Charles A. Hergrueter

A Multi-Institutional Analysis of the Socioeconomic Determinants of Breast Reconstruction: A Study of the National Comprehensive Cancer Network

Objective:To determine the rate of postmastectomy reconstruction and investigate the impact of socioeconomic status on the receipt of reconstruction. Summary Background Data:The National Comprehensive Cancer Network (NCCN) Outcomes Project is a prospective, multi-institutional database that contains data on all newly diagnosed breast cancer patients treated at one of the participating comprehensive cancer centers. Methods:The study cohort consisted of 2174 patients with DCIS and stage I, II, and III invasive breast cancer who underwent mastectomy at one of 8 NCCN centers. Rates of reconstruction were determined. Logistic regression analyses were used to evaluate whether socioeconomic characteristics are associated with breast reconstruction. Results:Overall, 42% of patients had breast reconstruction following mastectomy. Patients with Medicaid and Medicare were less likely to undergo reconstruction than those with managed care insurance; however, there was no difference for indemnity versus managed care insurance. Homemakers and retired patients had fewer reconstructions than those employed outside the home. Patients with a high school education or less were less likely to have reconstruction than those with more education. Race and ethnicity were not significant predictors of reconstruction. Conclusions:The reconstruction rate in this study (42%) is markedly higher than those previously reported. The type of insurance, education level, and employment status of a patient, but not her race or ethnicity, appear to influence the use of breast reconstruction. Because all patients were treated at an NCCN institution, these socioeconomic differences cannot be explained by access to care.

Growth factors and canine flexor tendon healing: Initial studies in uninjured and repair models***

The role of growth factors in a variety of bone and soft tissue healing processes has been studied extensively in numerous recent models, yet little is known about the specific growth factors that may be playing a role in flexor tendon healing. We used a number of established protein purification techniques and bioassays to isolate and partially characterize a heparin-binding growth factor from unoperated canine tendons. Our data provide evidence that basic fibroblast growth factor, a potent angiogenic growth factor, is present in normal canine intrasynovial flexor tendons. We then studied repaired canine flexor tendons to further elucidate the role of growth factors in the tendon healing process. Heparin-sepharose elution profiles from three repair intervals (3, 10, and 17 days) were graphed and compared to known profiles of isolated growth factors. The three repair intervals demonstrated two elution profile peaks, consistent with varying amounts of platelet-derived growth factor and epidermal growth factor. Although additional experimentation is required to identify definitively the various protein isolates, these data provide compelling evidence that a variety of growth factors are present in uninjured and healing digital flexor tendons.

Anterolateral thigh free flap.

The descending branch of the lateral femoral circumflex artery is a large-caliber artery that passes obliquely across the upper third of the thigh and descends between the vastus lateralis and rectus femoris muscles. It sends perforators through the septum between these muscles and through the vastus lateralis muscle and supplies a large area of skin on the anterolateral aspect of the thigh. We report our experience with our first 44 consecutive anterolateral thigh flaps, which were used for a variety of softtissue deficits. Twenty-five of these flaps were used for lower extremity reconstruction, 10 were used in the upper extremity, and 9 were used in the head and neck. The overall success rate was 96%. Six flaps required reoperation; of these, 2 flaps were lost, one from a venous thrombosis and the other from arterial thrombosis, both of which were in the lower extremity. In approximately one third of cases, the flap was raised as a septofascio-cutaneous flap, but in two thirds it was necessary to include a small segment of vastus lateralis muscle as well as fascia with the flap. The flap has been particularly useful for lower extremity reconstruction, and in patients who are not fit for general anesthesia, it is possible to perform the flap transfer with epidural anesthesia. The flap has the advantage of a long vascular pedicle with large-caliber vessels and thus is suitable as a flow-through flap. It may also be sensate and has provided a versatile soft-tissue coverage option with minimal long-term donor-site complications.

New trends in breast cancer management: is the era of immediate breast reconstruction changing?

Objective:Review of available literature on the topic of breast reconstruction and radiation is presented. Factors influencing the decision-making process in breast reconstruction are analyzed. New trends of immediate breast reconstruction are presented. Summary Background Data:New indications for postmastectomy radiation have caused a dramatic increase in the number of radiated patients presenting for breast reconstruction. The major studies and their impact on breast cancer management practice are analyzed. Unsatisfactory results of conventional immediate reconstruction techniques followed by radiotherapy led to a new treatment algorithm for these patients. If the need for postoperative radiation therapy is known, a delayed reconstruction should be considered. When an immediate reconstruction is still desired despite the certainty of postoperative radiotherapy, reconstructive options should be based on tissue characteristics and blood supply. Autologous tissue reconstruction options should be given a priority in an order reflecting superiority of vascularity and resistance to radiation: latissimus dorsi flap, free TRAM or pedicled TRAM without any contralateral components of tissue, pedicled TRAM/midabdominal TRAM, and perforator flap. Conclusions:When the indications for postoperative radiotherapy are unknown, premastectomy sentinel node biopsy, delayed-immediate reconstruction, or delayed reconstruction is preferable.

Incidence of major corrective surgery after post-mastectomy breast reconstruction and radiation therapy.

