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PubMed2005

Two-phase reconstruction for the assessment of left ventricular volume and function using retrospective ECG-gated MDCT: comparison with echocardiography.

OBJECTIVE: The aims of our study were to investigate the clinical feasibility of a two-phase reconstruction method based on ECG to evaluate left ventricular (LV) volume and function using cardiac MDCT and to compare these results with those from echocardiography. SUBJECTS AND METHODS: The LV end-diastolic and end-systolic volumes, stroke volume, and ejection fraction were measured using two different methods of cardiac MDCT in 19 patients who had undergone cardiac MDCT and echocardiography. The first was a two-phase reconstruction method based on retrospective ECG-triggering: The end-systolic phase was reconstructed when the reconstruction window was located halfway in the ascending T wave on ECG, and the end-diastolic phase was reconstructed when the reconstruction window was located at the starting point of the QRS complex on ECG. The second was a multiphase reconstruction method: 20 series of images were reconstructed at every 5% throughout the cardiac cycle. The LV volumes and function determined by the two reconstruction methods were compared. The results measured by cardiac MDCT were compared with those obtained by echocardiography. RESULTS: The LV end-diastolic and end-systolic volumes, stroke volume, and ejection fraction measured by the two-phase reconstruction method correlated well with those measured by the multiphase reconstruction method (r = 0.984, 0.978, 0.969, 0.969, respectively). There were no significant differences between the results of the two different reconstruction methods (p > 0.05). The LV volumes showed moderate to good correlation between cardiac MDCT and echocardiography (0.766 < r < 0.940). Ejection fraction measured by cardiac MDCT yielded a significant overestimation of 2.9% +/- 8.7% (mean +/- SD) compared with that measured by echocardiography. CONCLUSION: A two-phase reconstruction method on cardiac MDCT is relatively simple and can provide an objective standard for reconstructing the appropriate image sets for end-diastole and end-systole without the need to review serial preview images.

Adult↗

PubMed2003

[Radiotherapy and breast reconstruction: the issue of compatibility].

BACKGROUND: Breast reconstruction after mastectomy represents an improvement in the quality of life of breast cancer patients. Radiotherapy is also suggested for many of them to prevent local relapse. However, irradiation increases the risk of complications require surgical procedures. PURPOSE: This study was undertaken to analyse the compatibility of breast reconstruction and irradiation in the treatment of breast cancer. METHODS: Computerised searches for publications debating this issue were done of MEDLINE data. Studies were grouped according to the techniques and types of reconstruction: reconstruction with silicone implant or autogenous skin-muscle flap, timing of reconstruction (immediate or delayed), and sequencing of treatments (pre- or post-reconstruction irradiation). The results of studies were assessed and compared in respect to reconstruction related chronic complications. RESULTS: The incidence of complications was significant even in the absence of irradiation, but radiotherapy increased the risk of complications to less or more extent. When reconstruction was done with implant, the most common type of complication was Grade III-IV capsular contracture. In patients subjected to immediate reconstruction, the complication rates with or without radiotherapy were from 0% to 64% and from 0% to 12%, respectively. In women who underwent delayed reconstruction, the incidence of complications with or without irradiation was from 22% to 55%, and from 17% to 34%, respectively. The negative effect of radiotherapy was more significant with immediate than with delayed reconstruction. In patients who underwent reconstruction with skin-muscle flaps, the most common type of complication was skin necrosis. The incidence of complications with or without radiotherapy was from 12% to 39% and from 5% to 25%, respectively. Cancer, developing after cosmetic augmentation mammaplasty in the breast, can be treated with lumpectomy and radiotherapy without removal of the implant. In series with this method of treatment the incidence of complications (mainly capsular contracture) was from 0% to 65%. The use of moderate dose (45-50 Gy), wedge filters, and no use of bolus application decreased the risk of complications. CONCLUSIONS: Radiotherapy and breast reconstruction are not incompatible, but careful consideration of their relative timing and technique is important. Plastic surgeons should counsel patients before starting their cancer disease treatment, and those who choose to have reconstruction need to be informed about risks for specific complications associated with the procedure. Results of the studies debating this issue are controversial. Longer follow-up time, larger patient material and better specified parameters are needed to validate results.

Breast Implants↗

PubMed2006

Image reconstruction using filtered backprojection and iterative method: effect on motion artifacts in myocardial perfusion SPECT.

