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Biomedical subjects

M A Schusterman

Publications and source records attributed to M A Schusterman.

At least 55 records · Page 3Linked to original sources
PubMed1994

Immediate versus delayed free-tissue transfer salvage of the lower extremity in soft tissue sarcoma patients.

BACKGROUND: Free tissue transfer (FTT) can extend the limits of limb salvage in patients with soft tissue sarcoma (STS), but few data exist on the efficacy and morbidity in this patient population. METHODS: We prospectively examined 19 patients who underwent resection of STS and an immediate or a delayed FTT reconstruction between November 1989 and May 1992. RESULTS: There were 11 immediate and eight delayed FTT reconstructions (mean age 52 years). All delayed patients presented with complications resulting from previous STS treatment. Defects involved the leg (n = 7), knee (n = 2), and thigh (n = 10) and had a mean size of 129 cm2, 154 cm2, and 283 cm2, respectively. Preoperative radiatiotherapy had been administered to 74% of patients in the series (mean dose 53 Gy). FTT success rate was 95% (one failure in the delayed group). Limb salvage and postreconstruction ambulatory rates were both 95%. The overall complication rate was 47%, with the trend of a higher rate (63%) in the delayed group compared with the immediate group (36%). The immediate reconstruction group required no additional operative procedures before FTT and had a shorter hospital stay (13 days) compared with that of the delayed reconstruction group (40.6 days). Mean follow-up was 11.9 months (range 2-30). CONCLUSIONS: FTT is a reliable and versatile adjunctive treatment for lower extremity salvage of patients with STS. Immediate reconstruction appears to carry a lower complication rate and a faster rehabilitation for the patient.

Female↗
PubMed1994

Rationale for elective contralateral mastectomy with immediate bilateral reconstruction.

BACKGROUND: Women with breast cancer treated by mastectomy with immediate breast reconstruction can get exceptionally good results if the reconstruction is performed with autogenous tissue using the transverse rectus abdominis myocutaneous (TRAM) flap. Bilateral reconstruction with TRAM flaps is also possible, but only if both breasts are reconstructed at the same time. To avoid the possibility of subsequently developing contralateral malignancy and having to undergo assymetrical reconstruction with a different technique, some patients have chosen the alternative of bilateral mastectomy with bilateral immediate reconstruction. This is only reasonable if the incidence of failure in bilateral breast reconstruction is very low. METHODS: We prospectively studied reconstructive outcomes in 100 patients who had breast cancer and who underwent bilateral mastectomy and reconstruction (using implants as well as TRAM flaps). We also reviewed the histologic findings in 88 prophylactically removed high-risk breasts. RESULTS: Successful outcomes were initially achieved in 95 patients; of the 5 failures, two were successfully reconstructed with alternative techniques for an overall success rate of 97%. Of the 63 patients reconstructed with bilateral TRAM flaps, all but one (98%) were successful on the first try. TRAM flap reconstructions were significantly more likely to be successful than were those based on implants (p = 0.05). Previously unsuspected invasive cancer was found in 3 patients (3.4%), whereas carcinoma in situ was found in 5 patients (5.7%) and in another 18 patients (20%) cellular atypia was present. CONCLUSIONS: Bilateral breast reconstruction has a low incidence of failure, particularly if TRAM flaps are used. For selected patients, elective contralateral mastectomy with immediate bilateral reconstruction is a reasonable treatment alternative provided that the necessary expertise is available and the patients clearly understand the risks.

Adult↗
PubMed1994

The radial forearm free flap for head and neck reconstruction: a review.

