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At least 433 records · Page 24Linked to original sources

PubMed2000

Intraoperative renal duplex sonography: a valuable method for evaluating renal artery reconstructions.

OBJECTIVES: to determine the ability of duplex sonography to intraoperatively detect technical problems with renal artery reconstructions. DESIGN: retrospective evaluation of a standard protocol. PATIENTS AND METHODS: the outcome of intraoperative duplex was compared with postoperative angiography, surface duplex, MRA, echo or direct inspection in case of re-exploration in 77 renal artery reconstructions in 62 patients. These included six extracorporeal reconstructions, eight and 17 reconstructions with an artery and autogenous vein respectively, 10 renal artery re-implantations in the aorta (prosthesis), 32 endarterectomies and four reconstructions of kidney transplant vessels. RESULTS: intraoperative duplex was normal in 67/73 reconstructions with sufficient data. In six cases technical problems were revealed by intraoperative duplex and the reconstruction was re-explored. After re-exploration intraoperative duplex was normal in all cases. Confirmatory studies demonstrated normal results in 61/64 reconstructions with normal intraoperative duplex and abnormal results in 6/6 reconstructions with technical problems revealed by intraoperative duplex. Three reconstructions with normal intraoperative duplex occluded as demonstrated by angiography less than 2 weeks after surgery. CONCLUSIONS: renal duplex sonography is a valuable method available for intraoperative detection of technical problems. Haemodynamic duplex data were less important than B-mode imaging in discriminating between normal and abnormal reconstruction.

Adolescent↗

PubMed2003

Quantitative and qualitative assessment of left ventricular volume with ECG-gated multislice spiral CT: value of different image reconstruction algorithms in comparison to MRI.

PURPOSE: To assess the value of different image reconstruction algorithms for assessment of the left ventricular function using retrospectively ECG-gated multislice spiral computed tomography (MSCT) of the heart. MATERIAL AND METHODS: MSCT and cine magnetic resonance (MR) imaging of the heart were performed in 15 patients. For MSCT, standard and multisegmental image reconstruction with improved temporal resolution were used. Standardized multiplanar reformats in the short axis and long axis views were reconstructed from MSCT data. End-systolic (ESV) and end-diastolic volume (EDV), stroke volume (SV), ejection fraction (EF) and myocardial mass (MM) were calculated. Left ventricular wall motion was assessed qualitatively. RESULTS: MSCT was in acceptable agreement with MR imaging for quantification of the ventricular function. According to the Bland-Altman approach the mean differences for the left ventricular volumes (ESV, EDV, SV) ranged from -9.6 ml to 3.1 ml with standard image reconstruction and from -0.6 ml to 1.9 ml utilizing multisegmental image reconstruction with limits of agreement ranging from -26.6 ml to 12.5 ml and -15.6 ml to 15.0 ml, respectively. Applying the multisegmental image reconstruction algorithm, a significantly improved agreement with the MR data was found for EDV, SV and EF. For wall motion analysis, standard image reconstruction showed a significant difference to MR imaging with a correspondence in 83.75% of the 240 assessed segments, while multisegmental image reconstruction agreed with MR imaging in 92.5% of the segments. CONCLUSION: Multisegmental image reconstruction improves the quantitative assessment of left ventricular function when compared to standard image reconstruction. Multisegmental image reconstruction allows qualitative wall motion analysis.

Adult↗

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↗

PubMed2001

The deep inferior epigastric perforator free flap for breast reconstruction.