UNLABELLED: Patient motion during myocardial perfusion SPECT is a common source of errors. The extent and severity of motion artifacts have been described for filtered backprojection (FBP) reconstruction. In recent years, iterative reconstruction has been used increasingly in reconstruction of myocardial perfusion SPECT images and has been shown to be more accurate than FBP even in cases of incomplete datasets. This study evaluated the effect of iterative reconstruction on the extent and severity of motion artifacts. METHODS: Six normal, motion-free, and nongated (99m)Tc myocardial perfusion SPECT scans were selected, and simulated motion of 3 pixels was applied to the early, middle, and late phases of acquisition in 2 types of movement, returning and nonreturning. The images were acquired by a single-head gamma-camera in 32 steps at 30 s per step and in a 180 degrees arc from right anterior oblique to left posterior oblique. All original and shifted images were reconstructed using FBP and ordered-subset expectation maximization (OSEM) techniques and interpreted by 2 nuclear medicine specialists qualitatively and semiquantitatively (using 17 segments and a 5-point scoring system). RESULTS: Overall, 68.1% and 70.8% of shifted images were categorized as definitely abnormal in the FBP and OSEM reconstructions, respectively (P > 0.5). The mean summed score was 11.9 (+/-5.7) and 11.3 (+/-5.2) for nonreturning shifted images (P = 0.13) and 5.2 (+/-2.4) and 3.9 (+/-2.0) for returning shifted images (P < 0.001) in the OSEM and FBP reconstructions, respectively. The incidence of defects in different myocardial segments was similar with the 2 reconstruction methods. The summed score was higher with shifting in the middle phase of acquisition than in the late or early phase. CONCLUSION: Our study showed that the incidence of abnormal findings and the location of defects were not different between the 2 reconstruction types; however, with semiquantitative assessment, the severity of defects increased with OSEM reconstruction. Although OSEM reconstruction has been reported to be more tolerant to missing data than is FBP reconstruction, our study showed that OSEM reconstruction may be less tolerant to motion artifacts than is FBP reconstruction.

Algorithms↗

PubMedDate not supplied

Microvascular reconstruction of the breast.

The growth of microsurgical procedures has led to significant technological, scientific, and clinical advances that have made these procedures safe, reliable, reproducible, and routine in most major medical centers. In many instances, free flap reconstruction has become the primary reconstructive method for many major defects, including breast reconstruction. The advantages of free flap breast reconstruction include better flap vascularity, broader patient selection, easier insetting of the flap, and decreased donor site morbidity. Free flap breast reconstruction can occur either at the time that the mastectomy is performed or as a delayed reconstruction following a previous mastectomy. Immediate reconstructions have the advantage of avoiding scar contracture and fibrosis within the mastectomy flaps and at the recipient vessel site. The most common recipient vessel sites are the thoracodorsal vessels and the internal mammary vessels. The thoracodorsal vessels are most frequently used in immediate reconstruction because they are partially exposed during the mastectomy procedure. The internal mammary vessels are used more frequently in delayed reconstructions, to avoid repeat surgery in the axilla. This recipient site also allows more medial placement of the reconstruction. Flap selections for free autogenous breast reconstruction include the transverse rectus abdominis myocutaneous (TRAM) flap, the superior gluteal myocutaneous flap, the inferior gluteal myocutaneous flap, the lateral thigh flap, and the deep circumflex iliac soft tissue flap (Rubens). The TRAM flap is most commonly used in free flap breast reconstruction. For patients with inadequate abdominal tissue or prior abdominal surgery, the superior gluteal flap is typically used. Both the TRAM flap and the superior gluteal flap can be designed as perforator flaps, preserving all of the involved muscle and, in the TRAM perforator, all the rectus fascia. These flaps are more technically demanding, with minimal impact on donor site function. The other flaps are less frequently used and limited to special patient circumstances. Free flap autogenous breast reconstruction provides a natural, long-lasting result with a high degree of patient satisfaction. Semin. Surg. Oncol. 19:264-271, 2000.

Breast↗

PubMed2003

Anterior cranial base reconstruction using free tissue transfer: changing trends.

