Christian T. Bonde

Ten years' experience of free flaps for breast reconstruction in a Danish microsurgical centre: an audit.

We have done a total of 292 breast reconstructions using a free flap over a period of 10 years (1994–2003). During the last five years the number of deep inferior epigastric perforator (DIEP) flaps has increased. However, to secure an optimal blood supply we still use a muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flap sometimes. Our results with the two flaps were identical as far as operating time and length of hospital stay were concerned, but the DIEP flap has less donor site morbidity. Our results are influenced by our selection of patients and our technique but we think that muscle-sparing TRAM flaps may be used as an alternative to DIEP flaps.

Introducing the fast track surgery principles can reduce length of stay after autologous breast reconstruction using free flaps: A case control study

Abstract Introduction: The concept of fast-track surgery (FTS) is a peri- and postoperative care concept developed to reduce length of hospital stay (LOS) and morbidity after surgery. FTS programmes have been reported from other surgical specialities, but there are few reports of FTS in plastic surgery. Materials and methods: Autologous breast reconstructions have been performed with abdominal free flaps since 1994. In 2006, an FTS program was introduced. Important changes in procedure were: early mobilisation, fewer/faster removal of drains and urinary catheter, discontinuation of epidural analgesia, planned early discharge, and multimodal opioid-sparing analgesia. The results from all unilateral, breast reconstructions in the first 5 years after the implementation of the FTS (n = 177) were compared to results prior to the FTS (n = 292). Flap type, operating time, blood loss and ischaemic time, LOS, early flap related and systemic complications (< 30 days) were analysed. Results: FTS significantly reduced mean LOS from 7.4 days to 6.2 days (p = 0.0002). When compared to pre-FTS results, similar flap types, operating time, blood loss and ischaemic time were found. LOS > 7 days were due to complications, the most common being haematoma. Prevalence of complications (6.5 vs 7.9%) and flap loss (2 vs 2%) did not increase. Haematomas seemed more frequent with the use of NSAID than with COX-2 inhibitors (9 vs 4%); however, the difference was not statistically significant. Conclusion: By introducing a simple, peri- and postoperative care concept it is possible to reduce LOS after microsurgery by at least 1 day without an increase in complications or flap loss.

Perioperative Optimization of Autologous Breast Reconstruction.

Summary: The authors recently showed that fast-track surgery could reduce the length of stay after a deep inferior epigastric perforator flap procedure from 7.4 days to 6.2 days without increasing complication rates or flap loss. This study improves the protocol and identifies specific factors that kept patients in the hospital. The authors present their results from the first 16 consecutive cases. Multimodal opioid-sparing analgesia was used. Nurses removed suction drains, without consulting the doctors. Fulfilment of functional discharge criteria (e.g., flap monitoring, ambulation) was assessed twice daily, and specified reasons for not allowing discharge were registered. All patients were discharged to home after approximately 72 hours, on the third postoperative day, except one patient who was discharged on day 4. Drains were removed on postoperative day 2 (n = 3) or 3 (n = 13). All patients had normal gastrointestinal tract function and minimal pain, and were eating and managing personal hygiene on the morning of postoperative day 2. All were mobilized by the afternoon of postoperative day 2. Median visual analogue scale score at discharge was 1 (range, 0 to 4). There were no reoperations and no major complications. Length of stay after autologous breast reconstruction using deep inferior epigastric perforator flaps can be reduced to approximately 3 days using the fast-track methodology. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evaluation of Tissue Oxygen Measurements for Flap Monitoring in an Animal Model

Tissue oxygen tension (p(ti)O(2)) measurements are common in neurosurgery but uncommon in plastic surgery. We examined this technique as a monitoring method with probe placement in the subcutaneous tissue and addressed the importance of probe placement. Myocutaneous flaps were raised in an animal model and p(ti)O(2) measurements performed at different levels in the subcutaneous fat. Flap artery and vein were occluded until a 50% p(ti)O(2) reduction had occurred (T(1/2)). We found no significant effect of depth (P>0.10) on the level of p(ti)O(2). T(1/2)(arterial) was 7.2 minutes and T(1/2)(venous) was 18 minutes. We found no significant relation between initial levels of p(ti)O(2) and T(1/2). Location of the probe and absolute p(ti)O(2) value is of little relevance for flap monitoring. It is the relative change in p(ti)O(2) that is important. The p(ti)O(2) technique is well suited for monitoring in the subcutaneous tissue and is highly sensitive to changes in both arterial and venous blood flow.