Deep inferior epigastric perforator (DIEP) flap breast reconstruction is an improved method of autologous tissue breast reconstruction with minimal insult to the abdominal wall. This study summarizes the data collected on 148 consecutive DIEP flaps used for breast reconstruction in 109 patients. Of the patients, 90.7% had immediate breast reconstruction after mastectomy, 6.5% had secondary reconstruction, and 2.8% had bilateral reconstruction after having had a mastectomy and having a new primary cancer diagnosed in the remaining breast. A total of 78.7% patients underwent unilateral reconstruction, 21.3% underwent bilateral reconstruction, and 15.7% needed two flaps to make a single larger breast. There was one flap failure. Incidence of fat necrosis was 6.8% and incidence of incisional hernia was 1.4%. The advantages of a free transverse rectus abdominis musculocutaneous flap breast reconstruction are inherent in DIEP flap breast reconstruction. The increased technical effort for DIEP flap reconstruction is offset by the lesser insult to the abdominal wall with maintenance of the entire rectus abdominis muscle.

Adult↗

PubMed2004

Microsurgical free flap reconstruction outcomes in head and neck cancer patients after surgical extirpation and intraoperative brachytherapy.

OBJECTIVES: The management of recurrent or persistent head and neck cancer poses a challenging problem. Salvage surgery for these individuals consists of ablative surgery, interstitial brachytherapy, and microsurgical free flap reconstruction. This study reviews complications after such reconstruction. METHODS: We reviewed 139 consecutive head and neck cancer patients undergoing free flap reconstruction from January 1994 to May 2002. These included 66 patients with recurrent head and neck cancer undergoing intraoperative brachytherapy (IOBT) and free flap reconstruction and 73 undergoing free flap reconstructions only. A total of 142 reconstructions were performed, with three patients in IOBT group receiving two free flap reconstructions per patient, giving us a total of 69 reconstructions in the IOBT group versus 73 in the non-IOBT group. Nine patients were excluded from the IOBT group because of nonsynchronous use of brachytherapy and reconstruction, and 10 patients were excluded from the other group because they had prior radiotherapy or surgical treatment, leaving us with a total of 123 reconstructions, 60 in the IOBT group and 63 in the non-IOBT group. The IOBT group patients received iodine Vicryl seed implants, palladium seed implants, or both, to deliver an average dose of 79.3 +/- 31.8 Gy (mean +/- 1SD) to the surgical bed. RESULTS: All patients were followed for evidence of local wound complications. The IOBT group showed multiple complications in 23 (38.33%) of 60 reconstructions, the most common being wound dehiscence in 11. This, when compared with the non-IOBT group complications (15.87%), was found to be statistically significant (chi test, P <.01). CONCLUSION: IOBT increases the rate of complications in patients undergoing microvascular free tissue transfer. This, however, should not deter or alter the aggressiveness of cancer therapy used for managing recurrent head and neck cancer.

Adolescent↗

PubMed1991

Use of the AO plate for immediate mandibular reconstruction in cancer patients.

Free vascularized bone grafts have revolutionized mandibular reconstruction, yet their use in all mandibulectomy patients is not always necessary. A recently developed alternative to bony reconstruction has been the use of the AO reconstruction plate. We compared the use of the AO reconstruction plate with immediate free bone graft mandibular reconstruction in 31 patients. Reconstruction plates were used in 20 and immediate free bone grafts were used in 11 patients. The overall success rate for use of the plate was 15 of 20 (75 percent). There were 6 anterior reconstructions, of which only 2 (33 percent) were successful. This is opposed to 13 of 14 (93 percent) lateral reconstructions that were successful in lateral plate placements. There were 11 immediate composite free flaps: 4 iliac crest, 4 scapula, 2 fibula, and 1 composite radial forearm flaps. Six repairs were for anterior defects, and there were 5 full-thickness defects, 3 of which were in the anterior position. All 11 flaps were successful. In conclusion, we believe the reconstruction plates are a useful adjunct for mandibular replacement in the head and neck cancer patient but should be reserved for lateral defects. For anterior reconstructions, even in patients with locally advanced disease, free-tissue transfer of composite osteocutaneous flaps is the reconstructive method of choice.

Bone Plates↗

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↗

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

Functional outcome after soft-tissue reconstruction for limb salvage after sarcoma surgery.