INTRODUCTION: A consecutive series of 135 patients undergoing resection for malignant tumors involving the anterior cranial base between 1976 and 1999 was reviewed. PATIENT AND METHODS: In the years from 1976-1991, free-tissue transfer was used in 5 of 76 or 6.6% of cases, whereas free-tissue reconstruction was used in 24 of 59 or 40% of cases in the years 1992-1999. Of those cases reconstructed with free-tissue transfer in 1976-1991, 60% (three of five) underwent a complex resection defined as involving dura, brain, or more than one major structure adjacent to skull base. Of those patients reconstructed with conventional (pericranial or pericranial/galeal) pedicled flaps in this time period, 35% (25 of 71) underwent a complex resection. From 1992-1999, 75% (18 of 24) of patients reconstructed with free-tissue transfer received a complex resection, whereas only 6% (2 of 35) of patients reconstructed by other means received a complex resection. OUTCOMES: For those patients reconstructed by free-tissue transfer, there were no instances of flap loss. Comparison of these two time periods was notable for a similar patient composition in terms of age, histologic findings, and extent of resection. Major complication rates for patients who are reconstructed with free-tissue transfer for anterior cranial base resections (31%) are similar compared with patients who have been reconstructed with conventional pedicled flaps (35%). This was noted despite an increased extent and complexity of resection in those patients who underwent free-tissue transfer reconstruction (72%) compared with those patients reconstructed by more conventional means (26%) p <.001. CONCLUSION: In our institution, the use of vascularized, free-tissue transfer has replaced pedicled flaps as the preferred modality for reconstructing complex anterior cranial base defects involving resection of dura, brain, or multiple major structures adjacent to local skull base, including the orbit, palate, and other structures. Complication rates for patients reconstructed with free-tissue transfer techniques is similar to those patients reconstructed by conventional techniques, despite an increase in complexity of resection in this group.

Adolescent↗

PubMed2006

The effect of graft tensioning in anatomic 2-bundle ACL reconstruction on knee joint kinematics.

Recently, double bundle ACL reconstruction, in which the two bundles thought to have different effects on knee kinematics are reconstructed separately, is widely believed to more favorably restore normal knee kinematics than conventional single bundle ACL reconstruction. However, rotational kinematics during physiological movement after double bundle reconstruction has rarely been tested. The purpose of this study was to measure the kinematics of the ACL deficient and reconstructed knees using two different tensioning conditions in double bundle reconstruction, and to examine the effects of each graft on knee kinematics. Six cadaveric knees were used. Six degrees-of-freedom of knee kinematics and the tension of each graft were monitored during simulated knee extension with the ACL intact, resected, and reconstructed under two different tensioning conditions: 50 N on anteromedial bundle and 0 N on posterolateral bundle (AM-favored condition); 0 N on anteromedial bundle and 50 N on posterolateral bundle (PL-favored condition). Tibial translation: After ACL reconstruction, the tibia overcorrected posteriorly in both conditions. Such an overcorrection in the AM-favored condition was larger than in the PL-favored condition. Tibial rotation: The tibia was significantly externally rotated after ACL reconstruction at a low flexion angle in both conditions. However, at a high flexion angle, tibial external rotation was shown only in the AM-favored condition. Graft tension: While total tensions were similar between the two conditions, the AM bundle shared more tension in the AM-favored condition than in the PL-favored condition. A total of 50 N of tension force was assumed to be excessive for normalizing knee kinematics at a low flexion angle even if double bundle reconstruction was used. Additionally, the AM-favored tensioning reconstruction made the tibia rotate externally and translate posteriorly even at a high flexion angle. Further research is needed to normalize knee kinematics after ACL reconstruction, however it is recommended that a moderate tensioning force is applied to the PL bundle and a minimal tensioning force to the AM bundle in double bundle reconstruction to obtain better knee kinematics.

Aged↗

PubMed2002

Implementation and evaluation of an ordered subsets reconstruction algorithm for transmission PET studies using median root prior and inter-update median filtering.

