Baoguang Wang

Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction.

Free pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction is often advocated as the procedure of choice for autogenous tissue breast reconstruction in high-risk patients, such as smokers. However, whether use of the free TRAM flap is a desirable option for breast reconstruction in smokers is still unclear. All patients undergoing breast reconstruction with free TRAM flaps at our institution between February of 1989 and May of 1998 were reviewed. Patients were classified as smokers, former smokers (patients who had stopped smoking at least 4 weeks before surgery), and nonsmokers. Flap and donor-site complications in the three groups were compared. Information on demographic characteristics, body mass index, and comorbid medical conditions was used to perform multivariate statistical analysis. A total of 936 breast reconstructions with free TRAM flaps were performed in 718 patients (80.9 percent immediate; 23.3 percent bilateral). There were 478 nonsmokers, 150 former smokers, and 90 smokers. Flap complications occurred in 222 (23.7 percent) of 936 flaps. Smokers had a higher incidence of mastectomy flap necrosis than nonsmokers (18.9 percent versus 9.0 percent;p = 0.005). Smokers who underwent immediate reconstruction had a significantly higher incidence of mastectomy skin flap necrosis than did smokers who underwent delayed reconstruction (21.7 percent versus 0 percent;p = 0.039). Donor-site complications occurred in 106 (14.8 percent) of 718 patients. Donor-site complications were more common in smokers than in former smokers (25.6 percent versus 10.0 percent;p = 0.001) or nonsmokers (25.6 percent versus 14.2 percent;p = 0.007). Compared with nonsmokers, smokers had significantly higher rates of abdominal flap necrosis (4.4 percent versus 0.8 percent;p = 0.025) and hernia (6.7 percent versus 2.1 percent;p = 0.016). No significant difference in complication rates was noted between former smokers and nonsmokers. Among smokers, patients with a smoking history of greater than 10 pack-years had a significantly higher overall complication rate compared with patients with a smoking history of 10 or fewer pack-years (55.8 percent versus 23.8 percent;p = 0.049). In summary, free TRAM flap breast reconstruction in smokers was not associated with a significant increase in the rates of vessel thrombosis, flap loss, or fat necrosis compared with rates in nonsmokers. However, smokers were at significantly higher risk for mastectomy skin flap necrosis, abdominal flap necrosis, and hernia compared with nonsmokers. Patients with a smoking history of greater than 10 pack-years were at especially high risk for perioperative complications, suggesting that this should be considered a relative contraindication for free TRAM flap breast reconstruction. Smoking-related complications were significantly reduced when the reconstruction was delayed or when the patient stopped smoking at least 4 weeks before surgery.

local Recurrence Risk after Skin-sparing and Conventional Mastectomy: A 6-year Follow-up

In this study, the records of all patients at the University of Texas M. D. Anderson Cancer Center with T1 or T2 breast cancer who were treated between March of 1986 and November of 1990 with mastectomy followed by immediate breast reconstruction were reviewed for the presence of recurrent disease. Patients with in situ disease were not included. Patients were included in the study if a local recurrence occurred (regardless of the length of follow-up) or if a follow-up of 6 years or longer could be obtained. Patients were grouped according to the use or nonuse of skin-sparing mastectomy, by tumor stage, and by nuclear grade of the tumor. The series included 154 patients, of whom 114 had skin-sparing mastectomies and 40 had nonskin-sparing mastectomies. The local recurrence rate in the skin-sparing mastectomy group was 7.0 percent, whereas in the nonskin-sparing mastectomy group it was 7.5 percent. The sample size in the nonskin-sparing mastectomy group was too small for meaningful statistical analysis, but the data suggest that there is no clinically important difference in recurrence rates between the two groups. We conclude that the use of skin-sparing technique for early breast cancer patients does not significantly increase the risk of tumor recurrence after mastectomy.

Bilateral Breast Reconstruction: Conventional versus Free Tram

Free TRAM flap transfer is now routinely offered to patients requiring breast reconstruction. This study compares results of conventional superior-pedicled TRAM flaps and free TRAM flaps in bilateral breast reconstructions. A total of 92 breasts were reconstructed in 46 patients. Eighteen patients had free TRAM flap reconstructions, and 28 patients were reconstructed with conventional TRAM flaps. Comparison of average operative blood loss and average operative time for the two techniques showed blood loss of 575 cc and an operative time of 9.6 hours for the free TRAM reconstructions and a blood loss of 313 cc and an operative time of 6.6 hours for the conventional TRAM reconstructions. For free TRAM flap reconstructions, both blood loss and operative time decreased significantly between the first and second group of nine patients: from 819 to 360 cc of blood loss and from 10.5 to 8.9 hours of operative time. Partial flap loss (skin and fat necrosis) and fat necrosis only occurred in 13 and 7 percent, respectively, of conventional TRAM flaps, but neither occurred in free TRAM flaps. However, early in the series, three free flaps were lost in two patients, requiring implant placement. Bilateral breast reconstruction using the free TRAM flap may offer a lower complication rate than the conventional TRAM flap by virtue of improved blood supply and less abdominal wall disruption. Surgeons, however, are forewarned that this procedure has a steep learning curve, and surgeons lacking microsurgical expertise may be better served by the conventional TRAM flap. (Plast. Reconstr. Surg. 93: 1410, 1994.)