Limb salvage has been achieved for patients with sarcoma by means of compartmental resection, soft-tissue reconstruction, and adjuvant therapy without increased rates of local recurrence, metastasis, or mortality. Despite the prevalence of limb salvage procedures in the treatment of these tumors, relatively little information has been published regarding late functional results in these reconstructed extremities. This study reports on the functional outcome for soft-tissue reconstruction for limb salvage in patients with sarcoma. Over the past 6 years, 28 patients were treated for sarcomas of the extremity in which soft-tissue reconstruction was needed for complete limb salvage. The mean age of these patients was 48 years (range, 14 to 83 years); there were 14 male and 14 female patients. Of the 28 sarcomas, 23 cases involved the lower extremity and 5 cases were in the upper extremity. Reconstruction was performed primarily in 12 patients; 16 reconstructions were performed secondarily because of wound complications after initial extirpation. Adjuvant radiation therapy was administered either preoperatively or postoperatively in all cases. Of the 33 reconstructive procedures performed in these 28 patients, 16 involved free flaps and 17 involved local flaps. All patients achieved initial limb salvage after the reconstructive procedure(s). Mean follow-up was 38 months. Twenty patients were available for the evaluation portion of the study. Two patients had delayed amputations: one for recurrent disease and another for osteoradionecrosis. Two patients died before beginning the examination process: one patient from the sarcoma and another patient from colon cancer. Twenty of the remaining 24 patients agreed to participate and were examined using the Enneking outcome measurement scale. Patients were examined for range of motion, deformity, stability, pain level, strength, functional activity, and emotional acceptance and assigned a numerical score for each category. Based on this, an overall rating of excellent, good, fair, or poor was assigned. Nine patients (45 percent) achieved an overall rating of excellent, five patients (25 percent) achieved a rating of good, and six patients (30 percent) achieved a fair score. None had received a rating of poor. There were no differences in the results obtained comparing upper versus lower extremity, immediate versus delayed reconstruction, or reconstructions performed with a free flap versus a pedicled flap. This study supports the continued use of soft-tissue reconstruction for limb salvage in sarcoma surgery with good to excellent late functional results obtained in the majority of patients.

Adolescent↗

PubMed2000

Reconstruction of large sacral defects following total sacrectomy.

Total sacrectomies for cancer ablation often result in extensive defects that are challenging to reconstruct. In an effort to elucidate the criteria to select the most effective reconstructive options, we reviewed our experience with the management of large sacral wound defects. All patients who had a sacral defect reconstruction after a total sacrectomy at our institution between January of 1993 and August of 1998 were reviewed. The size of the defect, the type of reconstruction, postoperative complications, and functional outcome in each patient were assessed. A total of 27 flaps were performed in 25 patients for sacral defect reconstruction after a total sacrectomy. Diagnoses consisted of chordoma (n = 13), giant cell carcinoma (n = 2), sarcoma (n = 5), rectal adenocarcinoma (n = 4), and radiation induced necrosis (n = 1). The size of sacral defects ranged from 18 to 450 cm2 (mean, 189.8 cm2). Ten patients, including five who had preoperative radiation therapy, underwent transpelvic vertical rectus abdominis myocutaneous (VRAM) flap reconstruction for sacral defects with a mean size of 203.3 cm2. Of these, five patients (50 percent) had complications (four minor wound dehiscences and one seroma). Eight patients, including one who had preoperative radiation therapy, underwent bilateral gluteal advancement flap reconstruction for sacral defects with a mean size of 198.0 cm2. They had no complications. Two patients, both of whom had preoperative radiation therapy, underwent gluteal rotation flap reconstruction for sacral defects of 120 cm2 and 144 cm2. Both patients had complications (one partial flap loss and one nonhealing wound requiring a free flap). Three patients, including one who had preoperative radiation therapy, underwent reconstruction with combined gluteal and posterior thigh flaps for sacral defects with a mean size of 246 cm2; two of these patients had partial necrosis of the posterior thigh flaps. Three patients, all of whom had preoperative radiation therapy, underwent free flap reconstruction for sacral defects with a mean size of 144.3 cm2. They had no complications. Our experience suggests that there are three reliable options for the reconstruction of large sacral wound defects: bilateral gluteal advancement flaps, transpelvic rectus myocutaneous flaps, and free flaps. In patients with no preoperative radiation therapy and intact gluteal vessels, the use of bilateral gluteal advancement flaps should be considered. In patients with a history of radiation to the sacral area and in patients whose gluteal vessels have been damaged, the use of the transpelvic VRAM flap should be considered. If the transpelvic VRAM flap cannot be used because of previous abdominal surgery, a free flap should be considered as a last option.

