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Biomedical subjects

G L Robb

Publications and source records attributed to G L Robb.

At least 37 records · Page 2Linked to original sources
PubMed1999

The incidence of occult nipple-areola complex involvement in breast cancer patients receiving a skin-sparing mastectomy.

BACKGROUND: Surgical treatment of breast cancer traditionally has included resection of the nipple-areola complex (NAC), in the belief that this area had a significant probability of containing occult tumors. The purpose of this study was to investigate the true incidence of NAC involvement in patients who underwent a skin-sparing mastectomy (SSM) and to determine associated risk factors. METHODS: A retrospective chart review was conducted of 326 patients who had a SSM at our institution from 1990 to 1993. NAC involvement was reviewed in 286 mastectomy specimens. The charts were analyzed for tumor size, site, histology, grade, nodal status, recurrence, survival, and NAC involvement. RESULTS: Occult tumor involvement in the NAC was found in 5.6% of mastectomy specimens (16 patients). Four patients would have had NAC involvement identified on frozen section if they had been undergoing a skin-sparing mastectomy with preservation of the NAC. There were no significant differences between NAC-positive (NAC+) and NAC-negative (NAC-) patients in median tumor size, nuclear grade, histologic subtype of the primary tumor, or receptor status. There were significant differences in location of the primary tumor (subareolar or multicentric vs. peripheral) and positive axillary lymph node status. NAC involvement was not a marker for increased recurrence or decreased survival. CONCLUSIONS: Occult NAC involvement occurred in only a small percentage of patients undergoing skin-sparing mastectomies. NAC preservation would be appropriate in axillary node-negative patients with small, solitary tumors located on the periphery of the breast.

Breast Neoplasms↗
PubMed1999

Local recurrence risk after skin-sparing and conventional mastectomy: a 6-year follow-up.

In this study, the records of all patients at the University of Texas M. D. Anderson Cancer Center with T1 or T2 breast cancer who were treated between March of 1986 and November of 1990 with mastectomy followed by immediate breast reconstruction were reviewed for the presence of recurrent disease. Patients with in situ disease were not included. Patients were included in the study if a local recurrence occurred (regardless of the length of follow-up) or if a follow-up of 6 years or longer could be obtained. Patients were grouped according to the use or nonuse of skin-sparing mastectomy, by tumor stage, and by nuclear grade of the tumor. The series included 154 patients, of whom 114 had skin-sparing mastectomies and 40 had nonskin-sparing mastectomies. The local recurrence rate in the skin-sparing mastectomy group was 7.0 percent, whereas in the nonskin-sparing mastectomy group it was 7.5 percent. The sample size in the nonskin-sparing mastectomy group was too small for meaningful statistical analysis, but the data suggest that there is no clinically important difference in recurrence rates between the two groups. We conclude that the use of skin-sparing technique for early breast cancer patients does not significantly increase the risk of tumor recurrence after mastectomy.

Breast Neoplasms↗
PubMed1998

Soft tissue reconstruction following hemipelvectomy.

BACKGROUND: Resection of primary and metastatic pelvic bone disease may result in large soft tissue deficits. Guidelines for soft tissue reconstruction following pelvic bone resection were evaluated in a retrospective study. METHODS: Over a 5-year period 21 patients (31%) required soft tissue reconstruction following pelvic bone resection. Data on these patients were retrieved from case records. RESULTS: Twelve patients underwent immediate, planned reconstruction, 1 a two-stage reconstruction, and 8 patients required a delayed procedure for complications after bone resection and primary closure. Soft tissue reconstruction was usually accomplished with muscle-based flaps; (25 flaps in 20 patients: 20 pedicled, 5 free), or with skin grafts alone (1 patient). Specific postreconstruction complications occurred in 9 patients, 5 in flaps based on the ipsilateral rectus muscle. CONCLUSION: Flap closure is indicated to achieve primary closure and eliminate deadspace. The ipsilateral rectus muscle should be used with caution and contralateral-based rectus flaps considered. Indications for free flaps include the size and location of the defect and availability of tissue from an amputated limb.

Adult↗
PubMed1998

Reconstruction of posterior mandibular defects with soft tissue using the rectus abdominis free flap.

Immediate reconstruction of posterior mandibular composite defects by replacement with vascularised bone is ideal in principle, but may have excessive morbidity for certain patients who, because of poor general health or a poor tumour prognosis, are not good candidates for a complex surgical procedure. Also, if the temporomandibular joint (TMJ) is missing, the continuity of the entire mandible cannot be restored without either reconstructing the TMJ or resorting to a prosthesis. For such patients, reconstruction of the posterior defect without bone using a rectus abdominis free flap or other soft-tissue flap may be a good alternative. A series of 21 patients with posterior mandibular defects underwent this type of reconstruction. The patients reconstructed only with soft tissue were found to have a reasonable cosmetic appearance, and speech and swallowing function were very acceptable. For posterior mandibular defects that include a missing condyle this approach is an acceptable alternative, especially for patients who are poor candidates for more complex surgical procedures.

