Donald J. Morris

Skin-sparing mastectomy and immediate reconstruction : Oncologic risks and aesthetic results in patients with early-stage breast cancer

&NA; Skin‐sparing mastectomy has been advocated as an oncologically safe approach for the management of patients with early‐stage breast cancer that minimizes deformity and improves cosmesis through preservation of the skin envelope of the breast. Because chest wall skin is the most frequent site of local failure after mastectomy, concerns have been raised that inadequate skin excision could result in an increased risk of local recurrence. Precise borders of the skin resection have not been well established, and long‐term local recurrence rates after skin‐sparing mastectomy are not known. The purpose of this study was to evaluate the oncologic safety and aesthetic results for skin‐sparing mastectomy and immediate breast reconstruction with a latissimus dorsi myocutaneous flap and saline breast prosthesis. Fifty‐one patients with early‐stage breast cancer (26 with ductal carcinoma in situ and 25 with invasive carcinoma) undergoing primary mastectomy and immediate reconstruction with a latissimus flap were studied from 1991 through 1994. For 32 consecutive patients, skin‐sparing mastectomy was defined as a 5‐mm margin of skin designed around the border of the nipple‐areolar complex. After the mastectomy, biopsies were obtained from the remaining native skin flap edges. Patients were followed for 44.8 months. Histologic examination of 114 native skin flap biopsy specimens failed to demonstrate breast ducts in the dermis of any of the 32 consecutive patients studied. One of 26 patients with ductal carcinoma in situ had metastases to the skin of the lateral chest wall and back. Four other patients, one with stage I disease and three with stage II‐B disease, had recurrent breast carcinoma. The stage I patient had a local recurrence in the subcutaneous tissues near the mastectomy specimen. Two patients suffered axillary relapse, and one had distant metastases to the spine. The findings of this study support the technique of skin‐sparing mastectomy as an oncologically safe one, based on an absence of breast ductal epithelium at the margins of the native skin flaps and a local recurrence rate of 2 percent after 45 months of follow‐up. Although these results need to be confirmed with greater numbers of patients and longer follow‐up, skin‐sparing mastectomy and immediate breast reconstruction may be considered an excellent alternative treatment to breast conservation for patients with ductal carcinoma in situ and early‐stage invasive breast cancer. (Plast. Reconstr. Surg. 102: 49, 1998.)

Implant-Based Breast Reconstruction Using Acellular Dermal Matrix and the Risk of Postoperative Complications

Background: Acellular dermal matrix has been popularized as an adjunct to tissue expander or implant breast reconstruction given its utility in providing additional coverage and support for the inferior pole. This study was performed to assess the risk of postoperative complications associated with the use of acellular dermal matrix–assisted implant-based reconstruction. Methods: The authors performed a retrospective analysis of consecutive immediate breast reconstructions performed over a 6-year period. A total of 415 implant-based reconstructions were divided into two groups: tissue expander or implant-based reconstruction with or without acellular dermal matrix. Demographic information, comorbidities, oncologic data, adjuvant therapy, and complications were collected for comparison. Results: A total of 283 patients underwent 415 immediate breast reconstructions (151 unilateral and 132 bilateral); 269 reconstructions were performed using tissue expander or implants with acellular dermal matrix, and 146 reconstructions were performed without acellular dermal matrix. The seroma and infection rates were higher in the acellular dermal matrix group (14.1 versus 2.7 percent, p = 0.0003, for seroma; 8.9 versus 2.1 percent, p = 0.0328, for infection). Multiple logistic regression analysis showed that acellular dermal matrix and body mass index were statistically significant risk factors for developing seroma and infection. The use of acellular dermal matrix increased the odds of seroma by 4.24 times (p = 0.018) and infection by 5.37 times (p = 0.006). Conclusions: Acellular dermal matrix has enhanced implant-based reconstruction and remains useful in immediate prosthetic breast reconstruction. It is associated, however, with higher rates of postoperative seroma and infection. Careful patient selection, choice of tissue expander/implant volume, and postoperative management are warranted to optimize overall reconstructive outcome.