Adult↗

PubMed2000

Postoperative adjuvant irradiation: effects on tranverse rectus abdominis muscle flap breast reconstruction.

The use of postoperative irradiation following oncologic breast surgery is dictated by tumor pathology, margins, and lymph node involvement. Although irradiation negatively influences implant reconstruction, it is less clear what effect it has on autogenous tissue. This study evaluated the effect of postoperative irradiation on transverse rectus abdominis muscle (TRAM) flap breast reconstruction. A retrospective review was performed on all patients undergoing immediate TRAM flap breast reconstruction followed by postoperative irradiation between 1988 and 1998. Forty-one patients with a median age of 48 years received an average of 50.99 Gy of fractionated irradiation within 6 months after breast reconstruction. All except two received adjuvant chemotherapy. Data were obtained from personal communication, physical examination, chart, and photographic review. The minimum follow-up time was 1 year, with an average of 3 years, after completion of radiation therapy. Nine patients received pedicled TRAM flaps and 32 received reconstruction with microvascular transfer. Fourteen patients had bilateral reconstruction, but irradiation was administered unilaterally to the breast with the higher risk of local recurrence. The remaining 27 patients had unilateral reconstruction. All patients were examined at least 1 year after radiotherapy. No flap loss occurred, but 10 patients (24 percent) required an additional flap to correct flap contracture. Nine patients (22 percent) maintained a normal breast volume. Hyperpigmentation occurred in 37 percent of the patients, and 56 percent were noted to have a firm reconstruction. Palpable fat necrosis was noted in 34 percent of the flaps and loss of symmetry in 78 percent. Because the numbers were small, there was no statistical difference between the pedicled and free TRAM group. However, as a group, the findings were statistically significant when compared with 1,443 nonirradiated TRAM patients. Despite the success of flap transfer, unpredictable volume, contour, and symmetry loss make it difficult to achieve consistent results using immediate TRAM breast reconstruction with postoperative irradiation. TRAM flap reconstruction in this setting should be approached cautiously, and delayed reconstruction in selected patients should be considered. Patients should be aware that multiple revisions and, possibly, additional flaps are necessary to correct the progressive deformity from radiation therapy.

Adult↗

PubMed2001

Clinical determinants of patient satisfaction with breast reconstruction.

The main objective of this study was to examine the relationship between specific treatment variables and patient satisfaction with breast reconstruction. A questionnaire was developed that included questions on population demographics and satisfaction with the reconstruction. Of 206 women who completed the questionnaire, 23 (11.2 percent) responded that they were not satisfied, whereas 183 (88.8 percent) indicated that they were satisfied overall. A detailed retrospective chart review permitted a comparison of the treatment received by these two groups. Variables analyzed included patient age, time since surgery, reason for surgery, method and timing of reconstruction, additional surgical procedures received (mound revisions and nipple-areola complex reconstruction), and postoperative complications. Data analysis showed that the treatment received by the two groups was similar in many respects. There was no statistical association between the method or timing of reconstruction and a patient's satisfaction with the results. Furthermore, there was no difference in the number of mound revisions or nipple reconstructions performed on satisfied versus dissatisfied patients. However, the latter group experienced a substantially higher incidence of postsurgical complications (27 percent versus 61 percent, p = 0.0015). Patients were also asked to provide a written response explaining their feelings on breast reconstruction. Satisfied patients described benefits from reconstruction such as improved appearance or feelings of normalcy and wholeness. Conversely, unsatisfied patients were displeased because of poor cosmetic results, complications with the reconstructed breast, or abdominal problems. Although overall satisfaction with breast reconstruction is undoubtedly determined by multiple and complex clinical, emotional, and psychological factors, this study suggests that postoperative complications are a particularly important indicator of dissatisfaction with reconstruction.

