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Results for “Reconstruction”

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PubMed2002

Two-stage reconstruction with autografts for knee dislocations.

Traumatic knee dislocations are severe injuries that involve damage to the anterior cruciate ligament, the posterior cruciate ligament, and the lateral or medial ligamentous structures. There are no established methods of treatment. The objective of the current study was to report the clinical outcome of a two-stage autologous reconstruction on nine knees (eight patients). The mean followup was 40.1 months. The first stage of the reconstruction was done at a mean of 2 weeks after the injury, and the posterior cruciate ligament was reconstructed by an arthroscopically assisted technique using contralateral autogenous hamstring tendon as the graft material. Three months later, the second stage of the reconstruction was done for the ligaments that had not healed with conservative treatment. Arthroscopically assisted anterior cruciate ligament reconstruction was done on all of the knees using the ipsilateral autogenous hamstring tendon or bone-patellar tendon-bone as the graft material. At the same time, a medial collateral ligament reconstruction using an autogenous semitendinosus tendon was done on one knee, and reconstruction of the posterolateral ligamentous structures using a biceps tendon was done on three knees. Each of the knees that was reconstructed was capable of full extension, and the mean degree of passive flexion was 139.5 degrees +/- 5.2 degrees. The mean side-to-side difference in anteroposterior total laxity (KT-1000 arthrometer, manual maximum) was 2.3 +/- 1.9 mm. None of the knees had lateral or medial instability. All of the injured ligaments were able to be reconstructed with autografts, and severe contracture was able to be prevented. A good clinical outcome can be achieved when two-stage reconstruction is used for traumatic knee dislocations.

Adult↗

PubMed2004

Functional outcome after total parotidectomy reconstruction.

OBJECTIVES/HYPOTHESIS: The objective was to compare and contrast the functional and cosmetic outcomes of patients who underwent total parotidectomy with and without reconstruction using an inferiorly based sternocleidomastoid muscle flap. STUDY DESIGN: Retrospective review in the setting of a university medical center. METHODS: Twenty-four patients underwent a total parotidectomy. Fifteen patients had reconstruction with an inferiorly based sternocleidomastoid muscle flap, and nine patients had no reconstruction. Clinical examination was performed independently by two head and neck surgeons and one aesthetician to evaluate cosmetic outcome, presence of gustatory flushing or sweating, and return of facial nerve and greater auricular nerve function. RESULTS: With the mean follow-up of 22 months, the group having reconstruction showed a better cosmetic outcome compared with the group without reconstruction. Objective testing for Frey syndrome demonstrated gustatory sweating in 20% of the group having reconstruction group versus 22% in the group without reconstruction. There was no difference in length of operation, hospital stay, or facial nerve function. Objective testing of facial sensation revealed that only 40% in the group having reconstruction had normal sensation to light touch compared with 78% in the group without reconstruction. CONCLUSION: The inferiorly based sternocleidomastoid muscle flap offers improved cosmetic results in patients undergoing total parotidectomy. However, there is a decreased return of greater auricular nerve function, probably attributable to relocation of the nerve stump anteriorly. Benefit was not seen in prevention of Frey syndrome measured objectively; however, the group having reconstruction had fewer clinical symptoms of gustatory sweating or flushing.

Cosmetic Techniques↗

PubMed1995

The free flap and plate in oromandibular reconstruction: long-term review and indications.

The purpose of this study was to define the role of reconstruction plates as bone replacement in oromandibular reconstruction. From 1987 through 1991, 71 consecutive oral cancer patients underwent composite resection and reconstruction and were entered into one of two studies. In the first study of 31 patients, 15 underwent oromandibular reconstruction using a radial forearm osteocutaneous flap, while the remainder (16) received a radial forearm fasciocutaneous flap together with a mandibular reconstruction plate. The second study involved 40 subsequent patients, all receiving the latter form of reconstruction. Twenty-one of the plates were stainless steel, and the remaining 19 were of the titanium hollow screw (THORP) type. We followed the patients prospectively. We defined success as a reconstruction that we did not have to remove. Additionally, since the patients had limited life expectancy, we developed the idea of days of life lost and incorporated it into our definition of a successful outcome. Vascularized autogenous bone proved to be more successful than metallic plates used alone in terms both of reconstruction survival and of minimizing days of life lost. The overall success rate of mandibular plate reconstruction was 78.9 percent, but analysis by defect type revealed a failure rate of 35 percent when the defects were anterior and only 5 percent when they were lateral. THORP plates demonstrated a trend towards more durability. We would now recommend plate reconstruction only in lateral defects in patients with a poor prognosis.

