower limb reconstruction under general anesthesia while 9 (37.5%) had combined spinal-epidural anesthesia. During COVID-19 pandemic, six CLFF cases were performed under S-E (25%). The average time for pedicle transection of muscle CLFFs and muscle CLVCBFs was comparable between groups (60 days versus 62 days, p = 0.864). A significantly shorter average time was evidenced for pedicle division of fasciocutaneous flaps in the CLFF group when compared to CLVCBFs (45 days versus 59 days, p = 0.002). Conclusions In selected patients, CLFFs and CLVCBFs offer an optimal alternative for lower limb salvage using recipient vessels out of the zone of injury from the contralateral limb. Modification in the surgical protocols can decrease improve resource allocation in the setting of severely ill patients during COVID-19.Level of evidence: Level III, Therapeutic.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Institute of Plastic, Reconstructive and Aesthetic Surgery, Ciruesthetic, Clinic, Lima, Peru
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, NY USA
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, NY USA
| | - Lilyan Llanca
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - César Reynaga
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Horacio F. Mayer
- Department of Plastic Surgery, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Hospital Italiano de Buenos Aires University Institute (IUHIBA), Buenos Aires, Argentina
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28
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Ciudad P, Escandón JM, Llanos E, Ludeña J, Manrique OJ, Castro J, Rossi R. Inexpensive Materials for Microsurgery in Middle- and Low-Income Countries. Arch Plast Surg 2023; 50:121-124. [PMID: 36755642 PMCID: PMC9902198 DOI: 10.1055/s-0042-1758640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 08/04/2022] [Indexed: 02/08/2023] Open
Abstract
With the continuous incorporation of new technologies and advancements in surgical technique, microsurgical procedures around the world have generated a higher success rate and innovative procedures are now possible. In this setting, limitations regarding accessibility and acquisition of medical resources and equipment for these types of operations may be difficult in developing countries. We believe the dexterities of surgeons go beyond the surgical technique, meaning that we are able to use everyday materials to re-create affordable solutions that can be used during surgery in a safe way. This manuscript presents our experience with different surgical instruments and gadgets, developed out of necessity, to improve microsurgical interventions in developing countries.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru,Academic Department of Surgery, Hipolito Unanue School of Medicine, Federico Villarreal National University, Lima, Peru,Address for correspondence Pedro Ciudad, MD, PhD Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital 46170LimaPeru
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York
| | - Edgar Llanos
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Juan Ludeña
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York
| | - Jorge Castro
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Rafael Rossi
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
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Canales-Lachén E, Asunsolo Á, Manrique OJ, Blázquez J, Holguín P, Maldonado AA. The Use of Ultrasound Imaging for Upper Extremity Lymphedema after Breast Cancer: A Systematic Review. J Reconstr Microsurg 2023; 39:102-110. [PMID: 36162421 DOI: 10.1055/s-0042-1750824] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND The aim of this study was to analyze the different applications of ultrasound (US) in upper extremity lymphedema (UEL) after breast cancer. METHODS A systematic review of the literature was performed in line with the PRISMA statement using MEDLINE/PubMed databases from January 1970 to December 2021. Articles describing the application of US in patients with UEL after breast cancer were included. The quality of the study, the level of reproducibility, and the different applications and type of US technique were analyzed. RESULTS In total, 30 articles with 1,193 patients were included in the final review. Five different applications were found: (1) diagnosis of UEL (14 studies found a direct correlation between lymphedema and morphological and/or functional parameters); (2) staging/severity of UEL (9 studies found a direct correlation between the clinical stage and the soft-tissue stiffness/texture/thickness); (3) therapeutic assessment (3 studies found an improvement in the circulatory status or in the muscle/subcutaneous thickness after conservative treatments); (4) prognosis assessment of UEL (1 study found a correlation between the venous flow and the risk of UEL); and (5) surgical planning (3 studies determined the location of the lymphatic vessel for lymphovenous anastomosis [LVA] surgery). CONCLUSION Morphological and functional parameters have been correlated with the diagnosis, stage, therapeutic effect, prognosis of UEL, and surgical planning of LVA.
