Andrew L. Da Lio

Complications after microvascular breast reconstruction: experience with 1195 flaps.

Background: Reconstruction is an important adjunct to breast cancer management. This study evaluated the frequency of major and minor complications in the largest reported series of consecutive mastectomy patients treated with free tissue transfer for breast reconstruction. Methods: All patients treated with microvascular breast reconstruction at the University of California, Los Angeles, Medical Center over an 11-year period were identified using a retrospective analysis. Frequency of complications was assessed. Results: A total of 1195 breast reconstructions were performed in 952 patients. Transverse rectus abdominis musculocutaneous flaps were used in most cases (81.8 percent), whereas the superior gluteal musculocutaneous flap (10.1 percent) and other free flaps were used in the remaining patients. The overall complication rate was 27.9 percent and consisted primarily of minor complications (21.7 percent). Major complications were noted in 7.7 percent, including six total flap losses (0.5 percent). Obesity was a major predictor of complications. Smoking was not associated with increased rates of overall or microsurgical complications. Neoadjuvant chemotherapy was also an independent predictor of complications and was associated with wound-healing problems and fat necrosis. Prior abdominal surgery in transverse rectus abdominis musculocutaneous flap patients increased the risk of partial flap loss, fat necrosis, and donor-site complications. Conclusions: Microsurgical breast reconstruction is a safe and highly effective technique. Complications tend to be minor and do not affect postreconstruction adjuvant therapy. Obesity is a major predictor of flap and donor-site complications, and these patients should be appropriately counseled. Similarly, neoadjuvant preoperative chemotherapy and prior abdominal surgery increase the rates of minor complications.

Surgical treatment of breast cancer in previously augmented patients.

&NA; The incidence of breast cancer is increasing each year. Concomitantly, cosmetic breast augmentation has become the second most often performed cosmetic surgical procedure. As the augmented patient population ages, an increasing number of breast cancer cases among previously augmented women can be anticipated. The surgical treatment of these patients is controversial, with several questions remaining unanswered. Is breast conservation therapy feasible in this patient population and can these patients retain their implants? A retrospective review of all breast cancer patients with a history of previous augmentation mammaplasty who were treated at the Revlon/ UCLA Breast Center between 1991 and 2001 was performed. During the study period, 58 patients were treated. Thirty patients (52 percent) were treated with a modified radical mastectomy with implant removal. Twenty‐eight patients (48 percent) underwent breast conservation therapy, which consisted of lumpectomy, axillary lymph node dissection, and radiotherapy. Twenty‐two of the patients who underwent breast conservation therapy initially retained their implants. Eleven of those 22 patients (50 percent) ultimately required completion mastectomies with implant removal because of implant complications (two patients), local recurrences (five patients), or the inability to obtain negative margins (four patients). Nine additional patients experienced complications resulting from their implants, including contracture, erosion, pain, and rupture. The data illustrate that breast conservation therapy with maintenance of the implant is not ideal for the majority of augmented patients. Breast conservation therapy with explantation and mastopexy might be appropriate for rare patients with large volumes of native breast tissue. Mastectomy with immediate reconstruction might be a more suitable choice for these patients.

Immediate Placement of Implants in Breast Reconstruction: Patient Selection and Outcomes

Background: With the advent of skin-sparing mastectomy techniques, it became clear that immediate placement of an implant could be utilized for breast reconstruction in select patients. The authors assessed the safety, patient selection factors, and aesthetic results with this technique. Methods: Thirty-five consecutive patients (eight unilateral and 27 bilateral) who underwent immediate implant-based breast reconstruction were analyzed. Patient data and complication rates were obtained from a retrospective chart review. Postoperative photographs were evaluated by a blinded panel and scored on a four-point scale. Results: With a mean follow-up of 15 months, complications occurred in six patients (17.1 percent). There was one episode (2.9 percent) of skin necrosis resulting in implant loss, two episodes (5.7 percent) of postoperative infection, both of which resulted in implant salvage, and three patients who developed capsular contracture (8.5 percent). A total of 13 patients (37 percent) required additional surgery for revision. Revisions were necessary significantly more commonly in patients with a history of radiotherapy (p = 0.047), D-cup breast size or greater (p = 0.018), and ptosis of grade 2 or more (p = 0.017). The mean overall aesthetic score was 3.19, and upon subgroup analysis, patients with a history of radiation treatment (2.46), D-cup breast size or greater (2.64), and ptosis or grade 2 or more (2.98) had lower mean scores. Exclusion of these subgroups resulted in a mean score 3.39. Conclusions: Immediate implant-based breast reconstruction is a safe and viable option that can provide a very good aesthetic result in appropriately selected candidates. The authors recommend caution and appropriate patient counseling in patients with a history of radiotherapy, larger breasts, and/or ptotic breasts.