Bone Plates↗

PubMed1998

Periorbital melanocytic lesions: excision and reconstruction in 40 patients.

The treatment of melanoma arising in the periorbital region is a difficult reconstructive problem. The abundance of vital structures in close proximity to one another makes the resection and subsequent reconstructive procedures extremely challenging. Reported here is experience with periorbital melanocytic lesions in 40 patients with the emphasis on the types of reconstruction performed. Forty patients with periorbital melanocytic lesions were treated between 1984 and 1995. The periorbital region was subdivided into five zones. These zones are the following: zone I, upper eyelid; zone II, lower eyelid; zone III, medial canthus; zone IV, lateral canthus; and zone V, contiguous structures. Ocular melanomas were not included in this study. The distribution of the lesions in our 40 patients was zone I (n = 1), zone II (n = 14), zone III (n = 1), zone IV (n = 9), and zone V (n = 31). The ages of the patients ranged from 3 to 84 years at the time of reconstruction, with an average age of 57 years. Resection and reconstruction were performed simultaneously in all patients. Thirty-six of the patients were reconstructed with one procedure, three patients required two procedures, and one patient required five procedures. The tumor type was superficial spreading melanoma in 15 patients, melanoma in situ in 17 patients, malignant spindle cell neoplasm in 2 patients, desmoplastic melanoma in 2 patients, amelanocytic melanoma in 1 patient, epithelioid melanoma in 1 patient, and atypical melanocytic nevus in 2 patients in which an early, evolving melanoma could not be excluded. Elective lymph node dissection was performed in four patients for intermediate thickness lesions (1.5 to 4.0 mm). The types of reconstructions performed included full-thickness skin grafts, upper lid myocutaneous flaps, cheek advancement flaps, cervicofacial flaps, inferiorly based nasolabial flaps, tarsoconjunctival flaps, frontalis muscle flaps, medial transposition Z-plasty, and primary closure. The resection of periorbital melanomas can be difficult because of the number of important anatomic structures in the region. The challenge to the surgeon in handling head and neck melanomas in general lies in the need to provide the best functional and aesthetic result while still resecting the primary lesion with the intent of effecting a cure. We present our series to demonstrate that the adequacy of margins of resection need not be compromised to facilitate reconstruction and that excellent results are obtainable with reconstructive procedures performed after adequate resections. Several different types of flaps and grafts can be used, with the indications varying depending on the location of the lesion and the extent of resection. The major reconstructive options will be reviewed in detail.

Adolescent↗

PubMed1998

Reconstruction of total maxillectomy defects with preservation of the orbital contents.

Reconstruction after total maxillectomy with preservation of the orbital contents is technically more challenging than when the maxillectomy is combined with orbital exenteration. Reconstruction of such defects should (1) provide support to the orbital contents, (2) obliterate any communication between the orbit and nasopharynx, (3) reconstruct the palatal surface, and (4) achieve facial symmetry and a good aesthetic result. We report our experience in performing reconstructive surgery on 14 patients who had a total maxillectomy and preservation of the orbital contents using nonvascularized bone grafts for reconstruction of the orbital floor and maxilla, in conjunction with a soft-tissue free flap or pedicled muscle flap. The orbital floor was reconstructed using split ribs in six cases (42.9 percent), split calvaria in six cases (42.9 percent), and iliac crest graft in two cases (14.3 percent). A myocutaneous rectus abdominis free flap was used for soft-tissue reconstruction and resurfacing of the palatal mucosa in twelve patients (85.7 percent), and a temporalis muscle transposition was used in two elderly patients (14.3 percent). One patient died 2 days after surgery. Mean follow-up and aesthetic and functional results were assessed in the remaining 13 patients a minimum of 6 months postoperatively. In 9 of these 13 patients (69.2 percent), postoperative radiotherapy was administered. No reexplorations or free flap failures were observed. One rectus flap developed partial necrosis of the skin island intraorally without affecting the final result. All patients had adequate functional vision. One patient had a mild vertical dystopia; there were no cases of enophthalmos. Ectropion was the most common undesirable result and was present in 10 of 13 cases (76.9 percent). It was graded as mild in four cases (40.0 percent), moderate in four cases (40.0 percent), and severe in the remaining two cases (20.0 percent). Speech was considered normal in six cases (46.2 percent), near normal in six cases (46.2 percent), and intelligible in one case (7.7 percent). Chewing function was considered good (soft to unrestricted diet) in all cases except for one patient who was only able to eat a pureed diet. Aesthetic results after immediate reconstruction were considered good in nine cases (69.2 percent) and fair in four cases (30.8 percent). Primary reconstruction of total maxillectomy defects with orbital content preservation remains a complex problem without a perfect solution. The combination of nonvascularized bone grafts for orbital/maxillary reconstruction with a soft-tissue free flap is a safe, reliable, and effective method of maximizing postoperative functional and aesthetic results.