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Affiliation(s)
| | - Ángel Asunsolo
- Department of Surgery, Medical and Social Science, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain.,Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | - Oscar J Manrique
- Deparment of Plastic Surgery, University of Rochester Medical Center, Rochester, New York
| | - Javier Blázquez
- Department of Radiology, University Hospital Ramón y Cajal, Madrid, Spain.,Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | | | - Andrés A Maldonado
- Department of Surgery, Medical and Social Science, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain.,Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain.,Department of Plastic Surgery, University Hospital Getafe, Madrid, Spain.,Department of Plastic, Hand and Reconstructive Surgery, BG Trauma Center Frankfurt am Main, Academic Hospital of the Goethe University Frankfurt am Main, Frankfurt am Main, Germany
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Escandón JM, Ciudad P, Mayer HF, Pencek M, Mantilla-Rivas E, Mohammad A, Langstein HN, Manrique OJ. Free flap transfer with supermicrosurgical technique for soft tissue reconstruction: A systematic review and meta-analysis. Microsurgery 2023; 43:171-184. [PMID: 35551691 DOI: 10.1002/micr.30894] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/16/2022] [Accepted: 04/29/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Supermicrosurgery is a technique that allows microsurgeons to accomplish dissections and anastomoses of vessels and nerve fascicles with diameters of ≤0.8 mm. Considering the potential benefits of this technique and limited literature synthesizing the outcomes of supermicrosurgery, the aim of this study was to summarize the available evidence of reconstructive supermicrosurgery and to estimate the success rate. METHODS We conducted a comprehensive search across PubMed, Scopus, Embase, and Web of Science. We included patient-based studies reporting on procedures for soft-tissue reconstruction with free flaps specifying the use of supermicrosurgery. We excluded studies reporting on lymphatic surgery, solely peripheral nerve surgery, and tissue replantation. Our primary endpoint was to calculate the flap success rate. Pooled estimates were calculated using a random-effects meta-analytic model. RESULTS Forty-seven studies reporting outcomes of 698 flaps were included for qualitative synthesis. Overall, 15.75% of flaps were used for head and neck, 4.4% for breast and trunk, 9.3% for upper limb, and 69.2% for lower limb reconstruction. The most used flap was the superficial circumflex iliac artery perforator flap (41.5%). The overall flap success rate was 96.6% (95%CI 95.2%-98.1%). The cumulative rate of partial flap loss was 3.84% (95%CI 1.8%-5.9%). The overall vascular complication rate resulting in complete or partial flap loss was 5.93% (95%CI 3.5%-8.3%). CONCLUSIONS Supermicrosurgery displays a high success rate. Further studies are necessary to explore the true potential of supermicrosurgery. This technique reformulates the boundaries of reconstructive surgery due to its extensive application.
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Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, Archbishop Loayza National Hospital, Lima, Peru
| | - Horacio F Mayer
- Department of Plastic Surgery, Hospital Italiano de Buenos Aires, University of Buenos Aires, Buenos Aires, Argentina
| | - Megan Pencek
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Esperanza Mantilla-Rivas
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, District of Columbia, USA
| | - Arbab Mohammad
- School of Medicine, Aarupadai Veedu Medical College and Hospital, Puducherry, India
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
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Manrique OJ, Bustos SS, Ciudad P, Adabi K, Chen WF, Forte AJ, Cheville AL, Jakub JW, McLaughlin SA, Chen HC. Overview of Lymphedema for Physicians and Other Clinicians: A Review of Fundamental Concepts. Mayo Clin Proc 2022; 97:1920-1935. [PMID: 32829905 DOI: 10.1016/j.mayocp.2020.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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] [Received: 06/13/2019] [Revised: 10/17/2019] [Accepted: 01/06/2020] [Indexed: 12/16/2022]
Abstract
Lymphedema has historically been underrated in clinical practice, education, and scholarship to the detriment of many patients with this chronic, debilitating condition. The mechanical insufficiency of the lymphatic system causes the abnormal accumulation of protein-rich fluid in the interstitium, which triggers a cascade of adverse consequences such as fat deposition and fibrosis. As the condition progresses, patients present with extremity heaviness, itchiness, skin infections, and, in later stages, dermal fibrosis, skin papillomas, acanthosis, and other trophic skin changes. Correspondingly, lymphedema results in psychological morbidity, including anxiety, depression, social avoidance, and a decreased quality of life, encompassing emotional, functional, physical, and social domains. For this review, we conducted a literature search using PubMed and EMBASE and herein summarize the evidence related to the fundamental concepts of lymphedema. This article aims to raise awareness of this serious condition and outline and review the fundamental concepts of lymphedema.
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Affiliation(s)
- Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN.
| | - Samyd S Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Kian Adabi
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN
| | - Wei F Chen
- Division of Plastic and Reconstructive Surgery, University of Iowa, Iowa City
| | | | - Andrea L Cheville
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
| | | | | | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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Escandón JM, Mohammad A, Mathews S, Bustos VP, Santamaría E, Ciudad P, Chen HC, Langstein HN, Manrique OJ. Definitive Closure of the Tracheoesophageal Puncture Site after Oncologic Laryngectomy: A Systematic Review and Meta-Analysis. Arch Plast Surg 2022; 49:617-632. [PMID: 36159387 PMCID: PMC9507600 DOI: 10.1055/s-0042-1756347] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 06/08/2022] [Indexed: 11/10/2022] Open
Abstract
Tracheoesophageal puncture (TEP) and voice prosthesis insertion following laryngectomy may fail to form an adequate seal. When spontaneous closure of the fistula tract does not occur after conservative measures, surgical closure is required. The purpose of this study was to summarize the available evidence on surgical methods for TEP site closure. A comprehensive search across PubMed, Web of Science, SCOPUS, and Cochrane was performed to identify studies describing surgical techniques, outcomes, and complications for TEP closure. We evaluated the rate of unsuccessful TEP closure after surgical management. A meta-analysis with a random-effect method was performed. Thirty-four studies reporting on 144 patients satisfied inclusion criteria. The overall incidence of an unsuccessful TEP surgical closure was 6% (95% confidence interval [CI] 1–13%). Subgroup analysis showed an unsuccessful TEP closure rate for silicone button of 8% (95% CI < 1–43%), 7% (95% CI < 1–34%) for dermal graft interposition, < 1% (95% CI < 1–37%) for radial forearm free flap, < 1% (95% CI < 1–52%) for ligation of the fistula, 17% (95% CI < 1–64%) for interposition of a deltopectoral flap, 9% (95% CI < 1–28%) for primary closure, and 2% (95% CI < 1–20%) for interposition of a sternocleidomastoid muscle flap. Critical assessment of the reconstructive modality should take into consideration previous history of surgery or radiotherapy. Nonirradiated fields and small defects may benefit from fistula excision and tracheal and esophageal multilayer closure. In cases of previous radiotherapy, local flaps or free tissue transfer yield high successful TEP closure rates. Depending on the defect size, sternocleidomastoid muscle flap or fasciocutaneous free flaps are optimal alternatives.
