Alanna M. Rebecca

Advantages of preoperative computed tomography in deep inferior epigastric artery perforator flap breast reconstruction.

Background: Preoperative computed tomography has been used to facilitate deep inferior epigastric artery perforator (DIEAP) flap breast reconstruction. This study identifies the improvements in outcome that this may provide. Methods: A retrospective review of a consecutive series of DIEAP and superficial inferior epigastric artery (SIEA) flap breast reconstructions was performed over 5 years. All patients underwent hand-held Doppler interrogation of the abdomen. Patient demographics, operative times, and postoperative outcomes were compared before and after the routine use of computed tomographic imaging. Results: Two hundred eighty-seven flaps were performed on 213 patients. There were 139 unilateral and 74 bilateral reconstructions, with 168 flaps performed immediately after mastectomy and 119 flaps performed in a delayed setting. One hundred one flaps were performed with computed tomographic imaging, whereas 186 flaps followed hand-held Doppler interrogation alone. Mean follow-up was 24 months. The use of computed tomography had a beneficial impact on operative times (unilateral, 370 versus 459 minutes; bilateral, 515 versus 657 minutes; p < 0.05), number of perforators included (1.5 versus 1.9; p < 0.05), and abdominal bulges (1 percent versus 9.1 percent; p < 0.05). Anastomotic complications (6.9 percent versus 8.1 percent), failure rates (2 percent versus 3.8 percent), fat necrosis (10.9 percent versus 13.4 percent), and abdominal wounds (11.8 percent versus 16.6 percent) were not found to be significantly different. Computed tomography did identify three cases of deep inferior epigastric vessel ligation from previous operations, which compromised these as suitable source vessels. Conclusions: This study suggests that preoperative computed tomography leads to decreased operative times and a reduction in abdominal bulge rates, and may reduce the learning curve in DIEAP breast reconstruction compared with hand-held Doppler evaluation alone.

Long‐Term Outcome in Occipital Nerve Stimulation Patients With Medically Intractable Primary Headache Disorders

Introduction:  Occipital nerve stimulation (ONS) may provide relief for refractory headache disorders. However, scant data exist regarding long‐term ONS outcomes.

Vastus lateralis motor nerve can adversely affect anterolateral thigh flap harvest

Background: The vascular anatomy of the anterolateral thigh flap has been well studied, but no study has evaluated the effect of the vastus lateralis motor nerve anatomy on anterolateral thigh flap harvest. Methods: A retrospective review was performed of all anterolateral thigh flaps from January of 2003 through December of 2004. Information regarding the motor nerve to the vastus lateralis muscle was recorded, along with its influence on anterolateral thigh flap harvest. Results: Forty-three anterolateral thigh flap procedures were performed over a 2-year period. In three cases (7 percent), the course of the motor nerve to the vastus lateralis resulted in a significant modification in anterolateral thigh flap harvest. In one case, the motor nerve passed between the venae comitantes of the descending branch of the lateral femoral circumflex artery just proximal to the midperforator origin. In two cases, large skin islands were raised with two perforators included in each flap. The motor nerve passed between the two perforators in these cases. Conclusions: Two patterns of vastus lateralis motor nerve anatomy can adversely influence anterolateral thigh flap elevation. One involves the motor nerve passing through the main vascular pedicle. The other occurs when multiple perforators are required to support large flaps with the motor nerve passing between these perforators. In some cases, the course of the nerve may require transection of the nerve, with a subsequent deficit in vastus lateralis function. In similar cases, if the nerve is preserved, the vascular pedicle may require significant modification, which may possibly compromise flap perfusion.

Prophylactic flap reconstruction of the knee prior to total knee arthroplasty in high-risk patients.

Insufficient soft-tissue coverage following total knee arthroplasty (TKA) may threaten prosthesis retention or compromise joint function. A retrospective review was conducted of all patients who underwent prophylactic flap reconstruction of the knee prior to TKA or salvage flap reconstruction over a 6-year period. Twenty-three patients underwent prophylactic flap reconstruction. Complications at the time of flap transfer were common (48%), however, all flaps survived. All 23 successfully completed subsequent TKA with no wound complications occurring at the time of TKA. Complications in the salvage group were also frequent (44%) and 3 required above knee amputation. Postoperative range of motion was significantly better in the prophylactic group, as well as when cutaneous flaps were chosen. Prophylactic flap reconstruction of the knee prior to TKA in high-risk patients is an excellent option in this small subset of patients, many of whom would not be offered TKA without addressing the compromised soft-tissue envelope first.

Neoadjuvant therapy and breast cancer surgery: a closer look at postoperative complications

BACKGROUND Neoadjuvant therapy is important in the treatment of advanced breast cancer. METHODS Postoperative complications in neoadjuvant patients were analyzed. RESULTS One hundred forty patients underwent 148 breast cancer surgeries after neoadjuvant therapy: 28% breast-conserving therapy procedures, 36% mastectomies, 28% mastectomies with immediate reconstruction, and 8% mastectomies with delayed reconstruction. Forty-seven patients (34%) suffered 59 complications: 18% of those undergoing breast-conserving therapy, 30% of those undergoing mastectomy, 44% of those undergoing mastectomy with immediate reconstruction, and 67% of those undergoing mastectomy with delayed reconstruction. Major complications occurred in 18% of patients. Skin loss occurred in 6% of patients. One patient had partial nipple necrosis. Three patients suffered implant loss. One patient had deep inferior epigastric artery perforator flap loss. Eleven hematomas and 5 infectious complications required reoperation. CONCLUSIONS Surgery after neoadjuvant therapy is safe, but careful counseling is warranted given that 18% of patients experienced major complications. Complications rates are higher with reconstruction, but feared complications of skin, nipple, implant, or flap loss were infrequent.