Adult↗

PubMed1999

Microsurgical reconstruction in recurrent oral cancer: use of a second free flap in the same patient.

Primary microsurgical reconstruction is the treatment of choice for ablative defects of oral carcinoma. As a result of this trend, more and more patients with recurrent oral carcinoma who have been initially treated with surgical excision and reconstructed with free flaps are being seen. However, a second microsurgical reconstruction attempt in these cases raises questions about the flap choices, availability of recipient vessels, and effects of previous treatment modalities. Herein, 35 patients with perioral carcinoma who had two successive tumor resections and reconstruction with free flaps on each occasion are presented. A total of 75 free tissue transfers were carried out for the first and second reconstructions. After the first tumor resection, 28 radial forearm fasciocutaneous flaps, 7 fibula osteoseptocutaneous flaps, 1 iliac osteomyocutaneous flap, and 2 rectus abdominis myocutaneous flaps were used. For reconstruction after the recurrence, 17 radial forearm fasciocutaneous flaps, 13 fibula osteoseptocutaneous flaps, 3 rectus abdominis myocutaneous flaps, 2 anterolateral thigh flaps, 1 jejunum flap, and 1 tensor fasciae latae flap were used. More vascularized bone transfers were performed during the second reconstruction since the excision for the recurrence frequently required segmental mandibulectomy. The complete flap survival rate was 97.3 percent and 94.6 percent with a reexploration rate of 7.9 percent and 13.5 percent for the first and second free tissue transfers, respectively. The mean follow-up time throughout the procedures was 37.5 months. Disease-free interval between reconstructions was 20.8 months. At the time of evaluation, 54.3 percent of the patients were surviving an average of 19 months since the second reconstruction. The results suggest that free flaps represent an important option in reconstruction of recurrent perioral carcinoma cases undergoing reexcision. When used in this indication they are as safe and effective as the initial procedure.

Adult↗

PubMed2000

Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction.