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Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, New York
| | - Arbab Mohammad
- Department of Surgery, Aarupadai Veedu Medical College and Hospital, Puducherry, Tamil Nadu, India
| | - Saumya Mathews
- Department of Plastic and Microvascular Services, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Eric Santamaría
- Department of Plastic and Reconstructive Surgery, National Cancer Institute, Hospital General Dr. Manuel Gea Gonzalez, Mexico City, Mexico
| | - Pedro Ciudad
- Reconstructive and Burn Surgery Department, Arzobispo Loayza National Hospital, Lima, Peru.,Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, New York
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, New York
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33
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Escandón JM, Nazerali R, Ciudad P, Lo Torto F, Maruccia M, Butterfield JA, Vizcay M, Galán N, Manrique OJ. Minimally invasive harvest of the latissimus dorsi flap for breast reconstruction: A systematic review. Int J Med Robot 2022; 18:e2446. [DOI: 10.1002/rcs.2446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery Strong Memorial Hospital University of Rochester Medical Center Rochester New York USA
| | - Rahim Nazerali
- Division of Plastic and Reconstructive Surgery Department of Surgery Stanford University Palo Alto California USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery Arzobispo Loayza National Hospital Lima Peru
| | - Federico Lo Torto
- Unit of Plastic and Reconstructive Surgery Department of Surgery “P. Valdoni” Policlinico Umberto I Sapienza University of Rome Rome Italy
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery Department of Emergency and Organ Transplantation University of Bari Aldo Moro Bari Italy
| | - James A. Butterfield
- Division of Plastic and Reconstructive Surgery Strong Memorial Hospital University of Rochester Medical Center Rochester New York USA
| | - Macarena Vizcay
- Department of Plastic and Reconstructive Surgery Hospital Nacional A. Posadas Buenos Aires Argentina
| | - Natalia Galán
- Division of Plastic Surgery Hospital Militar Central Universidad Militar Nueva Granada Bogotá DC Colombia
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery Strong Memorial Hospital University of Rochester Medical Center Rochester New York USA
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34
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Escandón JM, Escandón L, Ahmed A, Weiss AC, Nazerali R, Ciudad P, Langstein HN, Manrique OJ. Breast Reconstruction using the Latissimus Dorsi Flap and Immediate Fat Transfer (LIFT): A Systematic Review and Meta-Analysis. J Plast Reconstr Aesthet Surg 2022; 75:4106-4116. [DOI: 10.1016/j.bjps.2022.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/28/2022] [Accepted: 08/16/2022] [Indexed: 10/31/2022]
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35
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Ciudad P, Escandón JM, Manrique OJ, Gutierrez-Arana J, Mayer HF. Lymphedema prevention and immediate breast reconstruction with simultaneous gastroepiploic vascularized lymph node transfer and deep inferior epigastric perforator flap: A case report. Microsurgery 2022; 42:617-621. [PMID: 35821630 DOI: 10.1002/micr.30939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 05/25/2022] [Accepted: 07/01/2022] [Indexed: 11/08/2022]
Abstract
Breast cancer-related lymphedema following axillary lymph node dissection (ALND) has been documented in 6%-55% of patients, mostly occurring within the next 3 years after radiation or surgery. We present a case of a 53-year-old patient with hormone positive, stage IB, left breast invasive ductal carcinoma treated with immediate lymphatic and microvascular breast reconstruction (MBR) using vascularized lymph node transfer (VLNT) for lymphedema prevention. A deep inferior epigastric perforator (DIEP) flap (18.3 × 11.2-cm) and simultaneous prophylactic gastroepiploic-VLNT (7 × 3-cm), orthotopically inset in the axilla, were used for reconstruction following mastectomy and radical ALND. The procedure was uneventful. The patient did not display increased postoperative arm circumferences. ICG lymphography did not show any changes at 2- and 3-years after surgery. Preventive lymphatic reconstruction with GE-VLNT and immediate MBR using the DIEP flap offers a new possibility for the primary prevention of lymphedema and simultaneous immediate autologous breast reconstruction without the risk of iatrogenic lymphedema. Further studies will be directed to unveil the external validity of these findings and the risk reduction rate of this approach.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Jessica Gutierrez-Arana
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Horacio F Mayer
- Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Buenos Aires, Argentina
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36