BACKGROUND: The radial forearm free flap has become a workhorse flap in head and neck reconstruction. Its lack of bulk, ease of dissection, vascularity, and malleability are among its many advantages. PATIENTS AND METHODS: A review of 157 radial forearm free flaps performed in 155 patients between March 1988 and June 1994 at The University of Texas M.D. Anderson Cancer Center was undertaken to determine outcome. Patient age ranged from 22 to 80 years (mean 56). There were 79 men and 76 women. Follow-up ranged from 2 to 75 months. The most prevalent neoplasm was squamous cell carcinoma (n = 129). RESULTS: The most frequent tumor staging was T3, N0, M0. Various defects were observed; however, those requiring floor-of-mouth coverage were most common (n = 95). Partial or segmental mandibular resection was seen in 42. An osseous component was included in the radial forearm flap in 9 patients, and 64 patients had undergone some form of previous tumor resection. Fifty-seven patients received preoperative irradiation and 52, postoperative. The internal jugular vein (n = 131) and the external carotid artery (n = 134) were the most frequent recipient sites for microvascular anastomosis. Vein grafts were needed in 4 cases, and end-to-side anastomoses were most commonly performed. Total flap loss occurred in 7 cases (4.5%) and partial flap loss in 1 (0.6%). For total flap loss, salvage was accomplished by a second radial forearm free flap in 2 cases and alternative rotational flaps in 5. Other complications (infection, hematoma, fistula formation, etc.) were seen in 34%. Donor-site difficulties were seen in 21 cases. CONCLUSION: The radial forearm free flap offers a variety of reconstructive options for the head and neck. Its low flap loss and complication rates offer the best choice for oral lining restoration if bulk is not required.

Adult↗
PubMed1994

Morbidity associated with free-tissue transfer after radiotherapy and chemotherapy in elderly cancer patients.

Because of their ages and associated medical problems, many elderly cancer patients are treated with radiotherapy and/or chemotherapy to avoid the increased morbidity perceived to occur with prolonged surgical procedures such as tumor resection and reconstruction with free tissue transfer (FTT). The failure of such therapy still often requires tumor resection and reconstruction in irradiated tissue, which may add to the morbidity of surgery. To determine the validity of these concerns, 66 elderly cancer patients who underwent tumor resection and FTT after previous radiotherapy and/or chemotherapy (PT) were compared to a similar group of 64 elderly patients who had not received such previous therapy (NPT). Despite the two groups having similar patient traits, reconstructive-site characteristics, types of flaps used, medical risk factors, and time variables, there were no statistically significant differences between groups for FTT failure (PT3 percent, NPT 6 percent), medical complication rate (PT 16 percent, NPT 27 percent), surgical complication rate (PT 41 percent, NPT 49 percent), or wound-healing problems. The perioperative mortality rate was 2 percent. The authors conclude, that when medical problems are appropriately corrected before surgery, FTT may be safely performed in elderly patients with a high degree of success, acceptable morbidity, and low mortality. Previous cancer treatment does not appear to predispose elderly patients to a higher rate of FTT failure or wound-healing problems after FTT reconstruction.

Aged↗
PubMed1994

The free transverse rectus abdominis musculocutaneous flap for breast reconstruction: one center's experience with 211 consecutive cases.

All patients undergoing breast reconstruction with free transverse rectus abdominis musculocutaneous (TRAM) flaps from February 1989 to November 1992 were registered into a computerized database and followed prospectively. There were 211 free TRAM flap breast reconstructions in 163 patients; 48 reconstructions were bilateral. A muscle split technique was used in 108 of 211 reconstructions (51%). Total flap loss occurred in 3 of 211 reconstructions for a success rate of 99%. Complications occurred in 81 of 211 reconstructions (38%). Fat necrosis or partial flap loss occurred in 15 of 211 (7%). Hernia or bulge occurred in 11 patients (5%). The bulge/hernia rate tended to be lower in the muscle split group (4 of 108 [4%]) than in those who did not have muscle split procedures (7 of 103 [7%]), whereas the fat necrosis rate was slightly higher in the former group (9 of 108 [8%]) than in the latter (6 of 103 [6%]). Neither difference was statistically significant. However, patients who currently or previously smoked cigarettes did have a significantly higher incidence of fat necrosis: 12 of 99 smokers (12%) had fat necrosis compared with 3 of 112 nonsmokers (3%; p = 0.02).

Adult↗
PubMed1994

Reconstruction of the pharynx and cervical esophagus using free jejunal transfer.

Although FJT has been perceived as unreliable, current FJT survival rates of 94% or greater, FJT salvage rates of up to 100%, and perioperative mortality of 6% or less demonstrate that FJT is a safe, reliable, one-stage method of reconstructing partial and circumferential pharyngoesophageal defects. FJT is associated with some morbidity; however, the procedure is well tolerated, and swallowing function is restored in 80% or more of patients within an average of 9 to 12 days after surgery. The success of the technique requires careful attention to details, such as designing the flap to avoid vein grafts, selecting large recipient vessels with high blood flow, careful in setting of the flap, meticulous microvascular anastomotic technique, close postoperative monitoring, and early, aggressive treatment of infection. If FJT failure should occur, a repeat FJT should be performed in the immediate postoperative period to increase the possibility of salvage and to decrease the risk of infection and mortality.