Predictive factors of wound complications after sarcoma resection requiring plastic surgeon involvement.

IntroductionThe most effective management of a patient with sarcoma is surgical resection. Often the resection is performed, the wound is irradiated, adjuvant chemotherapy is administered, and the wound is closed without plastic surgery consultation. Wound complications, after these treatment protocols, often require plastic surgery involvement and the treatment may require more advanced reconstructive techniques with higher rates of complications than if involvement occurred earlier. MethodsA retrospective review of all patients who underwent sarcoma excision from 2001 to 2011 was performed. Factors such as tumor size, radiation, chemotherapy, delayed reconstruction (>3 weeks), and immediate reconstruction (<3 weeks) were analyzed for their correlation with wound complications or flap loss. ResultsA total of 127 patients underwent sarcoma resection. Wound complications occurred in 49 (38%) patients. All 15 delayed reconstructions had a wound complication, whereas only 11 (37%) of immediate reconstructions had a wound complication. Wound complications with tissue excision less than 500 g occurred in 18 (26%) patients and occurred in 31 (54%) patients with excision greater than 500 g. Seventy-two patients underwent radiation with a wound complication rate of 46% compared with 29% for patients who were not radiated. Chemotherapy was used in 35 patients with a wound complication rate of 49%. ConclusionsThe most predictive factor of sarcoma complication is whether the procedure was a delayed or immediate reconstruction. The second most predictive factor is the amount of tissue excised, greater than 500 g of tissue excised was associated with significantly higher complication rates. Other aspects of sarcoma treatment that may be correlated with higher incidence of wound complications are radiation and the use of adjuvant chemotherapy. Early plastic surgery involvement can help with preoperative planning and reduce the complication rates in patients with sarcoma resection.

Intra-arterial tissue plasminogen activator: an effective adjunct following microsurgical venous thrombosis.

This study evaluates the efficacy of our protocol using intra-arterial infusion of tissue plasminogen activator (TPA) on free flap salvage following venous thrombosis. A retrospective review was conducted of every free flap performed by a single surgeon since the beginning of his practice. Free flap salvage rates were documented following flap exploration, intra-arterial infusion of TPA, and revision of the venous anastomosis, with or without vein grafting. One hundred twenty-two free tissue transfers were performed from July 2003 through April 2006. Twelve anastomotic complications occurred in 11 flaps (1 arterial thrombosis, 11 venous thromboses). One free muscle flap failed due to arterial thrombosis. All venous thromboses were salvaged using the TPA protocol, although one revision thrombosed on postoperative day 1 and required a second venous revision, leading to its ultimate salvage. We believe that intra-arterial TPA is an effective adjunct in the treatment of microsurgical venous thrombosis and may increase salvage rates following anastomotic complications.

Superficialization of deep arteriovenous access procedures in obese patients using suction-assisted lipectomy: A novel approach.

Successful dialysis access necessitates superficial arteriovenous fistula (AVF) placement to facilitate identification of anatomical landmarks for safe cannulation. Suction-assisted lipectomy (SAL) may be an alternative to traditional surgical AVF revision procedures for placing fistulas more superficially. Three patients with an average body mass index of 45.2 kg/m(2), with inaccessible AVFs due to obesity, underwent ultrasound-guided SAL of their upper extremities. Successful cannulation was achieved within two weeks. A clinically insignificant hematoma and arm swelling occurred in one patient. SAL provides a safe and effective alternative for salvaging deep AVFs for dialysis access in the upper extremities of obese patients.

Bilateral breast reconstruction using bilateral anterolateral thigh flaps: a case report.

Options for autologous reconstruction have been limited in some patients by previous abdominal surgeries, and by lack of adequate abdominal tissue. The anterolateral thigh (ALT) flap has previously been described as an alternate donor site for autologous breast reconstruction when abdominal tissue is unavailable or unsuitable.We describe our experience with a 41-year-old low body mass index (19.8 kg/m) patient with previous suction-assisted lipectomy underwent bilateral breast reconstruction using bilateral ALT flaps.At a follow-up of 2 years, the patient was delighted with her reconstructed breasts and despite her athletic build was able to fill a B cup bra.ALT flap has the advantages of a long pedicle, adequate soft adipose tissue, and also allowing supine positioning with a 2-team approach. The anterolateral flap is a credible alternative that may be considered for bilateral autologous breast reconstruction in selected patients.

Contradicting an established mantra: microsurgeon experience determines free flap outcome.

Background: Since the inception and popularization of microsurgery in the 1960s and 1970s, it has been commonly accepted that the outcome of free tissue transfer directly correlates with surgeon experience. Methods: The clinical outcomes of three young microsurgeons at a single institution were retrospectively reviewed. Free flaps performed by these individuals were categorized according to the surgeon’s years of practice and analyzed using statistical methods. Results: A total of 410 free flaps were identified. No correlation was found between the surgeon’s years of experience and the outcomes measured. Conclusions: There has been increased exposure to microsurgery during plastic surgery training at many programs, and consequently, residents have often already surpassed the learning curve. The imperfect correlation between experience and superior outcomes in medicine serves to suggest that further research in the specific underlying principles of surgical learning is needed to understand the relationship between experience and superior surgical outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.