Bone Transplantation↗
PubMed1998

Does prior irradiation increase the risk of total or partial free-flap loss?

Answers to the question, "Does previous irradiation of a recipient site interfere with reconstruction by free-tissue transfer?" have been elusive. In an attempt to address that question, all free-flap procedures performed for reconstruction of the breast or of head and neck defects at the University of Texas M. D. Anderson Cancer Center between May 1, 1988 and February 15, 1996 were reviewed. The effects of prior irradiation of the recipient site on the incidence of total flap loss, partial flap loss, and thrombosis were assessed. During the study period, 1384 eligible free-flap reconstructions were performed. Total flap loss and partial flap loss were more common in the 428 flaps transferred to previously irradiated sites than in the patients without previous irradiation, but multiple logistic regression analysis showed that these differences were due to confounding factors. The authors conclude that previous irradiation of flap recipient sites does not statistically significantly affect the rate of partial or total free-flap loss.

Adult↗
PubMed1998

Reconstruction of complex radiation-induced injuries using free-tissue transfer.

The purpose of this study was to evaluate the use of free-tissue transfers for the reconstruction of radiation-induced complex injuries. The case files for patients who underwent reconstruction for radiation-induced injuries between May 1988 and November 1995 at The University of Texas M.D. Anderson Cancer Center were retrospectively reviewed. Thirty patients in whom 33 free flaps were done were included. Radiation-induced defects were located in the head and neck (n=23), extremities (n=4), chest wall (n=2), and inguinal area (n=1) The mean period between irradiation and injury was 78 months (range: 4 months to 38 years). Free-tissue transfer was successful in 97 percent (32/33) of patients. The overall complication rate was 40 percent (12/30). Flap donor sites included the fibula (n=12), latissimus dorsi (n=6), rectus abdominis (n=6), iliac crest (n=4), scapula (n=3), and radial forearm (n=2). Large-caliber vessels in the cervical, axillary, or inguinal regions were most commonly used to revascularize flaps. Vein grafts were used in five cases for the artery (2/5) or vein (3/5). Pedicle thrombosis occurred in three cases in recipient vessels located within the irradiated field. Two flaps were salvaged; one was lost, and the patient required a second free-flap reconstruction The mean follow-up was 40 months (range: 2.5 to 83 months). The disease-free survival rate was 67 percent (20/30), local failures occurred in 10 percent (3/30) of patients, and 23.3 percent (7/30) of patients either died or were lost to follow-up. Healing of radiation-induced wounds may be achieved using free-tissue transfers, but complications are frequent. Large-caliber irradiated vessels may be used to revascularize flaps, but there may be an increased risk of pedicle thrombosis.

Adult↗
PubMed1998

A comparison of resource costs of immediate and delayed breast reconstruction.

The resource cost (cost to our hospital) of providing mastectomy plus breast reconstruction was calculated for 276 patients who had received both mastectomy and breast reconstruction at our institution. All patients had completed the entire reconstructive process, including reconstruction of the nipple. The resource costs of providing mastectomy with immediate breast reconstruction were compared with those of mastectomy with subsequent delayed reconstruction. We found that the mean resource cost for the 57 patients who had separate mastectomy followed by delayed breast reconstruction ($28,843) was 62 percent higher than that of mastectomy with immediate reconstruction ($17,801; n = 219, p < 0.001). Similar differences were found when patients were subgrouped by type of reconstruction (TRAM versus tissue expansion and implants), by laterality (unilateral versus bilateral), and by history of preoperative irradiation. We conclude that mastectomy with immediate breast reconstruction is significantly less expensive than mastectomy followed by delayed reconstruction and can potentially conserve resources.

Breast Neoplasms↗
PubMed1998

Fat necrosis in free and pedicled TRAM flaps.

One purported advantage of the free transverse rectus abdominis musculocutaneous (TRAM) flap for breast reconstruction is that, compared with the conventional TRAM flap, it has a better blood supply and therefore a lower incidence of fat necrosis. We tested this claim by reviewing the incidence of fat necrosis, both clinically and mammographically, in a group of 110 patients with 116 TRAM flap breast reconstructions who had undergone mammography of their reconstructed breasts. Of the 49 breasts reconstructed with free TRAM flaps, 4 (8.2 percent) had clinically evident fat necrosis, and 1 (2.0 percent) had fat necrosis that was detectable by mammography. Of the 67 breasts reconstructed with conventional TRAM flaps, 18 (26.9 percent) had clinically detectable fat necrosis, and 9 (13.4 percent) had fat necrosis that was detectable mammographically. Both of these differences were statistically significant (p = 0.0113 for clinical fat necrosis; p = 0.031 for mammographic fat necrosis). Fat necrosis was more common in patients who were obese or had a history of smoking, but neither association was statistically significant. We conclude that the use of the free TRAM flap reduces the incidence of fat necrosis in the reconstructed breast.