Female↗

PubMed2001

Evaluation of the factors related to postmastectomy breast reconstruction.

A retrospective study was conducted in 75 consecutive patients requiring postmastectomy breast reconstruction over a period of 30 months. Each woman was offered one of the following four reconstructive options: free transverse rectus abdominis musculocutaneous flap (total number of reconstructions, n = 34); latissimus dorsi musculocutaneous flap (with or without expander and implant, n = 14); endoscopically assisted harvest of the latissimus dorsi muscle (with expander and implant, n = 13); and application of expander and implant only (n = 12). Of those patients originally selected for retrospective study, six did not meet the short-term prognostic criteria, and concerted attempts to contact two others proved unsuccessful. The remaining 67 patients were examined for the clinically assessed aesthetic appearance of the reconstructed breast(s), the subjective self-assessment of patient satisfaction, and the possible development of postoperative complications. Of these patients, six required bilateral surgery, which accounts for a final sample size of 73 individual breast reconstructions. The 67 individual patients were assessed after a minimum time of 6 months postreconstruction and became the sampling units for analysis. The free transverse rectus abdominis musculocutaneous flap procedure was the preferred method of breast reconstruction in 34 of 73 patients (47 percent), provided that it was generally agreed that the patient could endure a prolonged operation and that there was sufficient unscarred abdominal tissue available. Thereafter, postmastectomy radiotherapy at the chest wall became the primary criterion for assignment of a patient to a particular surgical procedure. Whenever radiotherapy resulted in poor-quality skin at the chest wall, endoscopically assisted transfer of latissimus dorsi muscle flap was considered to be the optimal treatment (13 of 73 patients, or 18 percent). Body mass index and smoking were secondary factors that were taken into account when this alternative technique was being considered.In the absence of radiotherapy, and provided that the chest wall was minimally scarred, patients who were reluctant to have reconstruction with autologous tissue were treated with expander and implant only (12 of 73, or 16 percent). This third procedure is a physically less arduous ordeal for the patient and was therefore the choice for all patients for whom a prolonged operation was not a realistic option. The fourth (and final) surgical procedure, latissimus dorsi musculocutaneous flap (with or without expander and implant), was selected for all patients with a better quality of skin over the chest wall, those whose abdomen was extensively scarred, and those who were on a general surgeon's operating list to undergo immediate breast reconstruction after mastectomy (14 of 73, or 19 percent). Equally good aesthetic results could be demonstrated with each of the four treatment options, provided that the reconstructive procedure selected was optimal for the individual patient and in accordance with the criteria described above. A variety of potential risk factors were considered for association with postoperative complications, including prescribed medication, obesity, smoking behavior, use of radiotherapy, and the recorded aggregated operative time. Of these, only body mass index (p < 0.001) and use of steroids (p = 0.016) were identified as having statistically significant effects on the incidence of adverse events.Finally, the general level of satisfaction expressed by the patient was highly correlated with a good appearance of the reconstructed breast, the physical comfort experienced while wearing a brassiere, and the general mobility of the unsupported reconstruction.

Female↗

PubMed2001

Framework growth after reconstruction for microtia: is it real and what are the implications?