An ordered subsets (OS) reconstruction algorithm based on the median root prior (MRP) and inter-update median filtering was implemented for the reconstruction of low count statistics transmission (TR) scans. The OS-MRP-TR algorithm was evaluated using an experimental phantom, simulating positron emission tomography (PET) whole-body (WB) studies, as well as patient data. Various experimental conditions, in terms of TR scan time (from 1 h to 1 min), covering a wide range of TR count statistics were evaluated. The performance of the algorithm was assessed by comparing the mean value of the attenuation coefficient (MVAC) of known tissue types and the coefficient of variation (CV) for low-count TR images, reconstructed with the OS-MRP-TR algorithm, with reference values obtained from high-count TR images reconstructed with a filtered back-projection (FBP) algorithm. The reconstructed OS-MRP-TR images were then used for attenuation correction of the corresponding emission (EM) data. EM images reconstructed with attenuation correction generated by OS-MRP-TR images, of low count statistics, were compared with the EM images corrected for attenuation using reference (high statistics) TR data. In all the experimental situations considered, the OS-MRP-TR algorithm showed: (1) a tendency towards a stable solution in terms of MVAC; (2) a difference in the MVAC of within 5% for a TR scan of 1 min reconstructed with the OS-MRP-TR and a TR scan of 1 h reconstructed with the FBP algorithm; (3) effectiveness in noise reduction, particularly for low count statistics data [using a specific parameter configuration the TR images reconstructed with OS-MRP-TR(1 min) had a lower CV than the corresponding TR images of a 1-h scan reconstructed with the FBP algorithm]; (4) a difference of within 3% between the mean counts in the EM images attenuation corrected using the OS-MRP-TR images of 1 min and the mean counts in the EM images attenuation corrected using the OS-MRP-TR images of 1 h; (5) preservation of "good" image quality for both TR and EM reconstructed images. In conclusion, the OS-MRP-TR algorithm is particularly suitable for WB PET studies, allowing: (1) the acquisition of a very short TR scan (within 1 min), (2) the reconstruction of such TR data in low-noise TR images and (3) the use of the reconstructed OS-MRP-TR images for attenuation correction of corresponding EM data.

Algorithms↗

PubMed2006

Computer-assisted lung nodule volumetry from multi-detector row CT: influence of image reconstruction parameters.

PURPOSE: To investigate differences in volumetric measurement of pulmonary nodules caused by changing the reconstruction parameters for multi-detector row CT. MATERIALS AND METHODS: Thirty-nine pulmonary nodules less than 2 cm in diameter were examined by multi-slice CT. All nodules were solid, and located in the peripheral part of the lungs. The resultant 48 parameters images were reconstructed by changing slice thickness (1.25, 2.5, 3.75, or 5 mm), field of view (FOV: 10, 20, or 30 cm), algorithm (high-spatial frequency algorithm or low-spatial frequency algorithm) and reconstruction interval (reconstruction with 50% overlapping of the reconstructed slices or non-overlapping reconstruction). Volumetric measurements were calculated using commercially available software. The differences between nodule volumes were analyzed by the Kruskal-Wallis test and the Wilcoxon Signed-Ranks test. RESULTS: The diameter of the nodules was 8.7+/-2.7 mm on average, ranging from 4.3 to 16.4mm. Pulmonary nodule volume did not change significantly with changes in slice thickness or FOV (p>0.05), but was significantly larger with the high-spatial frequency algorithm than the low-spatial frequency algorithm (p<0.05), except for one reconstruction parameter. The volumes determined by non-overlapping reconstruction were significantly larger than those of overlapping reconstruction (p<0.05), except for a 1.25 mm thickness with 10 cm FOV with the high-spatial frequency algorithm, and 5mm thickness. The maximum difference in measured volume was 16% on average between the 1.25 mm slice thickness/10 cm FOV/high-spatial frequency algorithm parameters and overlapping reconstruction. CONCLUSION: Volumetric measurements of pulmonary nodules differ with changes in the reconstruction parameters, with a tendency toward larger volumes in high-spatial frequency algorithm and non-overlapping reconstruction compared to the low-spatial frequency algorithm and overlapping reconstruction.

Adolescent↗

PubMed1994

Kansas surgeons' attitudes toward immediate breast reconstruction: a statewide survey.

BACKGROUND: Immediate reconstruction following mastectomy provides patients the benefit of emerging from their operation with a reconstructed breast mound. METHODS: A survey was distributed to 197 Kansas surgeons to determine the frequency of breast reconstruction and to identify factors that may influence them to refer patients for immediate reconstruction. RESULTS: A response of 78.2% was obtained. Ten percent of mastectomy patients had breast reconstruction. Significant findings were that younger surgeons were more likely to discuss reconstruction with all patients and were more likely to preoperatively refer their patients to a plastic surgeon; surgeons in larger communities had more patients who had undergone immediate reconstruction; surgeons who discussed reconstruction with all patients had more patients who underwent immediate reconstruction; and frequency of immediate reconstruction increased along with increased time spent discussing reconstruction preoperatively. CONCLUSION: Our survey indicated that immediate breast reconstruction was rarely performed; however, when it was, a number of factors were correlated. These included the surgeon's age and practice location, attitude toward reconstruction, and time spent preoperatively with patients.