Influence of radiation on late complications in patients with free fibular flaps for mandibular reconstruction.

Carcinoma of the mandible is a disease that evokes images of devastating functional and cosmetic outcomes. Most of these malignancies require treatment with surgical resection and perioperative irradiation (XRT). To minimize the incidence of postoperative complications, the timing of perioperative XRT has been questioned. This study reviewed 140 patients at M.D. Anderson Cancer Center over a 7-year period who underwent mandibular resection and reconstruction with a free fibular flap. The patients were divided into the following four groups: (1) preoperative XRT followed by immediate reconstruction, (2) preoperative XRT followed by delayed reconstruction, (3) postoperative XRT, and (4) no XRT. The complications studied included exposure of bone and hardware, orocutaneous fistula, osteoradionecrosis, partial and complete flap loss, and severe cervical contractures. Of the 140 patients studied, 59 (42%) had at least one complication. Complications per group were the following: group 1, 45%; group 2, 46%; group 3, 47%; and group 4, 28%. The results show that the incidence of complications is relatively equal between groups that received preoperative vs. postoperative XRT.

Drug-induced vasodilation in an in vitro and in vivo study: the effects of nicardipine, papaverine, and lidocaine on the rabbit carotid artery.

&NA; Extreme arterial vasoconstriction (vasospasm) is a common problem encountered in microvascular surgery. An ideal pharmacologic tool able to counteract ischemia during microsurgery should be easy to apply and exert its action both locally and distally in the microcirculation of the flap. We have compared in vitro and in vivo vascular properties of nicardipine, papaverine, and lidocaine in the rabbit carotid artery. In vitro, rings from the rabbit carotid artery (n = 7) were bathed in Krebs‐Ringers solution and stretched progressively to an optimal tension of 3.7 to 4.2 g. The specimens were contracted with norepinephrine (1 &mgr;M), and a cumulative dose response curve was established. In vivo, microvascular anastomoses were performed bilaterally in the rabbit carotid artery in 35 animals using 9‐0 nylon suture and standard microsurgical techniques. During and after the anastomoses, nicardipine (0.1, 0.01 mg topical, or 0.1 mg/hour IV), papaverine (30 mg/cc topical), and lidocaine (2% with and without epinephrine) were applied (blinded) at the anastomotic site in five rabbits each. Heparinized sodium chloride was used as topical irrigation for control and to clean the anastomosis. Blood flow changes were monitored continuously with the transonic Doppler for 30 minutes after the procedure. The systemic blood pressure was also monitored in a group of pilot experiments. A documented decrease in blood flow was noted in all animals after the microvascular anastomosis. Nicardipine and papaverine evoked a concentrationdependent relaxation to precontracted rings to norepinephrine. Nicardipine was greater than papaverine in inducing relaxation. Lidocaine demonstrated a biphasic response with low concentrations potentiating contraction. Systemic nicardipine and papaverine significantly increased the blood flow in the rabbit carotid artery. Topical application of nicardipine and lidocaine did not significantly alter the blood flow; however, the application of nicardipine demonstrates a trend toward increased flow. Lidocaine with epinephrine significantly decreased the blood flow. No drug was found to alter the blood pressure of the animals. Our results demonstrate that nicardipine and papaverine seem to be pharmacologic tools able to increase the blood flow in anastomotic arteries. In contrast, the use of 2% lidocaine as a spasmolytic agent should be re‐evaluated, since this substance may act as a partial agonist. (Plast. Reconstr. Surg. 100: 1475, 1997.)

Immediate breast reconstruction with the TRAM flap after neoadjuvant therapy.

Neoadjuvant therapy is a relatively new weapon in the chemotherapeutic arsenal against breast carcinoma. However, there has been concern that preoperative chemotherapy might lead to an increased incidence of complications and delays in postoperative treatment. A retrospective study was performed at M.D. Anderson Cancer Center of all patients with locally advanced breast cancer who had undergone neoadjuvant therapy followed by mastectomy and immediate reconstruction with the transverse rectus abdominis musculocutaneous (TRAM) flap. Patients were evaluated for the incidence of complications and any delays in resumption of postoperative chemotherapy. Thirty-one patients underwent immediate reconstruction with the TRAM flap. Twenty-two patients were reconstructed with free TRAM flaps whereas 9 patients were reconstructed with pedicled TRAM flaps. Seventeen patients (55%) had complications postoperatively, but only 2 patients (6%) had a delay in the resumption of chemotherapy. Seven patients were smokers, five (71%) of whom had complications, which was not a significant difference from the rate in nonsmokers (50%). Although delays in postoperative chemotherapy occurred in smokers (29%, vs. 0% in nonsmokers), the number of patients was too small to attain statistical significance. Based on this study it is felt that immediate reconstruction with the TRAM flap can be performed safely in patients on a neoadjuvant protocol. Although not contraindicated, immediate reconstruction with the TRAM flap in smokers in this setting may be associated with higher morbidity.