Free pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction is often advocated as the procedure of choice for autogenous tissue breast reconstruction in high-risk patients, such as smokers. However, whether use of the free TRAM flap is a desirable option for breast reconstruction in smokers is still unclear. All patients undergoing breast reconstruction with free TRAM flaps at our institution between February of 1989 and May of 1998 were reviewed. Patients were classified as smokers, former smokers (patients who had stopped smoking at least 4 weeks before surgery), and nonsmokers. Flap and donor-site complications in the three groups were compared. Information on demographic characteristics, body mass index, and comorbid medical conditions was used to perform multivariate statistical analysis. A total of 936 breast reconstructions with free TRAM flaps were performed in 718 patients (80.9 percent immediate; 23.3 percent bilateral). There were 478 nonsmokers, 150 former smokers, and 90 smokers. Flap complications occurred in 222 (23.7 percent) of 936 flaps. Smokers had a higher incidence of mastectomy flap necrosis than nonsmokers (18.9 percent versus 9.0 percent; p = 0.005). Smokers who underwent immediate reconstruction had a significantly higher incidence of mastectomy skin flap necrosis than did smokers who underwent delayed reconstruction (21.7 percent versus 0 percent; p = 0.039). Donor-site complications occurred in 106 (14.8 percent) of 718 patients. Donor-site complications were more common in smokers than in former smokers (25.6 percent versus 10.0 percent; p = 0.001) or nonsmokers (25.6 percent versus 14.2 percent; p = 0.007). Compared with nonsmokers, smokers had significantly higher rates of abdominal flap necrosis (4.4 percent versus 0.8 percent; p = 0.025) and hernia (6.7 percent versus 2.1 percent; p = 0.016). No significant difference in complication rates was noted between former smokers and nonsmokers. Among smokers, patients with a smoking history of greater than 10 pack-years had a significantly higher overall complication rate compared with patients with a smoking history of 10 or fewer pack-years (55.8 percent versus 23.8 percent; p = 0.049). In summary, free TRAM flap breast reconstruction in smokers was not associated with a significant increase in the rates of vessel thrombosis, flap loss, or fat necrosis compared with rates in nonsmokers. However, smokers were at significantly higher risk for mastectomy skin flap necrosis, abdominal flap necrosis, and hernia compared with nonsmokers. Patients with a smoking history of greater than 10 pack-years were at especially high risk for perioperative complications, suggesting that this should be considered a relative contraindication for free TRAM flap breast reconstruction. Smoking-related complications were significantly reduced when the reconstruction was delayed or when the patient stopped smoking at least 4 weeks before surgery.

Adult↗

PubMed2001

Postmastectomy reconstruction of the previously augmented breast: diagnosis, staging, methodology, and outcome.

Although many of the health and safety issues associated with breast augmentation have been thoroughly discussed over the past decade, the literature is remarkably silent regarding postmastectomy reconstruction of the previously augmented breast. A retrospective review of the senior author's reconstructive practice was performed for the years 1983 through March of 1999, revealing 21 women who underwent postmastectomy breast reconstruction after previous breast augmentation. For purposes of measuring aesthetic results, these 21 patients were matched to a carefully selected control group of 15 patients. They were also compared with other, larger populations, including 777 of the senior author's other breast reconstructions, the breast cancer registry at the Lombardi Cancer Center in Washington, D.C., and several large, published epidemiologic studies. The interval between the previous augmentation and the diagnosis of breast cancer ranged from 9 months to 18 years, with a mean of 9.3 years. None of the previous augmentation implants was ruptured at the time of mastectomy. Of the nine patients with previous subpectoral augmentation, cancer was detected mammographically in five (56 percent), whereas of the 12 patients with previous subglandular augmentation, cancer was first detected mammographically in only three (25 percent). This difference was not statistically significant (p = 0.2). Overall, eight of the study patients' tumors (38 percent) were first detected mammographically, which is similar to other published reports of breast cancer patients in the general population. Seventy-one percent of the 21 study patients were node-negative, which also compares favorably with other published series. Sixteen of the women with previous augmentation (76 percent) had purely prosthetic reconstructions. Flaps were used in the other five reconstructions (23 percent): three latissimus dorsi flaps (14 percent) and two transverse rectus abdominis musculocutaneous flaps (9 percent). All five flaps were used in patients who had undergone radiation therapy. Throughout the senior author's entire reconstructive practice history, transverse rectus abdominis musculocutaneous flaps were more frequently used [282 of 777 nonaugmented reconstructions (36 percent)], whereas latissimus dorsi flaps were less frequently used [17 of 777 nonaugmented reconstructions (2.2 percent)] (p < 0.001). The cosmetic results of the breast reconstructions in the previously augmented study group were generally good-to-excellent, with a mean score by blinded observers of 3.35 of a possible 4.0. These results were comparable to or better than those in the matched controls, who scored a mean of 3.0.

Adult↗

PubMed2004

Local-regional radiation therapy after breast reconstruction: what is the appropriate target volume? A case-control study of patients treated with electron arc radiotherapy and review of the literature.