Alternative venous outflow vessels in microvascular breast reconstruction.

&NA; The lack of adequate recipient vessels often complicates microvascular breast reconstruction in patients who have previously undergone mastectomy and irradiation. In addition, significant size mismatch, particularly in the outflow veins, is an important contributor to vessel thrombosis and flap failure. The purpose of this study was to review the authors’ experience with alternative venous outflow vessels for microvascular breast reconstruction. In a retrospective analysis of 1278 microvascular breast reconstructions performed over a 10‐year period, the authors identified all patients in whom the external jugular or cephalic veins were used as the outflow vessels. Patient demographics, flap choice, the reasons for the use of alternative venous drainage vessels, and the incidence of microsurgical complications were analyzed. The external jugular was used in 23 flaps performed in procedures with 22 patients. The superior gluteal and transverse rectus abdominis musculocutaneous (TRAM) flaps were used in the majority of the cases in which the external jugular vein was used (72 percent gluteal, 20 percent TRAM flap). The need for alternative venous outflow vessels was usually due to a significant vessel size mismatch between the superior gluteal and internal mammary veins (74 percent). For three of the external jugular vein flaps (13 percent), the vein was used for salvage after the primary draining vein thrombosed, and two of three flaps in these cases were eventually salvaged. In three patients, the external jugular vein thrombosed, resulting in two flap losses, while the third was salvaged using the cephalic vein. A total of two flaps were lost in the external jugular vein group. The cephalic vein was used in 11 flaps (TRAM, 64.3 percent; superior gluteal, 35.7 percent) performed in 11 patients. In five patients (54.5 percent), the cephalic vein was used to salvage a flap after the primary draining vein thrombosed; the procedure was successful in four cases. In three patients, the cephalic vein thrombosed, resulting in two flap losses. One patient suffered a thrombosis after the cephalic vein was used to salvage a flap in which the external jugular vein was initially used, leading to flap loss, while a second patient experienced cephalic vein thrombosis on postoperative day 7 while carrying a heavy package. There was only one minor complication attributable to the harvest of the external jugular or cephalic vein (small neck hematoma that was aspirated), and the resultant scars were excellent. The external jugular and cephalic veins are important ancillary veins available for microvascular breast reconstruction. The dissection of these vessels is straightforward, and their use is well tolerated and highly successful. (Plast. Reconstr. Surg. 112: 448, 2003.)

Immediate Free Flap Reconstruction for Advanced-Stage Breast Cancer: Is It Safe?

Background: Numerous studies have demonstrated that immediate breast reconstruction following mastectomy is associated with improvements in quality of life and body image. However, immediate breast reconstruction for advanced-stage breast cancer remains controversial. This study evaluates its safety in patients with advanced-stage breast cancer. Methods: Over a 10-year period, patients diagnosed with stage IIB or greater breast cancer treated with mastectomy followed by immediate breast reconstruction were identified and analyzed. Complication rates and reconstructive aesthetics were determined. Results: One hundred seventy patients were identified who underwent 157 unilateral and 13 bilateral reconstructions (183 flaps) predominantly by means of free transverse rectus abdominis musculocutaneous flaps (n = 162). The average age was 47 years and the average hospital stay was 5.1 days. There were 15 major complications (8.8 percent), but adjuvant postoperative therapy was delayed in only eight patients (4.7 percent), with the maximum delay lasting 3 weeks in one patient. Although some degree of flap shrinkage was noted in 30 percent of patients treated with postoperative radiotherapy, only 10 percent of patients experienced severe breast distortion. Importantly, the overall cosmetic outcome in patients who underwent postoperative irradiation was comparable to that of those who did not. Conclusions: The authors have shown that immediate breast reconstruction in the setting of advanced-stage breast cancer is safe and well tolerated by patients, and is not associated with significant delays in adjuvant therapy. These findings make a strong argument for immediate reconstruction regardless of cancer stage. The authors found the changes caused by radiation to the reconstructed breast to be less significant than previously reported and readily addressed to complete an ultimate reconstruction that is aesthetically acceptable to both surgeon and patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. Figure. No caption available.