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Hyland CJ, Manrique OJ, Weiss A, Broyles JM. Preventive strategies for breast cancer-related lymphedema: Working toward optimal patient selection. Cancer 2022; 128:3284-3286. [PMID: 35797438 DOI: 10.1002/cncr.34374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/06/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Anna Weiss
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, Massachusetts, USA.,Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, Massachusetts, USA
| | - Justin M Broyles
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Abstract
Controversy exists regarding the influence of breast cancer-related lymphedema (BCRL) in the development of peripheral neuropathies. Our aim was to evaluate the association of secondary lymphedema with peripheral neuropathies in patients with breast cancer. We performed a systematic review by querying PubMed, EMBASE, Ovid Medline and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Cochrane Central Register of Controlled Trials databases. The keywords "lymphedema" AND ("neuropathy" OR "carpal tunnel syndrome" OR "cubital tunnel syndrome" OR "neuropathic pain") and synonyms in titles and abstracts were used to perform the search. Seventeen articles met the inclusion criteria. Discrepancies were found in studies that analyzed whether a cause-effect association exists between carpal tunnel syndrome (CTS) and secondary lymphedema. No evidence indicated that lymphedema predisposes to developing peripheral neuropathies such as CTS or brachial plexopathy. No studies found an association between patients with breast cancer at risk of or with lymphedema and the development or worsening of CTS. Carpal tunnel release can be safely performed in patients with BCRL. Neuropathic pain worsens with lymphedema, and treatment seems to improve the pain. Our study did not find enough evidence to conclude that BCRL is associated with the development of peripheral neuropathies. Carpal tunnel release is a safe procedure that can be performed in patients with BCRL and does not influence the development or worsening of lymphedema. Neuropathic pain seems to worsen after development of lymphedema, and treatment has been found to improve neuropathic pain.
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Affiliation(s)
- Antonio J. Forte
- Mayo Clinic, Jacksonville, FL, USA,Antonio J. Forte, Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | | | | | | | - Xiaona Lu
- Yale School of Medicine, New Haven, CT, USA
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38
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Yan M, Kuruoglu D, Boughey JC, Manrique OJ, Tran NV, Harless CA, Martinez-Jorge J, Nguyen MDT. Postmastectomy Breast Reconstruction is Safe in Patients on Chronic Anticoagulation. Arch Plast Surg 2022; 49:346-351. [PMID: 35832147 PMCID: PMC9142228 DOI: 10.1055/s-0042-1744405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background
Postmastectomy breast reconstruction (PMR) increases patient satisfaction, quality of life, and psychosocial well-being. There is scarce data regarding the safety of PMR in chronic anticoagulated patients. Perioperative complications can reduce patient satisfaction; therefore, it is important to elucidate the safety of PMR in these patients.
Methods
A retrospective case–control study of patients who underwent PMR with implants and were on chronic anticoagulation was performed at our institution. Inclusion criteria were women ≥ 18 years old. Exclusion criteria included autologous reconstructions, lumpectomy, and oncoplastic procedures. Two controls for every one patient on anticoagulation were matched by age, body mass index, radiotherapy, smoking history, type of reconstruction, time of reconstruction, and laterality.
Results
From 2009 to 2020, 37 breasts (20 patients) underwent PMR with implant-based reconstruction and were on chronic anticoagulation. A total of 74 breasts (40 patients) who had similar demographic characteristics to the cases were defined as the control group. Mean age for the case group was 53.6 years (standard deviation [SD] = 16.1), mean body mass index was 28.6 kg/m
2
(SD = 5.1), and 2.7% of breasts had radiotherapy before reconstruction and 5.4% after reconstruction. Nine patients were on long-term warfarin, six on apixaban, three on rivaroxaban, one on low-molecular-weight heparin, and one on dabigatran. The indications for anticoagulation were prior thromboembolic events in 50%. Anticoagulated patients had a higher risk of capsular contracture (10.8% vs. 0%,
p
= 0.005). There were no differences regarding incidence of hematoma (2.7% vs. 1.4%,
p
= 0.63), thromboembolism (5% vs. 0%,
p
= 0.16), reconstructive-related complications, or length of hospitalization (1.6 days [SD = 24.2] vs. 1.4 days [SD = 24.2],
p
= 0.85).
Conclusion
Postmastectomy implant-based breast reconstruction can be safely performed in patients on chronic anticoagulation with appropriate perioperative management of anticoagulation. This information can be useful for preoperative counseling on these patients.