Adult↗

PubMed1994

Unilateral vascular reconstruction for iliac obstructive disease.

PURPOSE: Controversy exists regarding the extent of vascular reconstructive surgery in the presence of unilateral symptomatic iliac obstructive disease. This study reviews the results of unilateral iliac reconstruction, with special emphasis on the need for consecutive contralateral intervention. METHODS: The outcomes of 184 unilateral and 350 aortobilateral reconstructions for obstructive disease performed during the same period were retrospectively analyzed. Treatment allocation was based on hemodynamic parameters. Unilateral reconstruction was performed by a way of a retroperitoneal approach through a pararectal incision and bilateral reconstruction by way of a transperitoneal approach through a midline abdominal incision. RESULTS: Symptom relief, improvement of noninvasively measured parameters, and graft patency were similar after unilateral and bilateral reconstruction. Both groups had a 10-year primary patency rate greater than 80%. There were no differences in morbidity rate, although respiratory complications occurred more often after bilateral reconstruction. Mortality rates were 1.6% after unilateral reconstruction and 4.9% after bilateral reconstruction. Secondary contralateral reconstruction was performed in only 6% of the patients who underwent an initial unilateral operation. CONCLUSIONS: The unilateral vascular reconstruction for iliac obstructive disease is a well-tolerated procedure with an excellent long-term outcome. It is a valuable alternative to conventional aortobilateral reconstruction in carefully selected patients. Prophylactic reconstruction of an asymptomatic iliac stenosis without signs of significant hemodynamic impairment is most often not indicated.

Arteriosclerosis↗

PubMed2003

Assessment of internal orbital reconstructions for pure blowout fractures: cranial bone grafts versus titanium mesh.

PURPOSE: To assess the adequacy of internal orbital reconstruction in pure blowout fractures using either cranial bone grafts or titanium mesh implants. PATIENTS AND METHODS: The preoperative and postoperative true coronal computed tomography (CT) scans of 58 patients with unilateral pure orbital blowout fractures were included in the study. Demographic data and measurements of the pretreatment size of the defects were tabulated. The accuracy of reconstruction was assessed subjectively by 1 surgeon by scoring the position of the implant/graft, repositioning of orbital soft tissues, and assessment of orbital volume using the uninjured side for comparison. The cross-sectional area of the anterior, middle, and posterior regions of the reconstructed defect was statistically compared with the same locations on the uninjured orbits by scanning the CT scans and calculating the number of pixels within the selected CT slices. A comparison of the accuracy of reconstructions for those reconstructed with cranial bone graft and those with titanium mesh was statistically performed using parametric (for subjective analyses) and nonparametric tests (for cross-sectional area data). RESULTS: Thirty-eight cases were classified as fractures of the orbital floor, 4 as isolated medial wall fractures, and 16 as combined floor/medial wall fractures. There was a statistically significant difference in the surgeon's subjective ratings of adequacy of reconstructions between titanium mesh and bone-grafted groups. Orbits reconstructed with titanium mesh were more accurate than those reconstructed with bone (P <.001). Overall, there was no significant difference in cross-sectional areas between the reconstructed and uninjured orbits in the middle and posterior regions of the defects, but the anterior region showed significantly smaller cross-sectional areas in the reconstructed orbits (P <.001). CONCLUSIONS: Although there was great individual variability and both materials could be successfully used, the orbits reconstructed with titanium mesh showed better overall reconstructions than those reconstructed with bone grafts.

Adolescent↗

PubMed2002

Immediate versus delayed free TRAM breast reconstruction: an analysis of perioperative factors and complications.