Abdominal Muscles↗
PubMed1998

Thoracodorsal vessels as a recipient site.

A variety of useful recipient vessel options exist for delayed breast reconstruction. The thoracodorsal vessels of the subscapular trunk, however, present the best option in immediate breast reconstruction, in particular for the transverse rectus abdominis myocutaneous (TRAM) flap, because of their consistent availability and reliability. One fundamental surgical advantage of the microvascular approach to breast reconstruction is the relative ease of obtaining consistently high-quality recipient vessels throughout the axilla and anterolateral chest wall to facilitate a predictably successful reconstructive outcome. This article discusses the process of selecting the best vessels and the techniques for their dissection.

Back↗
PubMed1997

Adjuvant therapy: the effects on microvascular lower extremity reconstruction.

Adjuvant therapy and microsurgery have allowed advances in surgical extirpation of lower extremity neoplasms. This retrospective study was designed to evaluate the microvascular transfer for lower extremity reconstruction in patients receiving pre- or post-operative irradiation and chemotherapy alone and in combination. Over a 5-year period, 24 free tissue transfers were performed in 22 patients undergoing surgical resection with adjuvant therapy for lower extremity neoplasms. There were 13 male and 9 female patients with an average age of 51 years. The latissimus dorsi muscle was most commonly transferred (N = 15). Eighteen tumors received pre- and three received postoperative radiotherapy. Two tumors received a combination of radiotherapy and brachytherapy. Pre- and/or postoperative chemotherapy was used in 14 patients. Twelve of these patients had both chemo- and radiation therapy. A total of six complications occurred, with no flap loss. Complications were evenly distributed among adjuvant regimens. All patients who underwent attempted limb salvage were able to ambulate postoperatively, except for 1 patients who had local recurrence. In conclusion, adjuvant therapy did not increase the complication rate for free tissue transfer in the lower extremity. Adjuvant therapy did not require alterations in the free tissue transfer and, similarly, free tissue transfer did not alter adjuvant therapy. We believe that free tissue transfer in complicated wounds allows for better wound healing with adjuvant therapy rather than local or primary wound closure alone.

Adult↗
PubMed1997

A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps.

A series of 178 immediate reconstructions with regional or distant tissue for repair of oropharyngeal defects caused by treatment of head and neck cancer was reviewed to determine whether reconstruction with free flaps was more or less expensive than reconstruction with regional myocutaneous flaps. In this series, three types of flaps were used: the radial forearm free flap (n = 89), the rectus abdominis free flap (n = 56), and the pectoralis major myocutaneous flap (n = 33). Resource costs were determined by adding all costs to the institution of providing each service studied using salaried employees (including physicians). The two free-flap groups were combined to compare free flaps with the pectoralis major myocutaneous flap, a regional myocutaneous flap. Failure rates in the two groups were similar (3.0 percent for pectoralis major myocutaneous flap, 3.4 percent for free flaps). The mean costs of surgery were slightly higher for the free flaps, but the subsequent hospital stay costs were lower. Therefore, the total mean resource cost for the free-flap group ($28,460) was lower than the cost for the myocutaneous flap group ($40,992). The pectoralis major myocutaneous flap may have been selected for more patients with advanced disease and systemic medical problems, contributing to longer hospitalization and added cost. Nevertheless, this study suggests that free flaps are not more expensive than other methods and may provide cost savings for selected patients.

Age Factors↗
PubMed1997

Comparison of nipple projection with the modified double-opposing tab and star flaps.

This study compared nipple projection after nipple reconstruction (following breast mound reconstruction) with either the modified double-opposing tab flap or the star flap. Areolar reconstruction and pigmentation of the nipple were achieved with tattooing. Nipple projection for 153 nipples was measured at least 6 months after the reconstruction, when projection was believed to have become stable. Mean follow-up was 2.27 years. In the 106 nipples reconstructed with modified double-opposing tab flaps, the mean projection was 2.4292 mm, while in the 47 nipples reconstructed with star flaps, the mean projection was 1.9681 mm (p = 0.021). We conclude that although both methods are effective, the modified double-opposing tab flap has slightly more projection after approximately 2 years. It is not known, however, whether this is because of reduced flap atrophy or longer initial projection by the modified double-opposing tab flap; further studies are ongoing.

Female↗
PubMed1997

Microvascular reconstruction for cutaneous defects.

