Adam Searle

One hundred cases of abdominal-based free flaps in breast reconstruction. The impact of preoperative computed tomographic angiography

An accurate preoperative evaluation of the vascular anatomy of the abdominal wall is essential in deep inferior epigastric perforator (DIEP) flap reconstruction. We present our experience of using computed tomographic angiography (CTA) of the abdomen as part of our standard preoperative assessment of abdominal-based breast reconstruction. One hundred consecutive cases were examined retrospectively, divided equally into non-CTA and CTA periods. Following use of CTA, fewer superficial inferior epigastric artery (SIEA) flaps were performed (18% vs. 0%), although the number of DIEP and muscle-sparing transverse rectus abdominis myocutaneous (MS TRAM) flaps remained similar. There was an increased use of single perforators in the CTA group than in the non-CTA group (48% vs. 18%) as well as increased numbers of medial-row perforators (65% vs. 32%). Unilateral reconstructions were performed 1h faster in the CTA group (489min vs. 566min). Finally, hernia rates decreased from 6% in the non-CTA group to 0% in the CTA group. A clear knowledge of the dominant perforator(s) to the abdominal skin prior to surgery can greatly increase the success of this procedure and reduce surgical time. In addition, by choosing the largest well-placed perforator supplying the bulk of the flap, it may be possible to reduce the overall morbidity.

Aggressive cutaneous squamous cell carcinoma of the head and neck in patients with chronic lymphocytic leukaemia.

We describe multiple cutaneous squamous cell carcinomas of the head and neck in five patients with chronic lymphocytic leukaemia (CLL). When associated with CLL, cutaneous squamous cell carcinomata behave in a much more aggressive manner than otherwise expected. Four patients developed local recurrence after primary treatment. All five patients developed lymph node metastases containing squamous cell carcinoma. Three of five patients (60 per cent) had multiple primary lesions. Whereas the increased incidence of second cancers in CLL and notably of skin cancers is documented, little has been written to describe the aggressive behaviour of these tumours. It is important, when treating these patients, to be aware of the high tendency towards local recurrence and lymph node metastasis and to consider an aggressive management plan and careful follow-up.

Flap reconstruction following gynaecological tumour resection for advanced and recurrent disease – A 12 year experience

We have reviewed all the cases of flap reconstruction following resection of a gynaecological malignancy at the Royal Marsden Hospital over 12 years from 1993 until 2005. Forty-six patients were identified who required 53 flaps. The predominant site of the primary tumour was vulva, accounting for 83% of the cases, with cervix, ovary, vagina and endometrium making up the remainder. Squamous cell carcinoma was the most common histological type, accounting for 71% of cases, with adenocarcinoma, Paget disease, leiomyosarcoma, melanoma and basosquamous carcinoma making up the remainder. Most patients (73%) had recurrent disease at the time of reconstruction and most patients (80%) had been treated with radiotherapy either before and/or after surgery. Local flaps accounted for 49% of the reconstructions performed, with 16 rhomboid flaps, five lotus petal flaps and five advancement flaps. Of the pedicled myocutaneous flaps, there were 21 rectus abdominis flaps, four gracilis flaps and one tensor fascia lata flap. There was one free flap. The complication rate was 53%, with wound breakdown predominating. The 5 year survival was 14%, with 67% of patients surviving 1 year. This group of patients often have advanced disease and a limited life span. The complications associated with performing a major reconstructive procedure need to be balanced against the potential wound problems associated with leaving these advanced tumours untreated surgically.

Surgical management of radiation-induced angiosarcoma after breast conservation therapy

BACKGROUND Radiation-induced angiosarcoma (RA) is a well-recognized complication of breast conservation therapy (BCT). METHODS Over a 12-year period, 14 patients with a median age of 68 years were identified retrospectively. The median latency from BCT to onset of RA was 81 months. The incomplete excision rate (complete histologic margin taken to be > 10 mm) was 46%. There was a significant difference in the size of the cutaneous defect between the complete and incomplete excision groups (412 vs 592 cm(2), respectively; P < .05), indicating more extensive disease in the latter group. RESULTS The tumor recurred locally in 12 patients (92%). The median time to local recurrence (LR) in patients with incomplete excision was 3 versus 23 months in patients who had a complete excision. The median survival time for patients who underwent complete versus incomplete excision was 42 and 6 months, respectively. CONCLUSIONS RA is a challenging condition, with a prolonged latency period and variable clinical progression. Incomplete excision of RA is a surrogate marker of aggressive disease and is associated with rapid LR and poor survival.

Case report: Pyoderma gangrenosum following Deep Inferior Epigastric Perforator (Diep) free flap breast reconstruction

Pyoderma gangrenosum is a rare but significant cutaneous disease that can lead to skin ulceration and necrosis. It is idiopathic but can occur post surgically. There has been only a limited number of case reports of PG complicating breast surgery.

Direct microvascular monitoring of a free autologous jejunal flap using microendoscopy: a case report

BackgroundEarly identification of flap failure is an indispensable prerequisite for flap salvage. Although many technical developments of free flap monitoring have now reached clinical application, very few are considered to be reliable and non-invasive for early recognition of flap failure.Case presentationWe used microendoscopic technique for microvascular monitoring of free autologous jejunal flap by the direct visualisation of the flow of erythrocytes through the capillary vasculature on both the mucosal and serosal surfaces.Blood flow was seen to be pulsatile, with individual erythrocytes visible in the capillaries. The best view was obtained when the scope was focussed directly on the capillary rather than the graft surface. The view of the unstained mucosal surface was bland apart from the fine capillary loops which were seen to fill with each pulsatile event. The microendoscopic examination of the serosal surface revealed much larger calibre vessels with obvious blood flow.ConclusionThe microendoscopic monitoring technique is simple and safe with direct visualisation of blood flow. The technique may also be useful for the monitoring of other free bowel transplants.

The current role of tissue engineering in head and neck reconstruction

Tissue engineering is an emerging field that has the potential to revolutionize the field of reconstructive surgery by providing off-the-shelf replacement products. The literature has become replete with tissue engineering studies, and the aim of this article is to review the contemporary application of tissue-engineered products. The use of tissue-engineered cartilage, bone and nerve in head and neck reconstruction is discussed.

Limb Salvage Surgery in the Excision of a Massive Fibromatosis

Fibromatosis is a rare fibroproliferative disorder with a tendency for local infiltrative and destructive growth. Local recurrence is frequent, despite apparent complete resection after radical excision. We present a case of a 22-year-old woman with massive recurrent thoracic fibromatosis extending into the neck and impairing the function of her right upper limb. This required a multidisciplinary approach to surgery to salvage the limb. The case highlights the fact that while every attempt should be made to achieve negative histologic margins, local recurrence is not uncommon. Therefore, if fibromatosis occurs adjacent to or involves vital structures, these should not be sacrificed to achieve negative margins. Function and structure preserving procedures are important as the primary goal, if not even more important.