Immediate breast reconstruction provides superior psychological benefit to the patient compared with delayed reconstruction, and has a financial advantage. Smokers undergoing immediate free TRAM breast reconstruction have a higher incidence of flap necrosis than smokers undergoing delayed free TRAM reconstruction. Whereas the differences in psychological benefit, effects of smoking and cost are well addressed in the literature, the differences in morbidity between immediate and delayed free TRAM breast reconstruction are still unknown. Knowledge of any differences would help to determine the best timing for reconstruction, and would support surgical decision making and preoperative patient advice. We present a retrospective review of 105 consecutive free TRAM breast reconstructions performed in 97 patients (89 unilateral and eight bilateral reconstructions). There were 48 immediate reconstructions and 57 delayed reconstructions. In the immediate-reconstruction group six flaps required revision of the anastomosis, and three flaps (6%) were lost. In the delayed-reconstruction group five flaps required revision of the anastomosis, and only one flap (2%) could not be salvaged. Delayed healing of the chest-wall skin flaps only occurred in immediate reconstructions (16%, P = 0.017).

Adult↗

PubMed1991

Breast reconstruction: systemic factors influencing local complications.

One hundred seven consecutive breast reconstructions in 83 women were retrospectively reviewed. The reconstructions were with subpectoral prostheses, 54 with permanent tissue expanders, 14 with temporary tissue expanders, and 39 with permanent implants. Immediate breast reconstruction was performed in 69 (64%) breasts and delayed breast reconstruction in 38 (36%) breasts. Risk factors for local complication were diabetes, smoking, age older than 60 years, obesity, and hypertension. Technical factors reviewed included timing of reconstruction, type of prosthesis used, and the presence or absence of drains. Women with immediate breast reconstruction sustained a significantly higher complication rate than women with delayed breast reconstruction; however, the majority of these were due to the antecedent mastectomy. Complications due to the reconstruction were not significantly different for women with immediate versus delayed breast reconstruction. Implant loss occurred in 5 women, 4 with immediate and 1 with delayed breast reconstruction (5.8% vs. 2.6%, p approximately 0.47). Diabetes was significant, and smoking and age greater than 60 years approached significance as risk factors for implant loss in women with immediate breast reconstruction (p approximately 0.01, 0.05, and 0.08, respectively). These risk factors also correlated directly with an increasing severity of complication in women with immediate breast reconstruction (r = 0.414, p = 0.06). Technical factors showed no significant effect on implant loss in women with immediate breast reconstruction.

Adult↗

PubMed2002

Reconstruction of the pelvis after tumor resection in children and adolescents.

Thirty patients younger than 19 years with malignant bone tumors of the pelvis were treated by limb salvage surgery between 1970 and 1998. Functional and oncologic results were reviewed retrospectively. In 10 patients the defect was reconstructed by an endoprosthesis and in 20 patients reconstruction by autologous grafts (n = 7), allograft and prosthesis combinations (n = 2), bone cement reconstruction (n = 1), iliosacral arthrodesis (n = 1), modified Girdlestone procedure (n = 3), or resection without reconstruction (n = 6) was done. Three and one-half reoperations per patient were necessary postoperatively after allograft reconstruction, 2.5 reoperations per patient were necessary after endoprosthetic reconstruction, and 0.8 reoperations per patient were necessary after other or no reconstruction. After a mean followup of 52 months (range, 2-241 months), 17 patients were alive, 15 of whom were continuously disease-free, and 13 patients had died of their disease. Functional ratings were 81% after autograft, 73% after allograft, and 60% after endoprosthetic reconstruction. Defect reconstruction varied according to the type of resection. Type I resections were best reconstructed by biologic methods. Endoprosthetic reconstruction after periacetabular resection with the advantage of preservation of a functional hip and body integrity was associated with a high rate of complications and reoperations. Its role compared with allograft reconstruction, modified Girdlestone procedure, or no reconstruction requires additional investigation.

Adolescent↗

PubMed1999

Thoracodorsal vessels as recipient vessels for the free TRAM flap in delayed breast reconstruction.