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Affiliation(s)
- Maria Yan
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Doga Kuruoglu
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Judy C. Boughey
- Division of Breast Melanoma Surgical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Oscar J. Manrique
- Division of Plastic Surgery, University of Rochester, Rochester, New York
| | - Nho V. Tran
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Christin A. Harless
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jorys Martinez-Jorge
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Minh-Doan T. Nguyen
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
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39
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Escandón JM, Santamaría E, Prieto PA, Duarte-Bateman D, Ciudad P, Pencek M, Langstein HN, Chen HC, Manrique OJ. Reconstruction of Pharyngolaryngeal Defects with the Ileocolon Free Flap: A Comprehensive Review and How to Optimize Outcomes. Arch Plast Surg 2022; 49:378-396. [PMID: 35832153 PMCID: PMC9142245 DOI: 10.1055/s-0042-1748652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Several reconstructive methods have been reported to restore the continuity of the aerodigestive tract following resection of pharyngeal and hypopharyngeal cancers. However, high complication rates have been reported after voice prosthesis insertion. In this setting, the ileocolon free flap (ICFF) offers a tubularized flap for reconstruction of the hypopharynx while providing a natural phonation tube. Herein, we systematically reviewed the current evidence on the use of the ICFF for reconstruction of the aerodigestive tract. A systematic literature search was conducted across PubMed MEDLINE, Web of Science, ScienceDirect, Scopus, and Ovid MEDLINE(R). Data on the technical considerations and surgical and functional outcomes were extracted. Twenty-one studies were included. The mean age and follow-up were 54.65 years and 24.72 months, respectively. An isoperistaltic or antiperistaltic standard ICFF, patch flap, or chimeric seromuscular-ICFF can be used depending on the patients' needs. The seromuscular chimeric flap is useful to augment the closure of the distal anastomotic site. The maximum phonation time, frequency, and sound pressure level (dB) were higher with ileal segments of 7 to 15 cm. The incidence of postoperative leakage ranged from 0 to 13.3%, and the majority was occurring at the coloesophageal junction. The revision rate of the microanastomosis ranged from 0 to 16.6%. The ICFF provides a reliable and versatile alternative for reconstruction of middle-size defects of the aerodigestive tract. Its three-dimensional configuration and functional anatomy encourage early speech and deglutition without a prosthetic valve and minimal donor-site morbidity.
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Affiliation(s)
- Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Eric Santamaría
- Department of Plastic and Reconstructive Surgery, Hospital General Dr. Manuel Gea Gonzalez, National Cancer Institute, Mexico City, Mexico
| | - Peter A. Prieto
- Surgery Department, University of Rochester Medical Center, New York; Wilmot Cancer Institute, University of Rochester Medical Center, New York
| | | | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Megan Pencek
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Howard N. Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
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40
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Rowley MA, Thawanyarat K, Shah JK, Cai L, Turner E, Manrique OJ, Thornton B, Nazerali R. Does Higher Intraoperative Fraction of Inspired Oxygen Improve Complication Rates Following Implant-Based Breast Reconstruction? Aesthet Surg J Open Forum 2022; 4:ojac039. [PMID: 35662907 PMCID: PMC9155143 DOI: 10.1093/asjof/ojac039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background The surgical literature debates about whether an average intraoperative fractional inspired level of oxygen (FiO2) greater than 80% confers lower postsurgical complication rates. Although some evidence demonstrates minimal or no difference in short-term mortality or surgical site infections, few studies suggest negative long-term outcomes. Objectives To the best of our knowledge, this is the first study examining the relationship between intraoperative FiO2 levels and postoperative outcomes in the setting of immediate prepectoral implant-based breast reconstruction. Methods The authors retrospectively reviewed the complication profiles of 309 patients who underwent prepectoral 2-stage breast reconstruction following mastectomy between 2018 and 2021 at a single institution. Two cohorts were created based on whether intraoperative FiO2 was greater than 80% or less than or equal to 80%. Complication rates between the cohorts were analyzed using Chi-squared test, Fisher's exact test, and multivariable logistic regressions. Variables examined included demographic information; smoking history; preexisting comorbidities; history of chemotherapy, radiation, or axillary lymph node dissection; and perioperative information. Results Chi-squared and multivariable regression analysis demonstrated no significant difference between cohorts in complication rates other than reoperation. Reoperation rates were significantly increased in the FiO2 greater than 80% cohort (P = 0.018). Multivariable logistic regression also demonstrated that the use of acellular dermal matrix was significantly associated with increased postoperative complications (odds ratio 11.985; P = 0.034). Conclusions Complication rates did not statistically differ in patients with varying intraoperative FiO2 levels outside of reoperation rates. In the setting of implant-based prepectoral breast reconstruction, hyperoxygenation likely does not lead to improved postsurgical outcomes. Level of Evidence 3
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Affiliation(s)
- Mallory A Rowley
- Upstate Medical University, State University of New York, Syracuse, NY, USA
| | - Kometh Thawanyarat
- AU/UGA Medical Partnership, Medical College of Georgia at Augusta University, Athens, GA, USA
| | - Jennifer K Shah
- Vice Provost for Undergraduate Education, Stanford University, Stanford, CA, USA
| | - Lawrence Cai
- Division of Plastic & Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Oscar J Manrique
- Division of Plastic & Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Rahim Nazerali
- Corresponding Author:Dr Rahim Nazerali, 770 Welch Road, Suite 400, Palo Alto, CA 94304, USA. E-mail:
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Escandón JM, Santamaría E, Prieto PA, Duarte-Bateman D, Ciudad P, Pencek M, Langstein HN, Chen HC, Manrique OJ. Commentary: Reconstruction of Pharyngolaryngeal Defects with the Ileocolon Free Flap: A Comprehensive Review and How to Optimize Outcomes. Arch Plast Surg 2022; 49:V3. [PMID: 38404935 PMCID: PMC10883797 DOI: 10.1055/s-0043-1777252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Affiliation(s)
- Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Eric Santamaría
- Department of Plastic and Reconstructive Surgery, Hospital General Dr. Manuel Gea Gonzalez, National Cancer Institute, Mexico City, Mexico
| | - Peter A. Prieto
- Surgery Department, University of Rochester Medical Center, New York; Wilmot Cancer Institute, University of Rochester Medical Center, New York
| | | | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Megan Pencek
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Howard N. Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
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Ciudad P, Escandón JM, Manrique OJ, Bustos VP. Lessons Learnt from an 11-year Experience with Lymphatic Surgery and a Systematic Review of Reported Complications: Technical Considerations to Reduce Morbidity. Arch Plast Surg 2022; 49:227-239. [PMID: 35832669 PMCID: PMC9045509 DOI: 10.1055/s-0042-1744412] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Complications experienced during lymphatic surgery have not been ubiquitously reported, and little has been described regarding how to prevent them. We present a review of complications reported during the surgical management of lymphedema and our experience with technical considerations to reduce morbidity from lymphatic surgery. A comprehensive search across different databases was conducted through November 2020. Based on the complications identified, we discussed the best approach for reducing the incidence of complications during lymphatic surgery based on our experience. The most common complications reported following lymphovenous anastomosis were re-exploration of the anastomosis, venous reflux, and surgical site infection. The most common complications using groin vascularized lymph node transfer (VLNT), submental VLNT, lateral thoracic VLNT, and supraclavicular VLNT included delayed wound healing, seroma and hematoma formation, lymphatic fluid leakage, iatrogenic lymphedema, soft-tissue infection, venous congestion, marginal nerve pseudoparalysis, and partial flap loss. Regarding intra-abdominal lymph node flaps, incisional hernia, hematoma, lymphatic fluid leakage, and postoperative ileus were commonly reported. Following suction-assisted lipectomy, significant blood loss and transient paresthesia were frequently reported. The reported complications of excisional procedures included soft-tissue infections, seroma and hematoma formation, skin-graft loss, significant blood loss, and minor skin flap necrosis. Evidently, lymphedema continues to represent a challenging condition; however, thorough patient selection, compliance with physiotherapy, and an experienced surgeon with adequate understanding of the lymphatic system can help maximize the safety of lymphatic surgery.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
- Academic Department of Surgery, School of Medicine Hipolito Unanue, Federico Villarreal National University, Lima, Perú
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Valeria P. Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical University, Boston, Massachusetts
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Ciudad P, Huayllani MT, Forte AJ, Boczar D, Avila FR, Escandón JM, Manrique OJ, Chen HC. Vascularized Lymph Node Transfer for the Treatment of Posttraumatic Lower Extremity Lymphedema: A Preliminary Report. Indian J Plast Surg 2022; 55:97-101. [PMID: 35444749 PMCID: PMC9015821 DOI: 10.1055/s-0041-1740520] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background
Posttraumatic lymphedema develops more frequently than expected and reports on its management are scarce in the literature. We aimed to report the clinical outcomes of a case series of posttraumatic lymphedema patients treated with different vascularized lymph node transfers (VLNTs).
Patients and Methods
Five patients with secondary posttraumatic lower limb lymphedema treated with VLNT were included in this report. The groin-VLNT (
n
= 1), supraclavicular-VLNT (
n
= 2), and gastroepiploic-VLNT (
n
= 2) were implemented. The average flap area was 69.8 cm
2
. Patients underwent postoperative complex decompressive therapy for an average of 10.0 months.
Results
The average mean circumference reduction rate was 24.4% (range, 10.2–37.6%). Postsurgical reduction in the number of infection episodes per year was observed in all patients. The mean follow-up was 34.2 months.
Conclusions
VLNT is a promising surgical treatment for posttraumatic lymphedema patients. In our report, VLNT has demonstrated to reduce the volume and number of infections per year in posttraumatic lymphedema.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Maria T. Huayllani
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Antonio J. Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Daniel Boczar
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Francisco R. Avila
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, United States
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, United States
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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44
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Ciudad P, Escandón JM, Bustos VP, Manrique OJ, Kaciulyte J. Primary Prevention of Cancer-Related Lymphedema Using Preventive Lymphatic Surgery: Systematic Review and Meta-analysis. Indian J Plast Surg 2022; 55:18-25. [PMID: 35444756 PMCID: PMC9015841 DOI: 10.1055/s-0041-1740085] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background
Several studies have proven prophylactic lymphovenous anastomosis (LVA) performed after lymphadenectomy can potentially reduce the risk of cancer-related lymphedema (CRL) without compromising the oncological treatment. We present a systematic review of the current evidence on the primary prevention of CRL using preventive lymphatic surgery (PLS).
Patients and Methods
A comprehensive search across PubMed, Cochrane-EBMR, Web of Science, Ovid Medline (R) and in-process, SCOPUS, and ScienceDirect was performed through December 2020. A meta-analysis with a random-effect method was accomplished.
Results
Twenty-four studies including 1547 patients fulfilled the inclusion criteria. Overall, 830 prophylactic LVA procedures were performed after oncological treatment, of which 61 developed lymphedema.