Historically, fashioning an auricle for a patient born with microtia has been one of the most challenging endeavors in the repertoire of reconstructive surgeons. Despite many ideas advanced on types of materials for the auricular framework, the hands-down favorite and today's medium of choice is autogenous costal cartilage. A subject that remains up for discussion, however, is the question of growth potential in these cartilaginous frameworks. Popularization of the surgical technique for auricular reconstruction has led to much bandying about of opinions on this very important question of growth. Although previous reports allude to the probability of an increase in auricular size after reconstruction, this report is the first to document changes in auricular size with measurements taken directly from patients at the time of graft implantation and during subsequent long-term follow-up. The goals of this study are to define the behavior of the autogenous framework after reconstruction of the microtic auricle. This information serves to clarify the issue of proper framework sizing and to make evident the early age at which reconstruction can begin. The records of patients who underwent costal cartilage auricular reconstruction for grade III microtia between 1990 and 1996 were reviewed, and a cohort of 10 patients was chosen for inclusion based on availability for follow-up and lack of any interval modifications of their cartilaginous framework. The average age was 6.7 years, and the average time interval from initial reconstruction to follow-up was 3.2 years. Measurements of the auricular framework height and width were taken at implantation and at time of final follow-up, and measurements were recorded of the normal ears of patients with unilateral microtia. The mean auricular size was examined for significance of interval change using the two-sample Student's t tests, assuming unequal variances. The results revealed an average height increase of 5 mm (10.4 percent) in the study population. Auricular width changes averaged 2.75 mm (7.02 percent). Growth trends revealed a distinct tendency toward increasing auricular framework size over time, with slowing as patients neared adolescence. Comparison of the reconstructed auricle to the normal ear of each patient with unilateral microtia showed that the reconstructed ear paralleled the growth of the normal side, with no statistically significant differences in height or width at follow-up. This is the first report of auricular framework behavior based on patients having direct measurement of their framework initially and in long-term follow-up. This patient sample underscores a clear pattern of growth in the reconstructed auricles paralleling that of the normal ears. The implications of this finding are important in that the initial oversizing of the framework becomes unnecessary. Moreover, the decision as to age at initial reconstruction is not affected by anticipated growth rates.

Anthropometry↗

PubMed2002

Breast reconstruction using tissue expanders and implants in Hodgkin's patients with prior mantle irradiation.

Women treated for Hodgkin's disease with mantle irradiation have an increased risk for developing breast cancer. Typically, breast malignancy in Hodgkin's patients presents bilaterally in a younger age group. Skin flap ischemia, poor skin expansion, implant extrusion, capsular contracture, and poor cosmesis are common sequelae of tissue expander/implant breast reconstruction after breast irradiation for failed breast conservation therapy. This has led most surgeons to favor autologous tissue reconstruction in this setting. This study was performed to determine the efficacy of tissue expander/implant breast reconstruction in breast cancer patients who have been treated with prior mantle irradiation for Hodgkin's disease. A retrospective analysis of all breast cancer patients with a history of Hodgkin's disease and mantle irradiation treated with mastectomy and tissue expander/implant reconstruction between 1992 and 1999 was performed. There were seven patients, with a mean age of 35 years (range, 28 to 42 years). The average interval between mantle irradiation and breast cancer diagnosis was 16 years (range, 12 to 23 years). All patients underwent two-stage reconstruction. Textured surface tissue expanders were placed in a complete submuscular position at the time of mastectomy. Expansion was initiated 2 weeks after insertion and continued on a weekly basis until completion. Expanders were replaced with textured surface saline-filled implants as a second stage. Patients were evaluated for skin flap ischemia, infection, quality of skin expansion, implant extrusion, capsular contracture, rippling, symmetry, and final aesthetic outcome. Breast cancer was bilateral in five patients and unilateral in two. Two patients did not undergo simultaneous bilateral breast reconstruction because of metachronous cancer development. One of the patients had an initial transverse rectus abdominis muscle flap breast reconstruction, followed by a tissue expander/implant reconstruction of the opposite breast. The average follow-up was 3 years. Complications were limited to one case of cellulitis after implant placement that resolved with intravenous antibiotics. There were no cases of skin flap ischemia, poor skin expansion, or implant extrusion. Overall patient satisfaction was high and revisions were not requested or required. Symmetry was best achieved with bilateral implants. This study demonstrates the efficacy of tissue expander/implant breast reconstruction in patients treated with prior mantle irradiation. In this series, tissue expansion was reliable with low morbidity. Second-stage placement of permanent implants yielded good aesthetic results without significant capsular contracture. Mantle irradiation did not appear to compromise the prosthetic breast reconstruction. Tissue expander/implant breast reconstruction should remain a viable option in this category of irradiated patients.