Esophagus↗
PubMed1994

Breast reconstruction with myocutaneous flaps in previously irradiated patients.

Breast reconstructions performed with latissimus dorsi and transverse rectus abdominis myocutaneous (TRAM) flaps in 82 patients with a history of previous chest-wall irradiation were compared with similar reconstructions in 202 nonirradiated patients to determine whether prior irradiation was associated with more frequent complications and to determine the success rate of breast reconstruction using distant flaps in irradiated patients. The mean dose of radiation administered was 5637 cGy. Complications in the reconstructed breast were more frequent in the irradiated patients (39 percent) than in the nonirradiated patients (25 percent; p = 0.03). In the irradiated group, breast complications were more common in reconstructions performed with the latissimus dorsi flap (63 percent) than in those performed with the TRAM flap (33 percent; p = 0.063). Aesthetic outcomes also were slightly poorer in the irradiated patients. Although complications were more common and aesthetic outcomes not as good in previously irradiated patients, we do not consider such irradiation to be a contraindication to breast reconstruction.

Abdominal Muscles↗
PubMed1994

A single center's experience with 308 free flaps for repair of head and neck cancer defects.

Since its inception at our institution in 1988, microvascular reconstructive surgery has become an integral part of the treatment of head and neck cancer patients. This review of 308 free flaps performed over the last 4 years was done to evaluate the complication and flap loss rates and to investigate which factors may contribute to these rates. The overall complication rate was 36.1 percent, the vessel thrombosis rate was 6.8 percent, the flap loss rate was 5.5 percent, and the flap salvage rate was 19.0 percent. Multifactorial analysis of delayed reconstruction, tobacco use, alcohol consumption, previous radiation therapy, previous surgery, and use of vein grafts showed that only previous surgery and the use of vein grafts led to significantly higher rates of flap loss (p < 0.01 for both).

Adolescent↗
PubMed1994

Bilateral breast reconstruction: conventional versus free TRAM.

Free TRAM flap transfer is now routinely offered to patients requiring breast reconstruction. This study compares results of conventional superior-pedicled TRAM flaps and free TRAM flaps in bilateral breast reconstructions. A total of 92 breasts were reconstructed in 46 patients. Eighteen patients had free TRAM flap reconstructions, and 28 patients were reconstructed with conventional TRAM flaps. Comparison of average operative blood loss and average operative time for the two techniques showed blood loss of 575 cc and an operative time of 9.6 hours for the free TRAM reconstructions and a blood loss of 313 cc and an operative time of 6.6 hours for the conventional TRAM reconstructions. For free TRAM flap reconstructions, both blood loss and operative time decreased significantly between the first and second group of nine patients: from 819 to 360 cc of blood loss and from 10.5 to 8.9 hours of operative time. Partial flap loss (skin and fat necrosis) and fat necrosis only occurred in 13 and 7 percent, respectively, of conventional TRAM flaps, but neither occurred in free TRAM flaps. However, early in the series, three free flaps were lost in two patients, requiring implant placement. Bilateral breast reconstruction using the free TRAM flap may offer a lower complication rate than the conventional TRAM flap by virtue of improved blood supply and less abdominal wall disruption. Surgeons, however, are forewarned that this procedure has a steep learning curve, and surgeons lacking microsurgical expertise may be better served by the conventional TRAM flap.

Blood Loss, Surgical↗
PubMed1993

Influence of prior radiotherapy on the development of postoperative complications and success of free tissue transfers in head and neck cancer reconstruction.