The oncologic safety and cosmetic outcome of immediate breast reconstruction in breast cancer patients requiring radiation therapy remains ill-defined. Between 1980 and 1998, 18 patients were treated at the University of Utah Medical Center with mastectomy, immediate breast reconstruction, and adjuvant radiation therapy delivered via an electron arc technique. A case-control study was performed matching reconstructed patients in a 1:2 ratio with patients undergoing mastectomy without reconstruction, using number of lymph nodes and tumor size. Median follow-up was 61 months for the reconstructed group. Five-year local-regional control, disease-free survival, and overall survival rates were 87%, 58%, and 74% respectively in the reconstructed group, versus 88%, 57%, and 67% respectively in the matched control group. Cosmesis was good/excellent in 11 of 13 living patients (85%). Significant capsular contraction occurred in 18% of prosthetic reconstruction patients, and revisional surgery was required in 24% of prosthetic reconstruction patients. Utilizing the electron arc technique, the median radiation dose to the chest wall at the midlevel of the ribs was 20% of the prescribed dose, and no patient failed deep to the implant. These results suggest that in appropriately selected patients, structures deep to the reconstruction are not at high risk for local-regional recurrence, and immediate breast reconstruction yields comparable local-regional control, disease-free survival, and overall survival rates to nonreconstructed patients, with acceptable cosmetic results.

Adult↗

PubMed2002

A classification system and reconstructive algorithm for acquired vaginal defects.

Although multiple flaps have been used for vaginal reconstruction, a logical approach to reconstruction of these often complex defects has not been described. The objective of this study was to establish a classification system for acquired vaginal defects and to develop a reconstructive algorithm derived from this system. This study is a retrospective review of a 7-year experience with 51 flaps in 37 consecutive vaginal reconstructions. Twenty-two partial defects and 15 circumferential defects were reconstructed in 35 patients. Average patient age was 48 years (range, 19 to 69 years). Of the 22 patients with partial vaginal defects, six involved primarily the anterior and lateral wall and 16 the posterior vaginal wall. Among the 15 patients with circumferential defects, four included only the upper two-thirds of the vagina and 11 encompassed the entire vagina. On the basis of these defects, a classification system was developed. Partial defects involving the anterior or lateral vaginal wall were classified as type IA defects and were reconstructed primarily with pedicled Singapore fasciocutaneous flaps. Partial defects involving the posterior wall were classified as type IB and were reconstructed with pedicled rectus abdominis myocutaneous flaps. Circumferential defects involving the upper two-thirds of the vagina were classified as type IIA defects and were reconstructed with a rolled rectus flap or, less commonly, sigmoid colon (one patient). Total circumferential defects, type IIB, were reconstructed largely with bilateral gracilis flaps. Six patients had major complications, including one perioperative death, one complete flap loss, one partial flap loss, and three pelvic abscesses. Three patients had minor complications that included delayed wound healing and donor-site infection. Vaginal defects can be categorized into one of four types on the basis of the location and extent of resection. Flap selection is determined on the basis of the type of defect. Using this algorithm, immediate vaginal reconstruction with pedicled regional flaps can be performed with minimal patient morbidity and few surgical complications.

Adenocarcinoma↗

PubMed2003

Microvascular reconstruction of the hypopharynx: defect classification, treatment algorithm, and functional outcome based on 165 consecutive cases.

The objectives of this study were three-fold: to develop a scheme for classification of hypopharyngeal defects, to establish a reconstructive algorithm based on this system, and to assess the functional outcome of such reconstruction. This study is a retrospective review of a 14-year experience with 165 consecutive microvascular reconstructions of the hypopharynx in 160 patients. The average patient age was 59 years (95 percent CI, 37 to 81). Thirty-four patients were operated on for recurrent disease; 71 had preoperative radiotherapy. Partial defects were reconstructed with radial forearm flaps (n = 52); circumferential defects were reconstructed with jejunum (n = 90); and extensive, noncircumferential longitudinal defects were reconstructed with rectus abdominis flaps (n = 23). The overall free flap success rate was 98 percent. Six flaps required reexploration, two of which were salvaged. The incidence of fistula was 7 percent and stricture, 4 percent. Preoperative radiotherapy was significantly associated with risk of recipient site complications (OR, 2.3; 95 percent CI, 1.0 to 5.0). Follow-up data were available on 95 percent of patients: 53 percent were able to tolerate an unrestricted diet, 23 percent a soft diet, 12 percent liquids only, and 12 percent were limited to tube feedings. The treatment algorithm for microvascular hypopharyngeal reconstruction is based on the type of defect with partial defects with radial forearm flaps, circumferential defects reconstructed with free jejunal flaps, and extensive, multilevel defects reconstructed with rectus abdominis myocutaneous flaps. Microvascular reconstruction of pharyngeal defects is highly successful with few postoperative complications. With appropriate flap selection, functional outcome can be optimized.