The pooled cumulative rate of upper extremity lymphedema after axillary lymph node dissection (ALND) and PLS was 5.15% (95% CI, 2.9%–7.5%;
p
< 0.01). The pooled cumulative rate of lower extremity lymphedema after oncological surgical treatment and PLS was 6.66% (95% CI < 1–13.4%, p-value = 0.5). Pooled analysis showed that PLS reduced the incidence of upper and lower limb lymphedema after lymph node dissection by 18.7 per 100 patients treated (risk difference [RD] – 18.7%, 95% CI – 29.5% to – 7.9%;
p
< 0.001) and by 30.3 per 100 patients treated (RD – 30.3%, 95% CI – 46.5% to – 14%;
p
< 0.001), respectively, versus no prophylactic lymphatic reconstruction.
Conclusions
Low-quality studies and a high risk of bias halt the formulating of strong recommendations in favor of PLS, despite preliminary reports theoretically indicating that the inclusion of PLS may significantly decrease the incidence of CRL.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
- Academic Department of Surgery. School of Medicine Hipolito Unanue. Federico Villarreal National University, Lima, Perú
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, United States
| | - Valeria P. Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, United States
| | - Juste Kaciulyte
- Department of Surgery “P.Valdoni,” Unit of Plastic and Reconstructive Surgery, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
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45
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Maita K, Garcia JP, Torres RA, Avila FR, Kaplan JL, Lu X, Manrique OJ, Ciudad P, Forte AJ. Imaging biomarkers for diagnosis and treatment response in patients with lymphedema. Biomark Med 2022; 16:303-316. [PMID: 35176878 DOI: 10.2217/bmm-2021-0487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Lymphedema is defined as a dysfunction of the lymphatic system producing an accumulation of lymphatic fluid in the surrounding tissue, as well as edema and fibrosis. A total of 250 million people worldwide are affected by this condition. Greater than 99% of these cases are related to a secondary cause. As there is a lack of curative therapy, the goal involves early diagnosis, in order to prevent the progression of the disease. Additionally, early diagnosis can aid in decreasing the demand for more complex surgical procedures. Currently, there is an impressive breadth of diagnostic tests available for these patients. We aimed to review the available literature in relation to the utilization of imaging biomarkers for the early diagnosis and treatment response in lymphedema.
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Affiliation(s)
- Karla Maita
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - John P Garcia
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Ricardo A Torres
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Francisco R Avila
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Jamie L Kaplan
- Division of General Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Xiaona Lu
- Division of Plastic & Reconstructive Surgery, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Oscar J Manrique
- Division of Plastic Surgery, University of Rochester Medical Center, Rochester, NY, 14627, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive & Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
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46
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Escandón JM, Vyas KS, Manrique OJ. High-Definition Lipoplasty in Male Patients: A Systematic Review of Surgical Techniques and Outcomes. Aesthet Surg J 2022; 42:68-85. [PMID: 34309661 DOI: 10.1093/asj/sjab300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Lipoplasty has undergone a series of refinements since its inception. It is now possible to apply superficial suction to enhance the outline of a muscle in order to improve the results of aesthetic lipoplasty. OBJECTIVES The aim of this study was to summarize the available evidence on the techniques and surgical outcomes of high-definition lipoplasty (HDL) in male patients. METHODS A systematic search across PubMed MEDLINE, Web of Science, Ovid MEDLINE In-Process & Other Non-Indexed Citations, and SCOPUS was performed in accordance with the PRISMA guidelines. Data regarding the surgical techniques, outcomes, and complications were extracted. RESULTS Thirteen studies comprising 1280 patients fulfilled the inclusion criteria. The age of patients ranged from 18 to 71 years. The average BMI was 26.5 kg/m2. The follow-up ranged from 2 weeks to 10 years. The liposculpting concepts reported were abdominal etching, high-definition, muscular sculpture, and dynamic definition. Four studies used conventional liposuction, 3 used VASER-assisted HDL, and 6 studies used power-assisted liposculpting. Eight studies reported the use of fat grafting. All studies reported the use of postoperative garments and a well-established wound treatment protocol. Overall satisfaction ranged from 84% to 100%. The most common complications reported were fluid collection, hyperpigmentation, contour irregularities, anemia, and port dehiscence. CONCLUSIONS A wide variety of techniques are available to perform HDL with a variable degree of definition. Careful patient selection is critical for successful results because HDL is not suitable for every patient. Finally, proper training and adequate knowledge of abdominal anatomy is necessary to avoid complications. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Krishna S Vyas
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
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47
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Ciudad P, Escandón JM, Manrique OJ, Bustos VP, Chen HC. The use of free colon flap transfer for management of xerostomia in a patient. Microsurgery 2021; 42:199-200. [PMID: 34951058 DOI: 10.1002/micr.30852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/26/2021] [Accepted: 10/22/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru.,Academic Department of Surgery, Hipolito Unanue School of Medicine, Federico Villarreal National University, Lima, Peru.,Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
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48
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Bustos VP, Escandón JM, Santamaría E, Ciudad P, Forte AJ, Hernandez-Alejandro R, Leckenby JI, Langstein HN, Manrique OJ. Abdominal Wall Vascularized Composite Allotransplantation: A Scoping Review. J Reconstr Microsurg 2021; 38:481-490. [PMID: 34905782 DOI: 10.1055/s-0041-1740121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Abdominal wall vascularized composite allotransplantation (AW-VCA) is a novel reconstructive technique used for large abdominal wall defects in combination with intestinal transplantation (ITx) or multivisceral abdominal transplantation (MVTx). Since the introduction of this procedure, several studies have been published reporting their experience. This study aims to present a scoping review looking at all available evidence-based medicine information to understand the most current surgical techniques and clinical outcomes. METHODS This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) extension for scoping reviews checklist. A comprehensive research strategy of several databases was conducted. RESULTS A total of 31 studies were included in this review, which comprised animal, cadaveric, and human studies. In human studies, four surgical techniques with high flap survival rates and low complication rates were found. In cadaveric studies, it was shown that the use of iliofemoral cuff-based flaps provided adequate tissue perfusion to the abdominal wall graft. Also, the use of thoracolumbar nerves have been described to provide functionality to the AW-VCA and prevent long-term muscle atrophy. CONCLUSION AW-VCA is a safe and efficient alternative for patients with large and complex abdominal wall defects. The future holds a promising evolution of a functional AW-VCA, though surgeons must face and overcome the challenge of distorted anatomy frequently present in this population. Forthcoming studies with a better level of evidence are required to evaluate functionality and differences between surgical techniques.