The purpose of this study was to determine whether prior radiotherapy had any effect on the development of postoperative complications in patients undergoing microvascular tissue transfers for reconstruction of head and neck cancer. A prospective database was used to review 354 consecutive patients who had a total of 368 free tissue transfers limited to the head and neck during the 4-year period from July 1988 to June 1992. Postoperative complications in 167 patients who received preoperative radiotherapy (XRT) were compared with those of 187 patients who did not undergo radiotherapy preoperatively (NR). No statistical differences in complications or flap loss between the two groups were noted using the chi 2 test or Fisher's exact test (p > 0.2). Total flap loss occurred in 5.3% of the XRT group (9 of 169) and 5.0% of the NR patient group (10 of 199), and partial flap loss occurred in 4.1% of the irradiated patients and 2.5% of the nonirradiated patients. Major wound complications requiring additional surgery occurred in 16% of the XRT group and 11% of the NR group. Minor wound complications that did not require further surgery occurred in 21% of the irradiated patients and 18% of the nonirradiated patients. No significant difference in the timing or dose of preoperative radiation, previous neck dissection, or anastomotic type could be documented in failed versus successful flaps (two-tailed t-test, p > 0.80, and chi 2, p > 0.2). Our results show that, in a large group of cancer patients undergoing free tissue transfers to the head and neck, prior radiotherapy or surgery did not predispose them to a higher rate of acute flap loss or wound complications than their nonirradiated cohorts.

Adolescent↗
PubMed1993

Osseous free flaps for orbit and midface reconstruction.

Osseous free flaps were used for reconstruction of the orbit and midface in 10 patients. The reconstruction was done at the time of tumor resection in two patients (20%) and secondarily in eight patients (80%). Nine patients (90%) had previously received radiotherapy. The flaps used were fibula (four), radial forearm (two), scapula (two), and split iliac crest (two). Flap loss occurred in one patient. Complications occurred in 2 of 10 (20%) patients. The results were classified as good in seven patients, fair in two, and poor in one. The patient classified as having a poor result was the one who sustained the flap loss; he refused further surgery. Reconstruction was directed to the maxilla in five patients, the orbit in two, and both in three. The radial forearm flap was best used for orbit-only reconstruction because of the small amount of bone required. The fibula, iliac crest, and scapula were best used for larger defects involving the maxilla. Osseointegrated dental implants were used successfully in three patients. Osseous free flaps are indicated for midface reconstruction when bony support is needed and previous irradiation prevents the use of nonvascularized grafts.

Adolescent↗
PubMed1993

Interposition vein grafting in head and neck reconstructive microsurgery.

To characterize the role of interposition vein grafts, and to determine whether their use significantly influences the success of free tissue transfers in head and neck cancer reconstruction, we reviewed 191 consecutive cases with defects involving the aero-digestive tract soft tissues (80), the mandible (75), craniofacial resections (25), or cutaneous coverage (11). One hundred twenty patients had received prior loco-regional therapy, including 63 patients with recurrent lesions. Interposition vein grafts were used for the artery (11), vein (3), or both (3) in a total of 17 cases. The overall technical success rate was 93.2 percent (178/191). Cases in which vein grafts were used had a significantly (p < 0.001) lower success rate, 70.6 percent (12/17), than those without vein grafts, 95 percent (166/175). Grafts were most often used in patients who had received prior therapy (13/17). The use of vein grafts was associated with a significantly higher incidence of flap failure in head and neck cancer reconstruction; however, a causal relationship is not suggested.

Adult↗
PubMed1993

Incidence of autoimmune disease in patients after breast reconstruction with silicone gel implants versus autogenous tissue: a preliminary report.

OBJECTIVE: To test the hypothesis that there is a higher incidence of autoimmune disorders in patients who have undergone breast reconstruction with silicone gel implants rather than autogenous tissue. DESIGN: Prospective study. SETTING: Tertiary referral center dealing exclusively with cancer. PATIENTS: All female breast cancer patients who underwent breast reconstruction between January 1986 and March 1992. Patients were nonrandomly assigned to breast reconstruction with one of the following four methods: (1) silicone gel implant only, (2) latissimus dorsi flap with implant, (3) latissimus dorsi flap without implant, and (4) transverse rectus abdominis flap. The first two groups made up the implant cohort and the last two groups the autogenous tissue cohort. Selection of reconstructive method was made on clinical grounds and was based on both physician and patient preference. MAIN OUTCOME MEASURES: Documented diagnosis of autoimmune disorder by Board-certified rheumatologist. RESULTS: Three hundred eight implants were used in 250 patients, and 408 reconstructions with tissue were performed on 353 patients. The two groups were similar in age and tumor stage. The two groups contributed 615.8 and 663.4 person-years of follow-up, respectively. One patient from each group (< 0.5%) had a documented occurrence of an autoimmune syndrome requiring therapy. Both cases were considered mild, and after initial low-dose steroid therapy, both patients are now off steroids. CONCLUSION: The incidence of autoimmune disease in mastectomy patients receiving silicone gel implants is not different than in patients who had reconstruction with autogenous tissue.