Adult↗

PubMed2006

A single surgeon's 12-year experience with tissue expander/implant breast reconstruction: part II. An analysis of long-term complications, aesthetic outcomes, and patient satisfaction.

BACKGROUND: Few reports have critically evaluated long-term outcomes following two-stage implant reconstruction. The objective of this study was to evaluate long-term aesthetic results, late complications, and patient satisfaction following tissue expander/implant breast reconstruction. A single surgeon's extensive experience with implant-based reconstruction provides an opportunity to evaluate these results in a uniformly treated patient population. METHODS: A total of 1522 tissue expander/implant reconstructions were initiated in 1221 patients from July of 1992 to June of 2004. Data on a cohort of 315 patients (410 reconstructions) with a minimum of 1 year of follow-up were entered into a prospectively maintained outcomes database. Overall aesthetic grade, capsular contracture grade, patient satisfaction, and late complications were prospectively evaluated, and outcome data were recorded on an ongoing basis. RESULTS: Mean follow-up was 36.7 months. Eighty-eight percent of patients had a good to excellent aesthetic result. Laterality of reconstruction (bilateral versus unilateral) and radiation history were significant predictors of overall cosmesis. Aesthetic results were not related to preoperative breast size, implant volume, or body mass index. Pathologic capsular contractures (grade III/IV) developed in 10.4 percent of patients. Four percent of all permanent implants were exchanged for a second prosthesis. Ninety-five percent of patients were satisfied with their reconstruction. CONCLUSIONS: Tissue expander/implant reconstruction yields good to excellent long-term aesthetic results in the majority of patients, and overall patient satisfaction remains high. Bilateral reconstructions have higher overall aesthetic grades. Reconstruction may be performed in patients with larger-volume breasts with satisfactory cosmesis. Successful outcomes are possible in patients who receive chest wall irradiation.

Adult↗

PubMed2007

Microvascular reconstruction in burn and electrical burn injuries of the severely traumatized upper extremity.

BACKGROUND: As the versatility and variability of free flaps have significantly increased during recent years, so have the indications for free tissue transplantation in burn reconstruction expanded. METHODS: The authors report retrospectively the results of 42 free flaps for upper extremity reconstruction in 35 severely burned patients using 13 different free flaps. This experience enabled the authors to establish reconstructive principles pertinent to the type of injury (burn versus high-voltage injuries) and the timing of reconstruction procedures. RESULTS: In high-voltage injuries (n = 17), early free flap coverage with muscular flaps was the most frequently used type of reconstruction. The reconstruction site was predominately the forearm. In burn injuries, free flap coverage was performed during a later stage of the treatment course. Reconstruction with cutaneous or fascial flaps was the preferred method. The elbow and dorsum of the hand underwent defect coverage in most circumstances. For reconstruction of complex or large defects (n = 6), combined "chimeric" flaps were used. Overall, the flap failure rate was 12 percent (n = 5). Interestingly, there was a relationship between flap failure rate and timing of the procedure. Four of five flap failures occurred within 5 to 21 days after trauma, and all five flap failures occurred between 5 days and 6 weeks. No flap failure occurred during secondary reconstruction. CONCLUSIONS: The authors' data demonstrate that burn and high-voltage injuries are distinct entities, each requiring custom-tailored reconstructive solutions for limb salvage. Even if the authors' flap failures all occurred during the first 6 weeks, it should not be forgotten that this type of coverage is the only alternative to amputation in selected cases.

Adolescent↗

PubMed2003

TRAM flap breast reconstruction for patients with advanced breast disease.

Transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction in patients with advanced breast cancer is controversial. Management of these patients is often complex and consists of surgical extirpation, postoperative radiation, chemotherapy, and in some cases bone marrow transplantation. Few studies have attempted to examine patient long-term survival and overall satisfaction with the surgical procedure. This study examines one center's experience with patients undergoing breast reconstruction for stage III and stage IV breast carcinoma. A retrospective review was performed of all patients undergoing TRAM reconstruction with stage III or IV breast cancer. Surviving patients and family members were contacted for follow-up. Patients were asked to grade their satisfaction with the reconstructive procedure on a 5-point scale (5 points, extremely satisfied; 1 point, extremely dissatisfied). Postoperative complications and time to return to work were also recorded. During a 10-year period (1991-2000) 21 women underwent TRAM reconstruction for advanced breast cancer. Twenty patients had stage III disease and 1 patient had stage IV disease. Mean patient age was 49 years. A total of 26 TRAM flaps were performed; 5 patients had bilateral procedures. Of the 26 TRAM flaps, 17 were immediate and 9 were delayed, and 20 were free and 6 were pedicled. Follow-up averaged 6.5 years (range, 2-10 years). Postoperative complications occurred in 7 patients and included fat necrosis (N = 3), hematoma (N = 2), cellulitis (N = 1), delayed donor site healing (N = 2), and seroma (N = 1). There were no flap losses. Patients were able to return to normal activities or work at an average of 10.6 weeks. Eleven patients developed recurrent disease. Nine patients (43%) succumbed to their disease during the follow-up period. In these patients the average interval between TRAM reconstruction and death was 3.7 years (range, 1-6.5 years). Eleven patients or surviving family members participated in the patient satisfaction survey. The average satisfaction grade was 4.6 points. All patients would repeat the TRAM reconstruction again. Patients with advanced breast cancer can be considered appropriate candidates for TRAM reconstruction. The results of this study indicate that patients with advanced breast cancer do not have an increased rate of postoperative complications, and they recover within a reasonable time from their surgical procedure despite adjuvant radiation and chemotherapy. Furthermore, the majority of patients are satisfied with their reconstructed breast and postoperative course, and would choose this reconstructive option again.

Adult↗

PubMed2003

Successful renovascular reconstruction for renal allografts with multiple renal arteries.

BACKGROUND: Kidney grafts with multiple renal arteries have been considered a relative contraindication because of the increased risk of complications. In the present study, we retrospectively reviewed multiple renal artery reconstruction in kidney transplantation to elucidate the usefulness of these grafts. METHODS: From January 1997 until August 2001, 431 recipients underwent kidney transplantation at our institution; 393 patients are reviewed. The surgical techniques of vascular reconstruction and short-term outcome are reported. The living kidney transplant recipients were divided into vascular reconstructed and nonreconstructed groups, and mean serum creatine levels, warm and total ischemic times, and incidences of acute rejection and posttransplantation hypertension were compared. RESULTS: We noted multiple renal arteries in 96 (24.4%) of the 393 grafts. Arterial reconstruction was performed on 53 (13.5%) grafts, whereas 43 (10.9%) small polar arteries were simply ligated. Surgical management of the multiple arteries was variable. The most common reconstruction was conjoined anastomosis (17 cases) between two arteries of equal size and end-to-side anastomosis (14 cases) of smaller arteries to larger arteries. In nine cases, autogenous hypogastric or epigastric artery grafts were used to reconstruct multiple renal arteries. Multiple anastomosis was performed in six cases. In seven cases, complicated surgical vascular reconstruction was performed. The mean total ischemic times in the reconstructed and nonreconstructed groups were 102.6 and 71.0 min, respectively (P<0.01). The incidences of posttransplantation hypertension in the reconstructed and nonreconstructed groups were 68.2% (30/44) and 48.6% (141/290), respectively (P<0.05). There was no significant difference between the reconstructed and nonreconstructed groups in mean warm ischemic times, mean creatinine levels, and incidences of acute rejection. CONCLUSIONS: Allografts with multiple renal arteries can be used successfully in kidney transplantation.

Acute Disease↗

PubMed1999

Anti-aliased three-dimensional cone-beam reconstruction of low-contrast objects with algebraic methods.

