Adrian S.H. Ooi

Reducing infection risk in implant-based breast-reconstruction surgery: challenges and solutions.

Implant-based procedures are the most commonly performed method for postmastectomy breast reconstruction. While donor-site morbidity is low, these procedures are associated with a higher risk of reconstructive loss. Many of these are related to infection of the implant, which can lead to prolonged antibiotic treatment, undesired additional surgical procedures, and unsatisfactory results. This review combines a summary of the recent literature regarding implant-related breast-reconstruction infections and combines this with a practical approach to the patient and surgery aimed at reducing this risk. Prevention of infection begins with appropriate reconstructive choice based on an assessment and optimization of risk factors. These include patient and disease characteristics, such as smoking, obesity, large breast size, and immediate reconstructive procedures, as well as adjuvant therapy, such as radiotherapy and chemotherapy. For implant-based breast reconstruction, preoperative planning and organization is key to reducing infection. A logical and consistent intraoperative and postoperative surgical protocol, including appropriate antibiotic choice, mastectomy-pocket creation, implant handling, and considered acellular dermal matrix use contribute toward the reduction of breast-implant infections.

5-step harvest of supraclavicular lymph nodes as vascularized free tissue transfer for treatment of lymphedema

Treatment for lymphedema has entered an exciting new stage. Advances in microsurgery, imaging, and knowledge of the lymphatic system has led to the advent of physiologic procedures such as vascularized lymph node (VLN) transfer [1–6]. The core plastic surgical concept of replacing like with like is no more evident than in this operation, with the restoration of healthy lymph nodes to a limb in which lymphatic flow has been disrupted or where native lymph nodes are absent through development or surgery. Purported mechanisms include breaking of obstructive scar at recipient sites, hydrostatic “pumping” of intra-flap lymph via arterial inflow and venous outflow, and lymphangiogenesis aided by the production of VEGF-C by the transplanted lymph nodes [7–11]. While there is increasing literature proving the efficacy of VLN transfer, development of techniques are still in an early stage and no standard procedures have been agreed upon. Harvesting of lymph nodes from areas such as the groin and axilla, while well-described, can result in devastating permanent lymphedema of the donor limb [12,13]. Harvest of lymph nodes from the neck including the submental and supraclavicular regions, while technically demanding, offers the benefits of low donor site morbidity and minimal scarring. In addition, lymph node harvest and recipient site preparation can usually proceed simultaneously. Of the latter, the harvest of supraclavicular lymph nodes have the advantages of no risk to facial nerve injury and a lower placed scar that is aesthetically more pleasing [4,14]. However, surgeons must have a firm grasp of the anatomy and technique as the supraclavicular area has many critical structures, such as the carotid artery, internal jugular vein (IJV), and phrenic nerve that must be avoided. This flap must be approached with caution as the space is small and deep, and careless technique can lead to complications such as bleeding, chyle leak, and damage to the phrenic nerve or even brachial plexus. As in any surgical approach, with good knowledge of the anatomy and meticulous attention to surgical technique, the supraclavicular lymph node flap can be a great source for VLN. In addition, it can be harvested relatively quickly with minimal donor site morbidity. In this paper, we summarize the experience of the senior author in the harvest of the supraclavicular VLN and describe the technique in five sequential steps. We outline the anatomy and detail the intricacies of each step, and explain why this is our preferred source of VLN. MATERIALS AND METHODS

Discussion: Does the Use of Incisional Negative-Pressure Wound Therapy Prevent Mastectomy Flap Necrosis in Immediate Expander-Based Breast Reconstruction?

www.PRSJournal.com 567 A procedures are currently the most popular choice for postmastectomy breast reconstruction.1 Although autologous tissue remains the gold standard, improvements in knowledge, techniques, and materials have led to better outcomes for both expanderand implantbased procedures.1,2 The introduction of acellular dermal matrices has improved overall aesthetic results, closely matching those of autologous tissue. However, it has also led to significantly increased rates of seroma, infection, and overall complications, which in turn result in adverse consequences, including explantation and poor cosmesis.3 The introduction of negative-pressure wound therapy by Argenta and Morykwas brought a new dimension to wound care.4,5 Purported mechanisms of action are mechanical deformation and fluid control, with touted benefits including increased wound vascularity and granulation tissue with decreased bacterial load.6 With mounting evidence showing the efficacy of negative-pressure wound therapy in open wounds, attention has been directed to its use on closed wounds. A rising number of studies from the orthopedic, cardiothoracic, general, and plastic surgery literature show decreased seroma, infection, and wound dehiscence rates.7,8 In particular, patients at higher risk for wound breakdown, such as the obese population, may have greater benefit.9,10 Although still not fully understood, postulated beneficial effects of incisional negative-pressure wound therapy increased perfusion at the edges of the wound, decreased lateral tension aiding in up to 50 percent better wound tensile strength, and reduced seroma and hematoma formation.11,12 In the article under discussion, the authors seek to reduce the incidence of complications in postmastectomy expander reconstruction by the use of incisional negative-pressure wound therapy. With study and control groups of 45 and 183 breasts, respectively, they come to the conclusion that incisional negative-pressure wound therapy significantly decreases the rate of major mastectomy flap necrosis rates (i.e., those requiring operative intervention), overall mastectomy flap necrosis rates, and overall complication rates. Using univariate analysis, they also showed that the use of incisional negative-pressure wound therapy alone significantly lowered the risk of overall necrosis and complications, although its effect on major necrosis did not reach statistical significance. Their experimental and statistical methodology is sound, and they are careful to compare only patients with expanders and acellular dermal matrix. On further analysis, some questions and confounding factors remain. Essentially, the only real benefit shown is the decrease in major mastectomy flap necrosis rates, with no effect on minor mastectomy flap necrosis, hematoma, or seroma rates. As acknowledged by the authors, the numbers in the study group are small, and performing a direct comparison with a larger group of conventional dressing patients may lead to skewed results. How is it that minor mastectomy flap necrosis rates are not similarly affected? Mastectomy skin flap necrosis is dependent on a variety of factors. The present study cites factors for major mastectomy flap necrosis such as high patient body mass index and high mastectomy weight, corroborating previous studies.13 However, other proven detrimental