Abstract: To evaluate the likelihood of requiring major corrective surgery (MCS) after modified radical mastectomy (MRM), immediate reconstruction and radiation therapy (RT) to the reconstructed breast. The study population consisted of 62 patients who underwent MRM and immediate breast reconstruction between 1990 and 1999, had postoperative radiation and at least one follow‐up visit or procedure ≥2 months after radiation. Reconstruction consisted of a pedicled transverse rectus abdominis myocutaneous flap in 42 patients, latissimus dorsi flap in five, latissimus dorsi plus implant in six, and implant alone in nine. Median follow‐up time after reconstruction was 13 months (range: 2–58) for non‐implant patients and 10 months (range: 4–57) for implant patients. The primary endpoint was the incidence of major complications requiring MCS. Ten patients (16%) underwent MCS between 1 and 28 months after radiation (median in these patients of 8 months). 4/47 non‐implant patients (9%) underwent MCS, compared to 6/15 implant patients (40%). Of patients followed ≥6 months after RT, 0/38 non‐implant patients underwent MCS within 6 months compared to 3/13 (23%) implant patients (p = 0.01); of patients followed for ≥12 months after RT, the rates of MCS within 12 months were 1/24 (4%) and 2/7 (29%), respectively (p = 0.12). Patients who undergo immediate reconstruction after mastectomy using an implant followed by radiation have a high rate of subsequent MCS. The difference in the rate of MCS between the implant and non‐implant groups is significant in early follow‐up. Patients considering an implant followed by RT should be apprised of this increased risk. Prospective studies of these risks and the cosmetic outcomes are warranted.

Human recombinant tissue type plasminogen activator and its effect on microvascular thrombosis in the rabbit.

A new potent thrombolytic agent, human tissue type plasminogen activator (t-PA), has become available for study through recombinant DNA technology. In this series of experiments, we have tested t-PA in a reliable microvascular thrombosis model previously developed in our laboratory. Its action in preventing thrombus formation and lysing fresh clot by direct local infusion and systemic infusion was tested. The results revealed that t-PA was able to keep locally infused vessels open for 4 hours and reopen them after they were allowed to clot in 100 percent of the animals tested. Those vessels exposed only to systemic levels of t-PA achieved by the same local infusion remained thrombosed and were unaffected. Laboratory studies showed no evidence of activation of the systemic lytic state or alteration in coagulation parameters. t-PA has proved to be a protein with characteristics that make it attractive for use in microvascular surgery. The results suggest that further research may lead the way toward clinical use.

Prevention of microvascular thrombosis with short-term infusion of human tissue-type plasminogen activator.

A locally active thrombolytic agent, human tissue-type plasminogen activator (t-PA), given over a finite time period (24 hours) by local infusion, maintains long-term microvascular patency (7 days) in a proven thrombosis model using an arterial inversion graft in the rabbit model. Thirteen rabbits in the control group and 16 rabbits in the experimental group underwent an arterial inversion graft followed by continuous infusion (24 hours) with human tissue-type plasminogen activator (experimental) or normal saline (control). No significant clinical bleeding or alteration of coagulation parameters was noted in hematologic studies in both experimental and control groups. Scanning electron microscopy of the postoperative human tissue-type plasminogen activator-perfused arteries suggests an interaction of the human tissue-type plasminogen activator with specific platelet receptors in reversing microvascular thrombosis by decreasing or preventing further platelet aggregation and adhesion. Human tissue-type plasminogen activator infused locally for a finite period (24 hours) allows adequate time for platelet metamorphosis to occur in converting a thrombogenic to a nonthrombogenic vessel surface. The clinical ramifications in preventing or reversing microvascular thrombosis in free-tissue transfers and replantation surgery are apparent. Further study in this area will enhance our understanding of the pathogenesis and prevention of microvascular thrombosis.

Seven-digit replantation: digit survival after 39 hours of cold ischemia.

A patient who has undergone successful replantation of seven of eight amputated digits is presented. Survival in the last viable digit was seen 39 hours after amputation with cold ischemia preservation. No graded ischemia-related changes in the digits have been appreciated over 35 months of follow-up.

The value of the delay phenomenon in flap prefabrication: an experimental study in rabbits.

Neovascularisation of thin skin flaps after arteriovenous pedicle implantation (flap prefabrication) and the impact of the delay mechanism on the viability of these flaps were investigated. Twenty-four full thickness skin flaps were raised in twelve New Zealand white rabbits. Delay incisions were made at the lateral borders of the planned flaps at the same time as pedicle implantation, 1 week before pedicle implantation, or 1 week after pedicle implantation and the flaps based on the implanted vessels raised at 2 weeks after implantation. Flap survival assessed at 1 week was found to be improved when flap delay was performed 1 week before or after pedicle implantation. Angiographic studies demonstrated an increased density and linearity of the vascular pattern in these delay group flaps. The combination of the time-tested concept of delaying a flap with the newer technique of flap prefabrication appears to improve flap viability.

Postmastectomy complications in breast reconstruction.

In a group of patients where breast reconstruction was performed at the time of mastectomy, the incidence of complications was studied. One hundred one consecutive patients had an autologous reconstruction using the transverse rectus abdominis musculocutaneous flap, and 115 consecutive patients had a prosthetic reconstruction with tissue expanders or with tissue expander and/or implant. One patient in the autologous reconstruction group had a cardiac arrhythmia requiring monitoring, but there were no other serious complications. Infection was more common in the group undergoing prosthetic reconstruction (5% compared with 3% in the autologous reconstruction group). A total of 8% of the patients in the group undergoing prosthetic reconstruction had to have their implants removed because of infection or exposure of the implant. Seven percent of the transverse rectus abdominis musculocutaneous flap patients had significant necrosis of a portion of the flap. Secondary surgical revision of the reconstructed breast was much more common (20%) in the prosthetic reconstruction group compared with 6% in the autologous reconstruction group.