Predictive factors in identifying subspecialty fellowship applicants who will have academic practices.

Background: The challenge of subspecialty fellowship directors is to recruit surgeons who are motivated to continue the tradition of teaching by entering academic medicine. The authors looked for predictive factors to help with more accurate selection of applicants. Methods: Application and follow-up data from plastic surgery subspecialty fellows in craniofacial surgery, hand surgery, and microsurgery from the University of California, Los Angeles were reviewed for the years 1987 through 2002 (n = 62). Fellows were divided into three groups as follows: group 1, full-time academic; group 2, part-time clinical faculty; and group 3, private practice at 1 year and 5 years after fellowship. Common factors of fellows within the three groups were listed. Results: Although a majority of applicants (95 percent) indicated an aspiration to practice academic medicine, only one-third remained in full-time academics 5 years after their subspecialty training. There was a trend toward leaving academic practice: the rates at 1 year were 74 percent for group 1 (academic) and 5 percent for group 3 (private practice), but by 5 years this had equalized (group 1, 34 percent; group 3, 32 percent). Group 1 (academic) showed more academic productivity publications per year, academic titles, editorial boards, and active participation in medical societies compared with group 3 (private practice). The factors that were more common to group 1 were married or married with children, five or more publications, one or more years of research, and 7 or more years of training. Conclusion: Plastic surgery fellowship directors may look at the following predictive factors of applicants if they would like their graduates to carry on the tradition of teaching future plastic surgeons: (1) previous dedicated research training, (2) more years of clinical training, and (3) more scientific publications.

Staged wise-pattern skin excision for reconstruction of the large and ptotic breast.

Background: The postmastectomy reconstruction of large and/or ptotic breasts poses a more difficult aesthetic challenge than the reconstruction of small or moderately sized breasts because of an excessively large skin envelope in both horizontal and vertical dimensions. The Wise-pattern skin excision best addresses this excess skin but is associated with a high incidence of tissue necrosis with subsequent wound breakdown, primarily at the T point. To optimize the aesthetic potential and minimize complications in the setting of these large skin envelopes, the authors have deconstructed the single-stage Wise-pattern skin excision into a two-stage procedure, eliminating the need for a primary simultaneous T-point closure. Methods: In the first stage, the mastectomy and reconstruction are performed using a vertical excision, which tightens the breast skin envelope horizontally. In the second stage, the redundant skin at the inframammary fold is excised horizontally, tightening the breast skin envelope vertically. The summation of the two staged excisions recreates the Wise pattern, breaking up the T point into two straightforward primary closures. Results: Twelve patients (21 breasts) underwent successful reconstruction using the staged Wise-pattern skin excision. The breast size, shape, and projection of the patients were greatly improved without any wound complications. Conclusions: The staged Wise-pattern skin excision for breast reconstruction is a simple technique that delivers superior results for the challenging reconstruction of large and/or ptotic breasts. This method offers an aesthetically pleasing breast shape, allows for the correction of ptosis, eliminates wound complications, and results in a standard Wise-pattern scar.

Free TRAM flap breast reconstruction after abdominal liposuction.

