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G P Reece

Publications and source records attributed to G P Reece.

At least 37 records · Page 2Linked to original sources
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↗
PubMed1997

Lower extremity salvage after radical resection of malignant tumors in the groin and lower abdominal wall.

BACKGROUND: Resection of a large malignant tumor in the groin often leaves a substantial soft-tissue defect that makes wound closure difficult. Nevertheless, palliation and lower extremity salvage is frequently possible if the tumor is widely excised and the wound closed with well-vascularized tissue; however, few data are available on patients undergoing such procedures. STUDY DESIGN: We retrospectively examined our experience with limb salvage in 25 patients undergoing radical groin resection for metastatic or recurrent malignant tumors between April 1, 1991 and April 8, 1996. RESULTS: Defect size ranged from 15 to 735 cm2 (mean, 238.5 cm2). Tumor resection included part of the abdominal wall in 14 patients and the femoral vessels in 5 patients. Defects were most commonly repaired with a vertical rectus abdominis myocutaneous flap (56%). Mean hospital stay was 10.4 days, and mean followup was 15.5 months. Although the complication rate was 68%, the limb salvage rate was 100%, and normal ambulation was achieved in 88% of patients. The most frequent complications were chronic lymphedema (42%) and seroma (29%). There was one perioperative death (4%). CONCLUSIONS: Functional limb salvage after radical resection of the groin and lower abdominal wall is very successful, has an acceptable morbidity rate, does not prolong hospital stay, and contributes significantly to the patient's quality of life. Chronic lymphedema is a frequent complication after this treatment but can be managed successfully with conservative techniques.

Abdominal Muscles↗
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↗
PubMed1996

Total midface reconstruction after radical tumor resection: a case report and overview of the problem.

We report an unusual repair of a massive midface defect resulting from resection of a recurrent squamous cell carcinoma of the nasal vestibule. The defect included both maxillas, the hard palate, the upper lip, and all nasal and perinasal tissues. After treatment, reconstruction was accomplished using prostheses and autologous tissue transferred from local and distant sites. The osseous component of the transferred tissue permitted placement of osseointegrated implants for fixation of maxillary and nasal prostheses. The rationale for this reconstruction and the problems associated with midface reconstruction after radical tumor resection are discussed.

Carcinoma, Squamous Cell↗
PubMed1996

Comparison of resource costs between implant-based and TRAM flap breast reconstruction.

Resource costs, as measured by hours of time in the operating room, days of stay in the hospital, and other costs of care, were evaluated for 240 patients who underwent mastectomy with immediate breast reconstruction using either TRAM flaps or breast implants at The University of Texas M. D. Anderson Cancer Center. To make costs comparable, only patients who completed reconstruction of the nipple were included. As expected, the initial resource costs of implant-based reconstruction were much lower than those of TRAM flap reconstruction. After correcting for patients whose reconstructions were unsuccessful and including the costs of surgery subsequent to the initial reconstruction, however, the cost advantage of implant-based reconstruction disappeared. If current trends continue, it is likely that with increased follow-up, the long-term resource costs of implant-based reconstructions will continue to increase, while those of autogenous tissue reconstructions will not. Autogenous breast reconstruction with the TRAM flap therefore appears to be more cost-effective, in terms of time as well as dollars, in the long run than reconstruction based on prosthetic implants.

Breast Implants↗
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↗
PubMed1996

Choice of flap and incidence of free flap success.

A review of 854 consecutive free flaps was performed to determine whether the choice of flap used for the reconstruction influenced the probability of a successful outcome. Flaps were grouped into nine categories: rectus abdominis, free transverse rectus abdominis myocutaneous, radial forearm, jejunum, latissimus dorsi, fibula, scapula, iliac crest, and other. There were significant differences among the success rates of different flaps (p < 0.0001). Rectus abdominis-based flaps used for breast or head and neck reconstruction had lower failure rates (0.9 percent) than did non-rectus abdominis flaps (6.6 percent; p < 0.0001). Flaps requiring vein grafts had a higher rate of flap loss (18.4 percent) than did flaps that did not require vein grafts (2.9 percent; p < 0.0001). There was a strong trend favoring survival of flaps without a bone component (compared with osteocutaneous flaps), and a weaker trend favoring survival of flaps in nonobese patients (compared with flaps in obese patients). Smoking, age, and previous irradiation had no significant effect on flap failure rates. Surgeons should consider the flap success rate as one (but not necessarily the most important) factor in choosing the best reconstruction for any individual patient.