The long-term effects of internal mammary chain irradiation and its role in the vascular supply of the pedicled transverse rectus abdominis musculocutaneous flap breast reconstruction

With an increase in breast-sparing surgery and adjuvant radiotherapy, there has been a concomitant increase in the complexity of breast reconstruction. The effects of radiotherapy on the Internal mammary artery were evaluated with respect to flap viability for conventional transverse rectus abdominis musculocutaneous breast reconstruction using the irradiated rectus muscle. Twenty-eight women who received postoperative irradiation for breast cancer were studied. All women had unilateral irradiation, and evaluation of the internal mammary arteries was performed at least 1 year after the completion of radiotherapy to allow for fibrosis and long-term vascular changes. Examination of the internal mammary artery (upper and lower chains) was performed using color Doppler sonography to assess vessel diameter, peak systolic velocity, and blood flow. The nonirradiated side was compared to the radiated internal mammary artery as an internal control. Based on the details of prior radiotherapy, the 28 women were designated into two groups. Group I included 14 women with radiation portals that specifically treated the internal mammary chain; the average dose to the internal mammary chain was 47.44 Gy. Group II comprised 14 patients that received tangential portals that did not directly target the internal mammary chain region; the average radiation dose was 48.21 Gy to the chest wall. No statistical difference was observed in group I between the irradiated and nonirradiated side for vessel diameter (p = .8631) or peak systolic velocity (p = .2646). However, an increase in blood flow on the irradiated side was significant (p = .0321). In evaluating group II alone in addition to the study population (28 patients), we failed to identify significant differences in these parameters. In conclusion, radiation portals that specifically target the internal mammary chain region may affect blood flow but did not have a statistical effect on vessel diameter and peak systolic velocity. Tangential radiation portals, which may or may not include the internal mammary chain region, appear to have little effect on the internal mammary artery. From these indirect measurements of internal mammary chain patency, prior radiotherapy may not preclude the use of the ipsilateral muscle as a possible vascular source for pedicled transverse rectus abdominis musculocutaneous flap breast reconstruction.

Drug‐induced vasodilation: In vitro and in vivo study on the effects of lidocaine and papaverine on rabbit carotid artery

Flap ischemia is often encountered during pedicled and free tissue transfer. In this study, the vascular effects of varying doses of lidocaine, papaverine, and a combination of the two agents were evaluated and compared in an in vitro and in vivo model in the rabbit carotid artery. In the in vitro study, 14 rings from the rabbit carotid artery were bathed in Krebs‐Ringers solution and stretched progressively to an optimal tension of 3.7–4.2 grams. Their isometric contractile activity was measured. The specimens were precontracted with norepinephrine (1 μM), and a dose response curve was established by adding cumulatively either lidocaine (to 7 arterial rings) or papaverine (to 7 arterial rings) at increasing concentrations. In the in vivo study, microvascular anastomoses were performed bilaterally in the rabbit carotid artery in 30 animals using 9–0 nylon suture and standard microsurgical techniques. In each animal, one side was treated with heparinized sodium chloride and served as the control. The other side was treated blindly, during and after the anastomoses, with a topical application of 1 ml of either lidocaine 2% (n = 5), lidocaine 20% (n = 5), papaverine (30 mg/ml, n = 5), lidocaine 2% combined with papaverine (30 mg/ml, n = 5), or lidocaine 20% combined with papaverine (30 mg/ml, n = 5). For 30–60 minutes after the procedure, blood flow changes in the vessels were continuously monitored with a transonic doppler applied to both carotid arteries. The 20% lidocaine group was flushed with saline at the end of the first hour and monitored for an additional 60 minutes. Papaverine elicited a concentration‐dependent relaxation of norepinephrine precontracted carotid artery rings in vitro. Lidocaine elicited a biphasic response, with low concentrations (10−6–10−4 M) increasing the norepinephrine‐induced contraction and high concentrations (10−4–10−2 M) relieving this contraction. Microsurgical anastomosis produced a significant decrease of blood flow through the rabbit carotid artery as measured by the transonic doppler. Drug application did not alter the systemic blood pressure of the animals. Topical application of lidocaine 2% did not significantly change the blood flow after microvascular anastomosis. Topical application of lidocaine 20%, papaverine (30 mg/ml), or lidocaine (2% or 20%) combined with papaverine significantly increased the blood flow in the rabbit carotid artery. In the lidocaine 20% group, the blood flow remained significantly increased after the drug was flushed with heparinized saline solution. These results demonstrate that topical lidocaine 20%, papaverine, and lidocaine 2% or 20% combined with papaverine significantly increase blood flow in the rabbit carotid artery after microvascular anastomosis. The data confirm the use of papaverine and lidocaine 20%, alone or in combination, as spasmolytics during clinical microsurgery. This suggests that lidocaine 2% alone is not the ideal drug to relieve vascular constriction, and further studies on the clinical use of low concentrations of topical lidocaine in microsurgery is warranted.