Liposuction is the most common cosmetic surgical procedure performed for women today. A large percentage of these cases involve abdominal liposuction, and more than 75 percent of these patients are younger than 50 years old.1 Concomitantly, the incidence of breast cancer is increasing, with one out of every eight women affected.2 Eighty percent of breast cancer cases are diagnosed in women older than 50.3–5 Therefore, the number of women with breast cancer who have undergone abdominal liposuction will most likely increase. Many of these women may wish to undergo autologous tissue breast reconstruction after mastectomy. The safety and success of performing a transverse rectus abdominis muscle (TRAM) flap breast reconstruction after abdominal liposuction have yet to be determined. No preoperative test has been conclusively shown to document the patency of the perforating vessels from the deep inferior epigastric system. Two case reports have documented successful TRAM flap reconstruction after abdominal liposuction. We present a series of three patients who underwent five free TRAM flaps after abdominal liposuction and describe the preoperative assessment used to help determine which patients were candidates for this procedure.

Influence of the recipient vessel on fat necrosis after breast reconstruction with a free transverse rectus abdominis myocutaneous flap.

Abstract The effect of the selection of recipient vessels on the rate of fat necrosis after microsurgical reconstruction of the breast remains largely unknown. Our aim was to evaluate the incidence of fat necrosis after unilateral breast reconstruction with a free transverse rectus abdominis myocutaneous (TRAM) flap after anastomosis with either the internal mammary vessels or the thoracodorsal artery and vein. Consecutive patients who had unilateral reconstruction with a free, muscle-sparing TRAM flap at two tertiary care centres over a 6-year period were identified. The incidence of fat necrosis, defined as postoperative firmness of 1 cm or more persisting for 3 months or more after anastomosis was calculated. To control for the effect of potentially confounding variables (body mass index (BMI), history of preoperative or postoperative radiation, previous abdominal operation, smoking, and hospital) we did a matched-cohort study. A total of 840 unilateral muscle–sparing TRAM flaps were done using either the internal mammary (n = 109) or the thoracodorsal (n = 731) vessels. Evaluation of the entire cohort showed that the incidence of fat necrosis after the two anastomoses was 13 (12%) compared with 130 (18%), respectively (p = 0.17). To control for the effect of confounding variables, 98 patients who had internal mammary anastomoses were matched 1:1 with 98 patients who had thoracodorsal anastomoses. Pair-wise comparisons showed that the incidence of fat necrosis was significantly higher when the thoracodorsal vessels were used (29; 30%) compared to when the internal mammary vessels were used (12; 12%; p = 0.002). Our results showed that a higher rate of fat necrosis may be seen after muscle–sparing TRAM flap reconstruction after anastomosis to the thoracodorsal vessels than with the internal mammary vessels. The exact mechanisms of this association are unknown and warrant additional investigation.

Improving recipient vessel exposure during microvascular breast reconstruction.

Microvascular tissue transfer has become the gold standard for breast reconstruction. The primary drawback to these procedures is the technical expertise required for microsurgical anastomosis. This problem is compounded by the difficulties in the exposure of recipient vessels deep within the axilla. Previous techniques used for exposure of these vessels are difficult to setup, provide less than optimal exposure, and have been associated with brachial plexus injuries. The authors retrospectively review their experience using the pediatric OMNI retractor for exposure of recipient vessels during microvascular breast reconstruction. Patient demographics, flap choice, recipient vessels, the incidence of neuropraxia/brachial plexopathy, and microvascular complications were analyzed. Patients in whom more traditional methods of vessel exposure were used (ie, Gelpi retractors, arm positioning, fish hooks; 517 reconstructions in 392 patients) were compared with patients in whom vessel exposure was performed using the pediatric OMNI retractor (699 reconstructions in 571 patients). No differences were noted in comorbid conditions or the incidence of microvascular complications. However, the use of the pediatric OMNI was associated with a significant reduction in operative time in unilateral reconstructions (6:23 ± 0.05 h vs 7:48 ± 0.05 h; P <0.01) and decreased incidence of brachial plexus injury (0.17% vs 3.3%; P <0.01). The authors think the decreased neuropraxia rate is the result of better exposure afforded by the pediatric OMNI retractor, which improves exposure and eliminates the need for excessive arm abduction or awkward positioning during the dissection and anastomosis of axillary recipient vessels.