Modification of the Radial Forearm Fasciocutaneous Flap in Partial Pharyngolaryngeal Reconstruction to Minimize Fistula Formation

Summary: Reconstruction of pharyngolaryngoesophageal defects following salvage surgery in patients with a history of chemoradiation is a challenging problem with a high incidence of pharyngocutaneous fistula. The authors describe three cases of successful reconstruction of partial pharyngolaryngoesophageal defects using a modified radial forearm free flap with additional dermal reinforcement and review the literature for innovations in the use of radial forearm free flap for reconstruction of these difficult cases. Modification of the radial forearm free flap makes it a versatile, reliable flap that has become the “go-to” flap for partial pharyngolaryngoesophageal reconstruction.

Implantable Doppler monitoring of buried free flaps during vascularized lymph node transfer

Reliable flap monitoring is crucial to the success of free tissue transfer, including vascularized lymph node transfer (VLNT). However, no large‐scale study has examined implantable Doppler monitoring in VLNT. We aimed to determine whether an implantable Doppler system can reliably monitor flap perfusion during VLNT and also to calculate the sensitivity and specificity of this system for detecting compromise in the monitored vessel.

The utility of the musculocutaneous anterolateral thigh flap in pharyngolaryngeal reconstruction in the high-risk patient

Prior radiotherapy leads to increased wound complication rates for microsurgical reconstruction of pharyngolaryngeal (PL) defects. Incorporating vastus lateralis muscle together with anterolateral thigh flap (ALT) skin in defect reconstruction is useful in protecting vital structures and reinforcing irradiated neck skin and suture lines. This study shows the utility of the musculocutaneous ALT (MC ALT) in PL reconstruction in previously irradiated patients.

Geometric Three-Dimensional End-to-Side Microvascular Anastomosis: A Simple and Reproducible Technique

Background End‐to‐side (ETS) anastomoses are useful when preservation of distal vascularity is critical. The ideal ETS microanastomosis should maintain a wide aperture and have a smooth take‐off point to minimize turbulence, vessel spasm, and thrombogenicity of the suture line. We have developed a unique, dependable, and reproducible geometric technique for ETS anastomoses, and analyze its efficacy in our series of patients. Methods The geometric ETS technique involves creating a three‐dimensional (3D) diamond‐shaped defect on the recipient vessel wall, followed by a slit incision of the donor vessel to create a “spatula” fitting this defect. This technique removes sutures from the point of most turbulent blood flow while holding the recipient vessel open with a patch vesselplasty effect. We perform a retrospective review of a single surgeons experience using this technique. Results The geometric 3D ETS technique was used in 87 free flaps with a total of 102 ETS anastomoses in a wide range of cases including head and neck, trunk and genitourinary, and extremity reconstruction. Overall, free flap success rates were 98%. Conclusions The geometric 3D ETS technique creates a wide anastomosis, minimizes turbulence‐inducing thrombogenicity, and mechanically holds the recipient vessel open. It is reliable and reproducible, and when performed properly has been shown to have high rates of success in a large group of free tissue transfer patients.