The internal mammary vessels have been recommended as the first choice recipient vessels for delayed breast reconstruction with the free TRAM flap. This approach has avoided surgery in the previously operated axilla, has required a shorter pedicle length, and has allowed for more medial placement of the TRAM tissue. Frequency of nonusable axillary vessels has been reported at 11 percent, with a 6 percent incidence of flap loss in the delayed reconstructive setting. We reviewed our experience with the thoracodorsal vessels as recipient vessels in delayed free TRAM breast reconstruction to assess more accurately the adequacy of these potential recipient vessels. All patients undergoing delayed TRAM reconstruction were reviewed. Forty-seven of 300 consecutive TRAM procedures were for planned delayed free reconstruction. In seven of the patients (15 percent), the thoracodorsal vessels were found to be inadequate for free reconstruction. A supercharged pedicled TRAM was used for reconstruction in each of these seven patients. Average operating room time was 7 hours. Mean follow-up time was 38 months. Nineteen percent of all patients developed at least one complication. Twelve percent of free TRAM patients developed a complication, whereas 57 percent of supercharged patients developed a postoperative complication. The difference in complication rates was statistically significant. The thoracodorsal vessels have provided an adequate recipient vessel in 85 percent of delayed free TRAM reconstructions, comparable to previous reports. Pedicling and supercharging the flap, in those situations in which the thoracodorsal vessels were inadequate, were associated with an increased incidence of postoperative complications. This suggests that in the delayed reconstructive setting, higher-risk patients benefit from free reconstruction over supercharged reconstructions. A second recipient vessel should be used when the thoracodorsal vessels are inadequate for planned free TRAM reconstruction. In these circumstances, we would recommend the use of the internal mammary vessels followed by the thoracoacromial vessels as reliable alternative recipient sites for delayed free TRAM reconstruction.

Adult↗

PubMed2000

Staged breast reconstruction with saline-filled implants in the irradiated breast: recent trends and therapeutic implications.

A retrospective review was performed of one surgeon's experience with 40 consecutive patients who had undergone two-stage saline-filled implant breast reconstruction and radiation during the period from 1990 through 1997. A randomly selected group of 40 other two-stage saline-filled implant breast reconstructions from the same surgeon and time period served as controls. This review was undertaken because of the absence of specific information on the outcome of staged saline implant reconstructions in the radiated breast. Previously published reports on silicone gel implants and radiation have been contradictory. At the same time, the criteria for the use of radiation in the treatment of breast cancer have been expanded and the numbers of reconstruction patients who have been radiated are increasing dramatically. For example, in a 1985 report on immediate breast reconstruction, only 1 of 185 patients over a 6-year period underwent adjuvant radiation therapy, whereas in this review, there were 40 radiated breasts with saline-filled implants, 19 of which received adjuvant radiation therapy during their expansion. The study parameters included patient age, breast cup size, implant size, length of follow-up, number of procedures, coincident flap operations, Baker classification, complications, opposite breast procedures, pathologic stage, indications for and details about the radiation, and outcomes. The use of radiation in this review of reconstructed breasts can logically be divided into four groups: previous lumpectomy and radiation (n = 7), mastectomy and radiation before reconstruction (n = 9), mastectomy and adjuvant radiation during reconstruction/expansion (n = 19), and radiation after reconstruction (n = 5). The largest and most rapidly growing group of patients is of those receiving postmastectomy adjuvant radiation therapy. A total of 47.5 percent (19 of 40) of radiated breasts with saline implants ultimately needed the addition of, or replacement by, a flap. Ten percent of a control group with nonradiated saline implant reconstructions also had flaps, none as replacements. Fifty percent or more of both the radiated and control groups had contralateral surgery. Complications were far more common in the radiated group; for example, there were 32.5 percent capsular contractures compared with none in the control group. The control nonradiated implant-only group and the flap plus implant radiated group did well cosmetically. The radiated implant-only group was judged the worst. The increasing use of radiation after mastectomy has important implications for breast reconstruction. The possibility for radiation should be thoroughly investigated and anticipated preoperatively before immediate breast reconstruction. Patients with invasive disease, particularly with large tumors or palpable axillary lymph nodes, are especially likely to be encouraged to undergo postmastectomy radiation therapy. The indications for adjuvant radiation therapy have included four or more positive axillary lymph nodes, tumors 4 cm (or more) in diameter, and tumors at or near the margin of resection. More recently, some centers are recommending adjuvant radiation therapy for patients with as few as one positive lymph node or even in situ carcinoma close to the resection margin. The use of latissimus dorsi flaps after radiation has proven to be an excellent solution to postradiation tissue contracture, which can occur during breast expander reconstruction. The use of the latissimus flap electively with skin-sparing mastectomy preradiation is probably unwise, unless postmastectomy radiation is unlikely. Skin-sparing mastectomy with a latissimus flap thus should be preserved for patients unlikely to undergo adjuvant radiation therapy. Purely autologous reconstruction such as a TRAM flap is another option for these patients, either before or after radiation therapy.