Adult↗

PubMed2002

The coincidence of TRAM flaps and prostheses in the setting of breast reconstruction.

It is well known that transverse rectus abdominis myocutaneous (TRAM) flaps can be used to replace unsatisfactory prosthetic breast reconstructions; however, little has been written about the scope of breast implant use in TRAM flap patients. In this study, to ascertain the range of such therapeutic options, their frequency, and their clinical outcomes, the authors retrospectively reviewed the senior author's breast reconstruction experience from 1989 to 2000 with patients in whom both a TRAM flap and an implant were used for breast reconstruction. The authors examined the surgical indications, body habitus, bra size, chest wall irradiation history, flap type, implant type, complications, and outcomes for those patients with TRAM flap and breast implant combinations.Thirty-two women who had 50 (various) combinations of a TRAM flap and a breast implant were identified. There were more clinical scenarios than patients because many of the women had multiple scenarios. The 50 combination scenarios were then divided into six groups. Group I consisted of 14 patients who had elective prostheses placed beneath simultaneous TRAM flaps; group II consisted of 10 patients who had TRAM flaps with contralateral prosthetic reconstruction (in which two implants were received before the TRAM flaps, five implants were received simultaneously with the TRAM flaps, and three implants were received after the TRAM flaps); group III consisted of eight patients who had contralateral augmentation in addition to their TRAM flaps; group IV consisted of 11 patients who had TRAM flaps that were used to cover or replace previous prosthetic reconstructions; group V consisted of four patients in whom prostheses were used to augment or improve previous TRAM flap reconstructions; and group VI consisted of three patients who required prostheses to either reconstruct or salvage total or near-total TRAM flap failures. A broad range of implant types was used, although anatomic saline implants predominated. Forty-one percent of the patients in the review had undergone irradiation during the course of their treatment for breast cancer. Eight of the 32 patients experienced a total of twelve complications, four of which were related to the implants and eight of which involved the TRAM flaps and abdominal donor sites.Although complex, the wide variety of potential TRAM flap/breast implant combinations can be useful for patients with challenging reconstructive scenarios, particularly those that involve radiation therapy. In the group of patients reviewed by the authors, TRAM flaps were most often used in successful partnership either on the same side as or opposite to an implant reconstruction. A TRAM flap was used to salvage or replace an unsatisfactory implant reconstruction in less than a third of the patients. From a risk point of view, implants used opposite a TRAM flap reconstruction had a lower incidence of complication than did implants used beneath TRAM flaps.

Adult↗

PubMed2003

Flap technology for reconstructions of urogenital organs.