Re-introducing the delto-acromial perforator flap: Clinical experience and cadaver dissection

BACKGROUND Although perforator flaps from the pectoral branch of the thoraco-acromial (TA) axis have been well-described, there are few reports of perforator flaps based on the delto-acromial (DA) branches. We have found a reliable perforator coming off the DA branch of the TA axis, and have named a flap based on this vessel the delto-acromial perforator (DAP) flap. We describe our experience with the DAP flap together with a fresh cadaver anatomical study. METHODS A retrospective review of all DAP flaps performed between December 2012 and January 2015 at our institution, with analysis of operative details, flap characteristics and surgical outcomes. We performed fresh cadaver dissection on 5 hemi-chest walls. RESULTS The main cutaneous perforator from the deltoid and/or acromial branches is found at the delto-pectoral groove, 8 cm lateral to the TA axis and 8 cm inferior to the acromio-clavicular joint. Five patients underwent DAP flap reconstruction. Three were pedicled and 2 were free flaps. Average pedicle length from the origin of the DA branch was 8 cm, with an arterial diameter of at least 1 mm and vein diameter 1.5 mm. All flaps survived completely. Cadaver dissection showed a consistent perforator arising from the common delto-acromial branch in 4 cadavers, and from the deltoid branch in 1 cadaver. CONCLUSIONS The DAP flap is a good addition to the armamentarium of reconstructive surgeons when a relatively thin fasciocutaneous flap with minimal hair is desired. It may be used for free tissue or locoregional transfer.

A Novel Strategy to Supercharge a Deep Inferior Epigastric Artery Perforator Flap after Port-a-Cath Removal

Summary: Autologous breast reconstruction using the deep inferior epigastric artery perforator (DIEP) flap has become increasingly popular because of its unique advantages. However, compared with some other forms of abdominal-based autologous reconstruction, DIEP flaps are associated with an increased risk of venous congestion. Many techniques—or lifeboats—have been introduced to diagnose and treat this potentially devastating complication. In this case report, we describe a novel strategy to augment venous drainage when venous congestion is encountered. A patient presented requesting autologous reconstruction and removal of a venous access catheter that had been used for chemotherapy administration. We performed left delayed breast reconstruction using a single-perforator DIEP flap from the right hemiabdomen. The superficial inferior epigastric vein to this flap was preserved. After removal of the Port-a-Cath from the left chest, we anastomosed the superficial inferior epigastric vein to the fibrous capsular sheath that had formed around the indwelling catheter to allow additional venous drainage. Flow through this conduit was confirmed using Doppler ultrasound. There were no flap-related complications, and the patient was discharged in good condition. Further research is warranted to characterize the indications and limitations of this novel lifeboat.

Discussion: Volumetric Planning Using Computed Tomographic Angiography Improves Clinical Outcomes in DIEP Flap Breast Reconstruction.

www.PRSJournal.com 781e O the past decade, the use of computed tomographic angiography in free deep inferior epigastric perforator (DIEP) flap breast reconstruction has increased.1,2 Initially used as a tool to aid in locating abdominal perforators, advances in protocols have enabled accurate delineation of perforator intramuscular course and the superficial venous communication of the flap.3 Potential advantages of preoperative computed tomographic angiography include faster operative times, lower abdominal wall morbidity, and decreased surgeon stress.4 More recently, computed tomographic scanning has been used to estimate flap volume through the use of algorithms based on surgeon-set points and landmarks, aiding preoperative planning.5 Simultaneously, computed tomographic scans have been used in measurement of breast volume.6,7 The main contraindications of computed tomographic angiography are renal failure and sensitivity to contrast medium. The other drawbacks of computed tomographic angiography are cost, which is reportedly offset by saved operative time; and exposure to radiation, which has been shown to be lower compared with other more regularly performed radiologic procedures.2,8 We commend the authors on their detailed study regarding the innovative use of computed tomographic scanning in breast reconstruction, their sound data collection and statistical analysis, and their algorithm for reducing DIEP flap perfusion-related complications. This is a follow-up on a previous study by the senior author (G.H.M.), where the inset rate concept was first introduced.7 The current study uses computed tomographic scans to match the volume of the nondiseased breast and divides this by the calculated total volume of the abdominal flap, producing the inset rate. Based on the inset rate, the authors then decide which concurrent procedures to perform intraoperatively to reduce flap perfusion-related and potential donor-site complications. Through a 5-year experience of three different cohorts, they have refined their algorithm based on inset rates of less than 0.5, 0.5 to 0.75, and greater than 0.75. The primary aim of this algorithm is to further aid surgeons in flap planning and determination of the need for adjunct procedures to reduce perfusion-related flap complications. An important finding of this study is that knowing the inset rate can lead to reduced flap perfusion-related problems. This is a well-done study and supports what we have known, namely, that as more flap tissue volumes (or zones) are required for reconstruction, we need to accordingly optimize the flap perfusion. This can be accomplished by including more perforators, draining the superficial system, or using a bipedicled approach. Although total flap loss is no longer a major issue, we have long known that use of larger flaps recruiting more tissue across the midline leads to higher fat necrosis rates.9 The literature has also shown that incorporating a higher number of adequate perforators in an abdominal flap leads to better perfusion-related outcomes.10 Although smaller flaps (inset rate, <0.75) have fewer complications, including more perforators and preserving a long segment of the superficial vein for additional venous drainage in any abdominal flap procedure regardless of the inset rate is prudent. A significant take-home message of the algorithm is that flaps with an inset rate greater than 0.75, implying abdominal flap zone IV requirement, should be bipedicled (Figs. 1 and 2). F1, F2