Adult↗
PubMed1992

13-cis-retinoic acid and interferon alpha-2a: effective combination therapy for advanced squamous cell carcinoma of the skin.

BACKGROUND: Retinoids (vitamin A derivatives) and interferon-alpha (IFN-alpha) are potent regulators of malignant cell differentiation and proliferation, and both have immunomodulatory and antiangiogenesis activity. A large body of preclinical and clinical data supports the use of combination therapy with 13-cis-retinoic acid (13-cRA) and IFN-alpha in patients with squamous cell carcinoma of the skin. This carcinoma is an extremely common and frequently severely disfiguring cancer, for which about 10% of patients remain uncured following standard local therapy. PURPOSE: Our purpose was to test whether a 20% or greater complete response rate could be achieved using a combination of these two agents in patients with advanced squamous cell carcinoma of the skin in whom local therapy had failed or was unfeasible or who had regional and/or distant metastases. METHODS: Thirty-two patients with heavily pretreated, advanced inoperable cutaneous squamous cell carcinoma of the skin were given a combination of oral 13-cRA (1 mg/kg per day) and subcutaneous recombinant human IFN alpha-2a (3 million units per day) for at least 2 months, unless disease progressed earlier, in a phase II trial. RESULTS: Nineteen (68%) of the 28 assessable patients responded, seven (25%) of whom had complete responses. Response rates were 93% (13 of 14) in patients with advanced local disease (six complete responses), 67% (four of six) in patients with regional disease (no complete responses), and 25% (two of eight) in patients with distant metastases (one complete response). The relationship between decreased response rate and increased extent of disease was highly statistically significant (P less than .005, chi-square test). The median response duration was greater than 5 months. No life-threatening toxic effects occurred in assessable patients treated with this combination, although dose reductions were required in 18 patients. The major limiting side effect in this elderly patient population (median age, 67 years) was cumulative fatigue. CONCLUSION: These results indicate that combined systemic therapy with 13-cRA and IFN alpha-2a is highly effective in patients with advanced squamous cell carcinoma of the skin.

Aged↗
PubMed1992

Comparison of the rectus abdominis free flap with the pectoralis major myocutaneous flap for reconstructions in the head and neck.

The pectoralis major myocutaneous flap (PMMF) is often used in the reconstruction of large head and neck defects. Unfortunately, its use is associated with a high incidence of minor complications, can distort the contour of the neck, and may cause significant donor site deformity, especially in women. This study compared 30 patients with major head and neck cancer-related defects who underwent reconstruction with a rectus abdominis free flap (RAFF) with 39 patients with similar defects who underwent reconstruction with the PMMF. The complication rate found in the RAFF group (13%) was significantly lower than that found in the PMMF group (44%; p = 0.0145). Flap necrosis was found in 10% of the PMMF group, whereas none was found in the RAFF group. The aesthetic outcome was also better in patients who had reconstructions with the RAFF. We conclude that, for most major head and neck defects, reconstruction methods that utilize the RAFF and other free tissue transfer techniques are preferable when the requisite equipment and expertise are available.

Abdominal Muscles↗
PubMed1992

Costs and complications in mandibular reconstruction.

Because of increasing concerns about the high cost of complex medical care, we compared the combined cost of ablation and reconstruction incurred using five different management strategies for patients undergoing mandibular resection. We also compared the rates of complication and failure for the methods used. The records of 69 patients undergoing segmental or total mandibulectomy between January 1, 1986, and June 30, 1990, were reviewed. Of these, 15 had reconstruction with soft tissue only (average cost, $36,137; complication rate, 33%), whereas 20 had immediate reconstruction with vascularized bone (average cost, $46,894; complication rate, 50%), and 15 had reconstruction with only a metal plate (average cost, $47,678; complication rate, 73%). Nine patients had plate reconstructions initially but subsequently underwent reconstructions with bone (average cost, $54,346; complication rate, 78%), whereas 10 patients had no initial reconstruction but subsequently underwent delayed reconstruction with bone (average cost, $52,486; complication rate, 70%). If reconstruction was performed with bone, immediate reconstruction was more cost effective than delayed reconstruction and had a lower complication rate as well.

Adult↗