PURPOSE OF REVIEW: The purpose of this review is to summarize the different reconstructive options for urogenital indications. The development of various flap techniques to restore congenital and acquired urogenital defects is presented. RECENT FINDINGS: Various reconstructive techniques have been demonstrated recently. On the basis of the reconstructive requirements, two main techniques can be defined: the standard local or regional flap technique (pedicled flap) and the more sophisticated microvascular free flap technique. Free tissue transplantation (transfer) is a procedure that involves microvascular transplantation of a flap (a fasciocutaneous, muscle or composite flap) in one stage from a donor site in the body to a distant recipient site. The viability of the transplanted flap is maintained by microvascular anastomosis between the flap's vessels (at least one artery and one vein) and recipient vessels. Re-innervation and functioning muscle contraction is achieved by suturing the vessels and a motor nerve in the recipient area to a motor nerve of a free transplanted muscle. After regeneration of the nerve and re-innervation of the transplanted muscle, a functioning free transplanted muscle offers enough contractile capacity and strength to replace the function of the missing muscles at the recipient site. The technique of microvascular free tissue transfer necessitates extensive experience in microvascular technique and this approach could be efficiently applied in cooperation with other specialists. Recent studies show the development and clinical application of these new surgical techniques in urology (e.g. in the treatment of bladder acontractility using innervated free latissimus dorsi muscle and in the use of a free microvascular fillet lower leg flap for the reconstruction of a large pelvic-floor defect). SUMMARY: Various reconstructive requirements define the techniques for reconstruction. The main principle is to obtain optimal anatomical and functional reconstruction with minimal donor site morbidity. Depending on the etiology of the defect, different reconstructive options are available to optimize the reconstructive result. Optimal reconstruction might best be achieved by adopting an interdisciplinary approach in which the primary objective is to provide the best possible outcome for each patient. This review presents the main indications for and principles of flap selection according to the reconstructive requirements.

Anastomosis, Surgical↗

PubMed2003

An outcome analysis comparing the thoracodorsal and internal mammary vessels as recipient sites for microvascular breast reconstruction: a prospective study of 100 patients.

The thoracodorsal vessels have been the standard recipient vessels for the majority of surgeons performing free transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions. Recently, the internal mammary vessels have been recommended as the first-choice recipient vessels for microvascular breast reconstruction. This approach requires a shorter pedicle length, allows for central placement of flap tissue, and avoids axillary scarring. The use of the internal mammary vessels may provide for a shorter operative time and a higher-quality aesthetic reconstruction. The authors performed a prospective trial examining the differences in operative and aesthetic outcomes between each recipient site. A prospective trial of 108 consecutive free-tissue transfers was conducted in 100 patients. The first 60 TRAM flap patients were randomized so that 30 flaps were anastomosed to the internal mammary vessels and 30 were anastomosed to the thoracodorsal vessels, whereas the recipient vessels for the remaining 40 patients were left to the discretion of the surgeon. Of the 40 nonrandomized patients, 10 patients underwent reconstruction using the internal mammary vessels and 30 patients underwent reconstruction using the thoracodorsal vessels. The patients' medical history and hospital course were noted. To evaluate aesthetic outcome, a group of five blinded nonmedical observers and three blinded plastic surgeons graded the reconstructions in the 60 TRAM flap patients for symmetry and overall aesthetic result on a scale of 1 to 5. Blinded practitioners administered postoperative questionnaires to patients regarding recovery time and satisfaction with the aesthetic result. Forty-three flaps were transferred to the internal mammary vessels and 65 were transferred to the thoracodorsal vessels. No significant differences existed between groups with regard to age of preoperative risk factors. Average operative time was 6 hours in each group. Average hospital stay was 5.8 days in each group. Conversion from initial recipient vessel to a secondary recipient site occurred in 12.5 percent of internal mammary reconstructions and 7 percent of thoracodorsal reconstructions. All converted internal mammary cases occurred in left-sided reconstructions and were attributable to problems with the veins. Overall, 20 percent of left-sided internal mammary reconstructions were found to have an inadequate recipient vein. Unusable thoracodorsal vessels were found only in delayed reconstructions, at a rate of 15 percent in the delayed setting. All flaps from converted procedures survived without complications. Average follow-up was 20 months, during which time there was one flap loss in the thoracodorsal group. There were no significant differences in complication rates between groups. Average aesthetic grade was 3.6 in each group. Postoperative recovery time and overall patient satisfaction were not significantly different between groups. Either recipient site can provide for a safe and acceptable result; however, surgeons should be aware of conversion rates and plan appropriately if recipient vessels appear unusable for free-tissue transfer.

Anastomosis, Surgical↗