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Affiliation(s)
- Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Eric Santamaría
- Department of Plastic and Reconstructive Surgery, Hospital General Dr. Manuel Gea Gonzalez, National Cancer Institute, Mexico City, Mexico
| | - Pedro Ciudad
- Department of Plastic, Reconstructive, and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Antonio J Forte
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Jacksonville, Florida
| | - Roberto Hernandez-Alejandro
- Division of Abdominal Transplantation and Hepatobiliaty Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Jonathan I Leckenby
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
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49
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Galán R, Manrique OJ, Bustos SS, Arango D, Correa D, Terán D, Vergara M, Moran SL. A4 Pulley Reconstruction Using the Superficialis Oblique Flap and the Transverse Double Loop Techniques: A Biomechanical Evaluation Using a Chicken Model. Ann Plast Surg 2021; 87:650-656. [PMID: 34270466 DOI: 10.1097/sap.0000000000002796] [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 The pulley system plays an important role in flexion mechanism. Reconstruction after trauma can be challenging. Numerous techniques have been described with several drawbacks. Herein, we describe the superficialis flap oblique technique for A4 pulley reconstruction using an animal model. METHODS Forty-two fresh legs of 21 eight-week-old chickens were used to evaluate the maximum flexion angle (MFA) and force at maximum flexion (FMF) in intact and sectioned A4 pulley equivalents of the third digit after reconstruction with the transverse double loop (TDL) technique and the superficialis oblique flap (SOF) technique. Biomechanical measurements were obtained in an exclusively designed instrument. Descriptive statistics were reported, and mean differences between the reconstructive techniques were analyzed. RESULTS Intact and severed A4 pulley equivalent average MFA were 96.50° ± 1.70° and 115.60° ± 1.50°, respectively. Average FMF were 8.16 ± 0.23 psi with the intact pulley and 6.92 ± 0.20 psi with the sectioned pulley (P < 0.001). After reconstruction with TDL and SOF techniques, the legs reached an average MFA at the distal interphalangeal joint of 98.13° ± 1.20° and 96.90° ± 1.30°, respectively. Mean MFA difference was 1.23° (P = 0.03). Force at maximum flexion was 8.12 psi and 8.10 psi for the TDL and SOF techniques (P = 0.6), respectively. CONCLUSIONS The authors believe that SOF technique for A4 pulley reconstruction can be used as first option when available, taking into account its theoretical advantages and its proven biomechanical characteristics. Long-term functional results should be assessed to translate these results into the clinical setting.
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Affiliation(s)
- Ricardo Galán
- From the Division of Plastic Surgery, Universidad Militar Nueva Granada, Hospital Militar Central, Bogotá, Colombia
| | - Oscar J Manrique
- Division of Plastic Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Samyd S Bustos
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Diego Arango
- From the Division of Plastic Surgery, Universidad Militar Nueva Granada, Hospital Militar Central, Bogotá, Colombia
| | - Diana Correa
- From the Division of Plastic Surgery, Universidad Militar Nueva Granada, Hospital Militar Central, Bogotá, Colombia
| | - Diego Terán
- From the Division of Plastic Surgery, Universidad Militar Nueva Granada, Hospital Militar Central, Bogotá, Colombia
| | - María Vergara
- From the Division of Plastic Surgery, Universidad Militar Nueva Granada, Hospital Militar Central, Bogotá, Colombia
| | - Steven L Moran
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN
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50
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Escandón JM, Bustos VP, Bustos SS, Mascaro A, Del Corral G, Ciudad P, Kim EA, Langstein HN, Manrique OJ. Reply: Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence. Plast Reconstr Surg Glob Open 2021; 9:e3954. [PMID: 35028263 PMCID: PMC8751773 DOI: 10.1097/gox.0000000000003954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Strong Memorial Hospital, Rochester, N.Y
| | - Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Samyd S Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minn
| | - Andres Mascaro
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic, Weston, Fla
| | - Gabriel Del Corral
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Esther A Kim
- Division of Plastic and Reconstructive Surgery, University of California, San Francisco, Calif
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Strong Memorial Hospital, Rochester, N.Y
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Strong Memorial Hospital, Rochester, N.Y
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