Breast Neoplasms↗
PubMed1996

Timing of pedicle thrombosis and flap loss after free-tissue transfer.

A series of 990 consecutive free flaps was reviewed to determine how often pedicle thrombosis occurred, when it occurred, and if the timing of thrombosis detection had any relationship to the probability of flap salvage. The overall thrombosis rate was 5.1 percent, and the flap loss rate was 3.2 percent. The majority (80 percent) of thrombi occurred within the first 2 postoperative days. Only 5 thrombi (10 percent) were known to have occurred after the third postoperative day. No flaps that developed thrombosis after the third postoperative day were salvaged successfully. Had flap monitoring been discontinued after the first 3 postoperative days, our results in this series would have been unchanged. Thrombosis of the vein (54 percent) was more common than arterial thrombosis (20 percent) or thrombosis of both artery and vein (12 percent). Almost all purely arterial thrombi (90 percent) occurred before the end of the first postoperative day, whereas 41 percent of all venous thrombi occurred later. We conclude that arterial monitoring is most critical immediately after surgery. Beginning on the second postoperative day, venous monitoring becomes progressively more important to flap success. The cost-effectiveness of postoperative monitoring of free flaps is greatest during the first 2 days, after which it decreases significantly.

Graft Rejection↗
PubMed1995

Postoperative radiation of free jejunal autografts in patients with advanced cancer of the head and neck.

BACKGROUND: Free jejunal autografts increasingly are being used to repair the pharynx after resections of head and neck carcinomas. Doses of greater than 45 Gy are generally considered to be above the tolerance of the small bowel, whereas the dose range for effective postoperative radiotherapy of advanced head and neck cancers is between 57.6 Gy and 63 Gy. Between July 1988, and December, 1992, 29 patients at the M. D. Anderson Cancer Center were treated with a combination of resection of the advanced head and neck cancer, reconstruction with free jejunal autograft, and postoperative radiation. Planned reductions in postoperative doses due to the presence of the jejunum within the field were not made. This retrospective study analyzes the outcome of these patients with attention to survival, local-regional control, and complications. METHODS: Twenty-seven of the 29 study patients had squamous cell carcinoma of the larynx or pharynx; 24 of these patients had Stage III or Stage IV disease. Two patients had recurrent papillary thyroid carcinoma. The median number of days from surgery to the start of radiation was 34. Radiation doses to the tumor bed ranged from 50 Gy to 72 Gy. The median doses to the tumor bed and the jejunal autograft were both 63 Gy. Surviving patients were followed from 12 to 68 months (median, 20 months) from the time of their surgery. RESULTS: The actuarial 2-year survival rate was 51%. Nine patients had local or regional recurrences above the clavicles. The 2-year local-regional control and freedom from relapse rates were 71 and 50%, respectively. The most severe complication during radiation was confluent mucositis in greater than 50% of the treated area, which developed in two patients. No patient developed a late complication related to the jejunal autograft. CONCLUSIONS: Postoperative radiation to free jejunal autografts used for pharyngeal reconstruction can be delivered safely. Doses in this setting of 57.6 Gy to 63 Gy depending on the anticipated risk of recurrence based on clinical, surgical, and pathologic findings are recommended. The presence of a free jejunal autograft did not require a reduction of the desired doses used for patients with postoperatively irradiated head and neck cancer.

Actuarial Analysis↗
PubMed1995

Microvascular craniofacial reconstruction in cancer patients.