Adult↗

PubMed2002

Autologous breast reconstruction with the extended latissimus dorsi flap.

The extended latissimus dorsi myocutaneous flap can provide autogenous tissue replacement of breast volume without an implant. Nevertheless, experience with the extended latissimus dorsi flap for breast reconstruction is relatively limited. In this study, the authors evaluated their experience with the extended latissimus dorsi flap for breast reconstruction to better understand its indications, limitations, complications, and clinical outcomes. All patients who underwent breast reconstruction with extended latissimus dorsi flaps at the authors' institution between January of 1990 and December of 2000 were reviewed. During the study period, 75 extended latissimus dorsi flap breast reconstructions were performed in 67 patients. Bilateral breast reconstructions were performed in eight patients, and 59 patients underwent unilateral breast reconstruction. There were 45 immediate and 30 delayed reconstructions. Mean patient age was 51.5 years. Mean body mass index was 31.8 kg/m2. Flap complications developed in 21 of 75 flaps (28.0 percent), and donor-site complications developed in 29 of 75 donor sites (38.7 percent). Mastectomy skin flap necrosis (17.3 percent) and donor-site seroma (25.3 percent) were found to be the most common complications. There were no flap losses. Patients aged 65 years or older had higher odds of developing flap complications compared with those 45 years or younger (p = 0.03). Patients with size D reconstructed breasts had significantly higher odds of flap complications compared with those with size A or B reconstructed breasts (p = 0.05). Obesity (body mass index greater than or equal to 30 kg/m2) was associated with a 2.15-fold increase in the odds of developing donor-site complications compared with patients with a body mass index less than 30 kg/m2 (p = 0.01). No other studied factors had a significant relationship with flap or donor-site complications. In most patients, the extended latissimus dorsi flap alone, without an implant, can provide good to excellent autologous reconstruction of small to medium sized breasts. In selected patients, larger breasts may be reconstructed with the extended latissimus dorsi flap alone. This flap's main disadvantage is donor-site morbidity with prolonged drainage and risk of seroma. Patients who are obese are at higher risk of developing these donor-site complications. In conclusion, the extended latissimus dorsi flap is a reliable method for total autologous breast reconstruction in most patients and should be considered more often as a primary choice for breast reconstruction.

Body Mass Index↗

PubMed2003

The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors.

The purpose of this study was to identify important sociodemographic factors affecting the utilization of immediate and early delayed postmastectomy breast reconstruction in the United States. Using the Surveillance, Epidemiology, and End Results (SEER) program, all cases of mastectomy-treated breast cancer that were reported to a SEER registry in 1998 were identified. Data were limited to reconstructions within the first 4 months postmastectomy, and logistic regression was used to analyze the effects of sociodemographic variables on reconstruction rates. Of the 10,406 mastectomy-treated breast cancer patients, 1607 (15 percent) underwent reconstruction within the first 4 months postmastectomy. Compared with women 45 to 54 years old, those 35 to 44 years old were significantly more likely to have breast reconstruction (OR = 1.52, p < 0.001), but women 55 to 64, 65 to 74, and 75 years and older were significantly less likely to have reconstruction (OR = 0.42, p < 0.001; OR = 0.16, p < 0.001; OR = 0.04, p < 0.001, respectively). Compared with Caucasian women, African American, Hispanic, and Asian women were significantly less likely to have reconstruction (OR = 0.48, p < 0.001; OR = 0.45, p < 0.001; OR = 0.29, p < 0.001, respectively). In addition, a four-fold difference in reconstruction rates existed in high-use versus low-use regions. With regard to the type of reconstruction, patients younger than 35 and 65 to 74 years old were significantly less likely to receive autogenous tissue reconstruction compared with women 45 to 54 years old (OR = 0.47, p = 0.047; OR p = 0.61, p = 0.031, respectively). However, African Americans were significantly more likely to receive autogenous tissue reconstructions compared with Caucasians (OR = 2.03, p = 0.021). According to these data, the utilization of immediate and early delayed breast reconstruction in the United States is low and is significantly influenced by patients' age, race, and geographic location. Further research is needed to evaluate the impact of provider bias, patient preference, and barriers to care on the utilization of breast reconstruction in the United States.

Adult↗