Advanced skin cancer of the head and neck is best managed by a multidisciplinary approach. The goal is to control the malignancy while maximizing function and aesthetics, and hence the quality of life, after therapy. As a member of the patient care team, the reconstructive surgeon brings specialized expertise in modern techniques of tissue transfer to provide the optimal restoration for patients following resection of the tumor. Microvascular surgery represents the current technical state of the art for reconstruction in these patients with advanced lesions.

Dermatologic Surgical Procedures↗
PubMed1996

Aesthetic breast reconstruction using a combination of free transverse rectus abdominis musculocutaneous flaps and breast implants.

Some women electing immediate bilateral postmastectomy breast reconstruction have inadequate autologous tissue to achieve an aesthetic result and also wish to avoid tissue expansion or a back scar. These patients are candidates for reconstruction using free transverse rectus abdominis musculocutaneous (TRAM) flaps and breast implants. Since November 1993, 5 women have been reconstructed bilaterally with a combination of free TRAM flaps and adjustable saline breast implants. Each patient was young (age, 29-47 years) and of slender body habitus. During the procedure, the implants were placed in a submuscular pocket formed by the pectoralis major, the serratus anterior, and the muscular portion of the TRAM flap. Careful approximation of the serratus anterior to the lateral border of the pectoralis major muscle created a reliable layer of tissue to protect the vascular pedicle of the TRAM flap from contact with the implant. The saline chambers of the implants were filled to 60% to 80% capacity at the time of surgery. TRAM flap skin was tailored to precisely replace missing breast envelope, and subcutaneous fat increased implant coverage, creating a mound with normal-appearing ptosis. There were no occurrences of microvascular thrombosis. Three patients experienced prolonged formation of serous fluid, with 2 patients requiring late aspiration of a serosa after drain removal. Although there were no documented infections, 1 patient experienced postoperative erythema of the mastectomy skin flaps and was treated empirically with antibiotics with resolution of the erythema. All breasts have remained soft and appear natural. Using free TRAM flaps and adjustable saline breast implants allows selected women to undergo immediate breast reconstruction without the need for prolonged tissue expansion or back scars. Aesthetic results are excellent and the immediate use of an implant does not appear to pose a risk to the success of the free tissue transfer.

Adult↗
PubMed1996

Silicon tissue assays: a comparison of nonaugmented cadaveric and augmented patient levels.

Tissue silicon assays were performed on 10 nonaugmented cadavers and 25 augmented women to confirm our previous cadaveric data and to establish silicon levels at local and distant sites in augmented women undergoing explant and further reconstruction. All assays were performed by inductively coupled plasma atomic emissions spectroscopy (ICP-AES). Cadaveric tissues were sampled from six sites: liver, spleen, breast, nipple, axilla (soft tissue and nodes), and subcutaneous tissue (abdominal). Augmented women undergoing explant surgery had a portion of their implant capsule, breast tissue, and for those undergoing autogenous reconstruction, a portion of the autogenous donor site or distant tissue sampled. Twenty-four women had silicone implants; one had saline. Results revealed baseline silicon levels in all 10 non-augmented cadavers. These results were equivalent to our previous data, confirming the validity of these baseline data. Silicon tissue levels in the 25 augmented women revealed elevated levels within the implant capsule and surrounding breast tissue. However, silicon levels obtained from distant sites in augmented women were equivalent to the baseline nonaugmented cadaveric levels. There was no correlation between intact or ruptured implants and symptoms of collagen-vascular disease. In conclusion, study validates our original data of baseline silicon levels in nonaugmented cadavers. Contrary to what some may perceive as silicone floating throughout the body, we have found elevated levels around the implant only, and levels at distant tissue sites were equivalent to the baseline cadaveric data.

Abdomen↗
PubMed1996

Comparison of resource costs of free and conventional TRAM flap breast reconstruction.

Resource costs, which are the costs to the hospital of providing a service, were measured for 154 patients who underwent mastectomy and immediate breast reconstruction with TRAM flaps. Unilateral and bilateral reconstructions were evaluated separately. The resource costs required to perform mastectomy and reconstruction with free TRAM flaps were then compared with those required when conventional TRAM flaps were used. The mean total resource cost in the free TRAM group was slightly higher than in the conventional TRAM group, but the difference was small (4.1 percent) and not statistically significant (p = 0.290). The mean resource cost of performing bilateral mastectomy and reconstruction was higher than that of unilateral mastectomy and reconstruction, but the difference was only 5.0 percent (p = 0.046). This study shows that the cost to an institution of providing breast reconstruction with free TRAM flaps is not significantly higher than that of performing reconstruction with conventional TRAM flaps. Also, our findings show that the resource costs of performing bilateral mastectomy and reconstruction are not much higher than those of treating only one breast.

Female↗