BACKGROUND: Resections of large malignancies involving the middle and upper thirds of the face and cranium result in complex defects, posing a difficult challenge for the reconstructive surgeon. Free tissue transfer may be the best means of reconstruction. METHODS: We reviewed 54 consecutive microvascular craniofacial reconstructions after tumor ablation performed at the University of Texas M.D. Anderson Cancer Center from May 1988 to September 1992. Information regarding patient characteristics, tumor stage and histology, history of prior therapy, the defect after tumor ablation, and the details of the reconstruction were entered in a microcomputer database at the time of the initial surgery. Free flap outcome, the number and type of complications, control of malignant disease, and the use of adjuvant therapy were recorded prospectively. RESULTS: Patients had defects of the scalp and cranium (15 of 50) or of the maxilla/orbit/cranial base (35 of 50) after resections for a variety of tumors. Immediate reconstruction was completed in 40 patients and delayed in 10. Prior therapy included surgery (39 of 50) and/or radiotherapy (35 of 50). The free flap success rate was 96% (52 of 54). In patients with successful flaps, significant wound complications occurred in 13.5% of patients (seven of 52) and donor site problems in 11.1% (six of 54) for an overall complication rate of 24.1% (13 of 54). There were no operative deaths or neurologic complications. The timing of surgery or a history of prior surgical therapy or radiotherapy did not significantly influence the complication rates. CONCLUSION: Free tissue transfers provide optimal restoration of large craniofacial defects resulting from cancer resection.

Combined Modality Therapy↗
PubMed1995

Perineal wound closure with the rectus abdominis musculocutaneous flap after tumor ablation.

BACKGROUND: We describe the transpelvic rectus abdominis musculocutaneous flap for closing large, often irradiated, perineal defects in patients with cancer. METHODS: We studied 9 men and 17 women who underwent wide excision of advanced T3 and T4 tumors and who had preoperative chemotherapy, radiotherapy, or both. After tumor ablation, we used a transpelvic rectus abdominis musculocutaneous flap to fill pelvic dead space and primarily close the perineal wounds. Twelve simultaneous vaginal reconstructions were performed. RESULTS: Wounds healed promptly in 14 patients. Healing was delayed in the remaining 12 patients due to poor flap adherence to irradiated tissue beds (9), complete flap loss (2), or partial flap loss (1). Delayed healing was associated with the combination of obesity and prior irradiation. Other perioperative complications included localized abdominal wound infection (2), enterocutaneous fistula (1), and abdominal herniation (1). Local disease was controlled in 20 of 26 patients. Mean follow-up was 22 months. CONCLUSION: Transpelvic rotation of the rectus abdominis musculocutaneous flap facilitates healing large, difficult, perineal wounds, resulting from cancer ablation.

Adult↗
PubMed1995

Closure of massive chest wall defects after full-thickness chest wall resection.

We report an unusual repair of a massive chest wall defect resulting from resection of a chronic ulcer after radiation therapy for stage IV breast carcinoma. The defect was 690 cm2 and included the body of the sternum, 10 ribs, and the anterior portion of the diaphragm. Chest wall reconstruction was accomplished with multiple flaps: a pectoralis major advancement flap, a reversed abdominoplasty, an omental flap, and a latissimus dorsiscapular-parascapular musculofasciocutaneous (hemiback) flap. Skeletal reconstruction with prosthetic material or bone grafts was not performed in this patient. The problems associated with complex chest wall reconstructions are discussed.

Aged↗
PubMed1995

Lateral thigh free flap in head and neck reconstruction.

To understand the role of the lateral thigh flap in head and neck reconstruction, we performed injection studies and anatomic dissections in 2 fresh and 61 preserved cadaver extremities followed by 10 clinical cases involving defects after tumor ablation. The flap, based on the third perforator of the profunda femoris artery, is designed on the posterolateral aspect of the distal thigh. The pedicle courses through the biceps short head, allowing optional transfer of this muscle. Defects of the oral cavity, pharynx, cervical esophagus, and external skin were successfully restored. One flap was unsuccessful because of intraoperative injury to the vascular pedicle. Compared with the radial forearm flap, the lateral thigh flap provides more tissue and the donor scar is more easily hidden, but the vascular pedicle is shorter, of smaller caliber, and more variable. The lateral thigh flap provides thin, pliable, and reliable tissue for a variety of needs in properly selected patients.

Adult↗