This paper examines the use of the algebraic reconstruction technique (ART) and related techniques to reconstruct 3-D objects from a relatively sparse set of cone-beam projections. Although ART has been widely used for cone-beam reconstruction of high-contrast objects, e.g., in computed angiography, the work presented here explores the more challenging low-contrast case which represents a little-investigated scenario for ART. Preliminary experiments indicate that for cone angles greater than 20 degrees, traditional ART produces reconstructions with strong aliasing artifacts. These artifacts are in addition to the usual off-midplane inaccuracies of cone-beam tomography with planar orbits. We find that the source of these artifacts is the nonuniform reconstruction grid sampling and correction by the cone-beam rays during the ART projection-backprojection procedure. A new method to compute the weights of the reconstruction matrix is devised, which replaces the usual constant-size interpolation filter by one whose size and amplitude is dependent on the source-voxel distance. This enables the generation of reconstructions free of cone-beam aliasing artifacts, at only little extra cost. An alternative analysis reveals that simultaneous ART (SART) also produces reconstructions without aliasing artifacts, however, at greater computational cost. Finally, we thoroughly investigate the influence of various ART parameters, such as volume initialization, relaxation coefficient lambda, correction scheme, number of iterations, and noise in the projection data on reconstruction quality. We find that ART typically requires only three iterations to render satisfactory reconstruction results.

Algorithms↗

PubMed2002

Efficient fully 3-D iterative SPECT reconstruction with Monte Carlo-based scatter compensation.

Quantitative accuracy of single photon emission computed tomography (SPECT) images is highly dependent on the photon scatter model used for image reconstruction. Monte Carlo simulation (MCS) is the most general method for detailed modeling of scatter, but to date, fully three-dimensional (3-D) MCS-based statistical SPECT reconstruction approaches have not been realized, due to prohibitively long computation times and excessive computer memory requirements. MCS-based reconstruction has previously been restricted to two-dimensional approaches that are vastly inferior to fully 3-D reconstruction. Instead of MCS, scatter calculations based on simplified but less accurate models are sometimes incorporated in fully 3-D SPECT reconstruction algorithms. We developed a computationally efficient fully 3-D MCS-based reconstruction architecture by combining the following methods: 1) a dual matrix ordered subset (DM-OS) reconstruction algorithm to accelerate the reconstruction and avoid massive transition matrix precalculation and storage; 2) a stochastic photon transport calculation in MCS is combined with an analytic detector modeling step to reduce noise in the Monte Carlo (MC)-based reprojection after only a small number of photon histories have been tracked; and 3) the number of photon histories simulated is reduced by an order of magnitude in early iterations, or photon histories calculated in an early iteration are reused. For a 64 x 64 x 64 image array, the reconstruction time required for ten DM-OS iterations is approximately 30 min on a dual processor (AMD 1.4 GHz) PC, in which case the stochastic nature of MCS modeling is found to have a negligible effect on noise in reconstructions. Since MCS can calculate photon transport for any clinically used photon energy and patient attenuation distribution, the proposed methodology is expected to be useful for obtaining highly accurate quantitative SPECT images within clinically acceptable computation times.

Algorithms↗

PubMed2003

A new framework of image reconstruction from fan beam projections.

In this paper, we present a unified framework to reconstruct images for both fan beam and cone beam projections. The important feature of our theoretical framework is that it does not depend on the classical concept of the Radon transform at all. This property allows us to directly generalize the ideas and techniques developed in this paper to the cone beam reconstruction problem. In this paper, we extract such a framework from developing a new image reconstruction scheme from fan beam projections. Our new scheme also provides us new understanding of fan beam reconstruction problem. Our main results for the fan beam reconstruction are the following: First, we derive a general reconstruction scheme, in which the data sufficiency condition is transparently revealed by the reconstruction formula. Specifically, the data sufficiency condition for an accurate reconstruction of a region of interest (ROI) is that all the lines passing through the ROI must intersect the source trajectory at least once. Second, we further simplify the general reconstruction scheme by following three major steps of our new framework: (i) using symmetries of intermediate function; (ii) handling the data redundancy; (iii) changing discrete summation over the possible focal points into an integral along the source trajectory. After these steps, we obtain a new filtered backprojection algorithm. The key characteristic of this new algorithm is to take derivative of measured data with respect to the trajectory parameter. In practice, we can trade this derivative to some other continuous functions. In the configuration of a circular source trajectory with a third generation arc/collinear detector, we demonstrate how to remove the undesirable derivative of measured projection data. It results in a new algorithm for the sequential reconstruction of a ROI with a general normalized weighting function.

Algorithms↗