Amanda K. Silva

Adipofascial perforator flaps for “aesthetic” head and neck reconstruction

Most head and neck reconstructions are performed for wound closure or functional rehabilitation with aesthetic restoration being an important but secondary consideration.

Comprehensive management of temporal bone defects after oncologic resection

To evaluate reconstructive outcomes following oncologic temporal bone resection.

Vascularized lymph node transfer and lymphovenous bypass: Novel treatment strategies for symptomatic lymphedema

Lymphedema is a debilitating disease that is commonly caused by cancer and it is treatments in the developed world. Surgery is an option for refractory disease. Lymphovenous bypass and vascularized lymph node transfer are newer modalities that show great promise. Further work is necessary to determine proper patient selection and ensure minimum donor site morbidity. Liposuction and direct excision still have a role, especially in advanced cases. Further investigations into prevention of iatrogenic lymphedema are underway. J. Surg. Oncol. 2016;113:932–939.

Cancer Risk after Fat Transfer: A Multicenter Case-Cohort Study.

Background: Fat transfer is an increasingly popular method for refining postmastectomy breast reconstructions. However, concern persists that fat transfer may promote disease recurrence. Adipocytes are derived from adipose-derived stem cells and express adipocytokines that can facilitate active breast cancer cells in laboratory models. The authors sought to evaluate the association between fat transfer to the reconstructed breast and cancer recurrence in patients diagnosed with local or regional invasive breast cancers. Methods: A multicenter, case-cohort study was performed. Eligible patients from four centers (Memorial Sloan Kettering, M. D. Anderson Cancer Center, Alvin J. Siteman Cancer Center, and the University of Chicago) were identified by each site’s institutional tumor registry or cancer data warehouse. Eligibility criteria were as follows: mastectomy with immediate breast reconstruction between 2006 and 2011, age older than 21 years, female sex, and incident diagnosis of invasive ductal carcinoma (stage I, II, or III). Cases consisted of all recurrences during the study period, and controls consisted of a 30 percent random sample of the study population. Cox proportional hazards regression was used to evaluate for association between fat transfer and time to recurrence in bivariate and multivariate models. Results: The time to disease recurrence unadjusted hazard ratio for fat transfer was 0.99 (95 percent CI, 0.56 to 1.7). After adjustment for age, body mass index, stage, HER2/Neu receptor status, and estrogen receptor status, the hazard ratio was 0.97 (95 percent CI, 0.54 to 1.8). Conclusion: In this population of breast cancer patients who had mastectomy with immediate reconstruction, fat transfer was not associated with a higher risk of cancer recurrence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Melting the Plastic Ceiling: Overcoming Obstacles to Foster Leadership in Women Plastic Surgeons

Summary: The underrepresentation of women leaders in plastic surgery echoes a phenomenon throughout society. The importance of female leadership is presented, and barriers to gender equality in plastic surgery, both intrinsic and extrinsic, are discussed. Strategies for fostering women in leadership on an individual level and for the specialty of plastic surgery are presented.

Breast Reconstruction with SIEA Flaps: A Single-Institution Experience with 145 Free Flaps.

Background: Refinements in microsurgical breast reconstruction have refined superficial inferior epigastric artery (SIEA) and superficial circumflex iliac artery (SCIA) flaps, yet technical difficulties and varied success rates limit widespread acceptance. The authors present the outcomes of their experience with 145 consecutive SIEA/SCIA flaps and suggest technical tips to improve success with this important flap. Methods: An institutional review board–approved retrospective chart review of all SIEA/SCIA free flaps performed by the senior authors between January 1, 2006, and February 6, 2014, was conducted. Data on patient demographics, flap characteristics, and complications were collected. Results: There were 145 flaps performed in 119 patients. Arterial donor and recipient mismatch occurred in 55 instances (38 percent). In these cases, 48 arteries (87 percent) were spatulated and seven (13 percent) were back-cut to improve size concordance. Nine flaps required operative return for flap viability concerns. Five were arterial, three were venous, and one flap had concomitant arterial and venous thrombosis. Total flap loss rate attributable to thrombotic events was 4.8 percent. No flaps with arterial thrombosis on reoperation were salvageable. Furthermore, 80 percent had arterial revisions at initial operation. No patients had an abdominal bulge or hernia, and the fat necrosis rate was 10.3 percent. Conclusions: SIEA/SCIA breast reconstruction can be reliably performed; however, flaps exhibiting postoperative arterial thrombosis with revision at initial surgery are unlikely salvageable on reoperation. Spatulation did not correlate with an increased thrombosis rate; in fact, the authors advocate for donor artery manipulation to manage size mismatch. CLINCAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Discussion: Evaluation of the Upper Limb Lymphatic System

www.PRSJournal.com 1332 T lymphoscintigraphy has been the gold standard for lymphedema diagnosis. However, to date, our knowledge of “normal” lymphatic function using this tool is limited. Previous standards for normal data rely on information from the contralateral limb in patients afflicted with lymphedema. Matteo Rossi et al. should be commended for their efforts to gather more information on normal lymphatic function using lymphoscintigraphy. They studied lymphoscintigraphic patterns in the upper extremities of patients with trunk or upper limb melanoma and a group of healthy controls. Interestingly, they found a wide array of patterns, common asymmetry, and traditionally considered slow tracer appearance times in normal limbs. Their results bring into question the use of the contralateral limb as a control, and transport time criteria in the diagnosis of lymphedema using lymphoscintigraphy. Although study does impart some valuable data and brings up some interesting questions, it does have its limitations. The small sample size, especially in the subgroups, may be underpowered to draw significant conclusions. In addition, in general, the results of lymphoscintigraphy can vary depending on the technique, and interpretation can be subjective. As the authors point out, lymphoscintigraphic images were captured at three distinct time points, leading to a possible overestimation of limb lymphatic asymmetry. Ultimately, although the results are interesting, they are more qualitative than quantitative. However, this work is important in that it highlights some pertinent areas in the field of lymphedema research that remain to be elucidated. Much work is still needed to improve our understanding of the anatomy and physiology of the lymphatic system and the development of lymphedema. Their results also point out the need for better assessment tools to evaluate the lymphatic system anatomy and function. In our practice, lymphoscintigraphy is not routinely performed in all patients. However, we still believe it is a useful tool, and use it as an adjunct to help clarify when the diagnosis of lymphedema is uncertain. A limitation of lymphoscintigraphy is that it offers poor resolution of lymphatics, which has led many to adopt the use of magnetic resonance lymphangiography1 and indocyanine green lymphography,2 which allow finer anatomical detail. This information is especially important in preoperative planning. This work is beneficial in that it highlights some important questions within the field of lymphedema. However, to date, in most cases the contralateral limb is still the best comparison for evaluating lymphedema; it just may be with measures other than lymphoscintigraphy.

Direct-to-Implant Breast Reconstruction with Acellular Dermal Matrix

Direct-to-implant breast reconstruction with acellular dermal matrix is described including indications, preoperative marking, key intraoperative steps including a dictation example, postoperative care, and coding.

Thoracodorsal Artery Perforator Flap for Breast Reconstruction

Autologous breast reconstruction with the thoracodorsal artery perforator flap is described including indications, preoperative marking, key intraoperative steps including a dictation example, postoperative care, and coding.

Superior Gluteal Artery Perforator Flap for Breast Reconstruction

Autologous breast reconstruction with the superior gluteal artery perforator flap is described including indications, preoperative marking, key intraoperative steps including a dictation example, and postoperative care.