Patient Satisfaction in Postmastectomy Breast Reconstruction: A Comparative Evaluation of DIEP, TRAM, Latissimus Flap, andImplant Techniques

Background: Despite a growing literature on patient satisfaction in breast reconstruction, few studies have compared perforator flaps with the more commonly practiced methods. The authors compared four reconstructive techniques and identified factors influencing patient satisfaction. Methods: All patients undergoing postmastectomy breast reconstruction between 1999 and 2006 at a single academic institution were included in our study. A total of 583 patients with tissue expander/implant, latissimus, pedicle transverse rectus abdominis muscle (TRAM), and deep inferior epigastric perforator (DIEP) flap reconstructions received a validated questionnaire on satisfaction, health-related quality of life, and sociodemographic data. Results: Patient response was 75 percent, with 439 completed questionnaires including 87 tissue expander/implant, 116 latissimus, and 119 pedicle TRAM and 117 DIEP flap patients. DIEP patients had the highest level of general satisfaction at 80 percent, and pedicle TRAM patients had the highest level of aesthetic satisfaction at 77 percent (p < 0.001 and p < 0.001, respectively). Health-related quality of life and length of time since surgery were identified as significant covariates influencing patient satisfaction. After logistic regression analysis, autologous reconstruction had significantly higher general and aesthetic satisfaction than implant-based reconstruction (p = 0.017 and p < 0.001). Among the autologous reconstructions, abdominal-based flaps had significantly higher general and aesthetic satisfaction than latissimus flaps (p = 0.011 and p = 0.016). When comparing the abdominal-based reconstructions, general and aesthetic satisfaction were no longer statistically significant between pedicle TRAM and DIEP flaps (p = 0.659 and p = 0.198). Conclusions: Autologous, abdominal-based reconstructions had the highest satisfaction rates across all four groups. After logistic regression analysis, differences in patient satisfaction between pedicle TRAM and DIEP flap reconstruction were no longer observed. Discussing satisfaction outcomes with patients will help them make educated decisions about breast reconstruction.

Pathogenesis of calciphylaxis: Study of three cases with literature review

Calciphylaxis is characterized by ischemic necrosis, primarily of skin. The early phase of the ischemia has not been studied, and the pathogenesis is uncertain. In this study of early calciphylaxis, the vessels responsible for the ischemia seem to be within the material available for microscopic review, and the various stenosing vascular lesions are quantified. A distinctive and previously described small vessel calcification with superimposed endovascular fibrosis is most common, and is much more frequent than two other lesions proposed to cause the ischemia (thrombosis and global calcific obliteration). The calcified stenotic vessels average 100 microns in diameter. Calcification precedes the endovascular fibrosis. Vessels with early endovascular fibroblastic activation are found statistically to be strongly associated with the presence of a giant cell reaction. This endovascular giant cell reaction has not been previously described in calciphylaxis. Two additional cases show similar findings. The histology resembles the reaction to calcium in a variety of other extraosseous calcification syndromes, for example, pseudogout, as if calciphylaxis were an endovascular form of calcium crystal-induced inflammatory disease. The literature is reviewed, and the clinicopathologic, radiographic, and therapeutic implications are discussed.

Nipple-sparing mastectomy: evaluation of patient satisfaction, aesthetic results, and sensation.

The purpose of this study is to describe our experience with nipple-sparing mastectomy and immediate reconstruction, with particular attention to patient satisfaction, aesthetic results, and nipple sensation. Immediate reconstruction was performed on 17 breasts in 10 patients, using either implants or autologous tissue flaps. Assessment of outcomes was performed through patient interviews, a self-reported patient satisfaction survey and review of postoperative photographs. Short-term complications included partial loss of the nipple-areolar complex requiring debridement (n = 3) and removal of the nipple-areolar complex (n = 2) for occult ductal carcinoma in situ. While all patients with completed breast reconstructions were satisfied with their general reconstructive experience, 6 of 9 patients were aesthetically satisfied with their breast reconstruction. Postoperative nipple sensation was reported in 75% of patients, although sensation was low (mean of 2.8 of 10). As nipple-sparing mastectomy is becoming an increasing patient preference, preoperative discussion needs to address expectations, aesthetic satisfaction, and long-term cancer control.

Three-dimensional folded free-flap reconstruction of complex facial defects using intraoperative modeling

Free-tissue transfer has emerged as the ideal way of reconstructing complex facial defects. Multifaceted free flaps are often needed, and we have developed a simple technique to determine both the volume of tissue required and the localization of the various epithelial surfaces, thereby simplifying these complex reconstructions.We report our experience in reconstructing 19 complex facial defects in which we have used an intraoperative alginate moulage that has provided an accurate three-dimensional model of the defect, helping to determine the volume of the flap required. The reconstruction was further simplified by converting this three-dimensional model into a two-dimensional pattern by wrapping the model with a piece of Esmarch bandage, thereby determining the locations and sizes of the epithelial surfaces. The pattern was then transferred to the donor site and the flap deepithelialized and thinned in situ with complete confidence that the tissue was “tailor-made” for the defect. (Plast. Reconstr. Surg. 93: 285, 1994.)

Dermal autografts for fascial repair after TRAM flap harvest.

&NA; To find an alternative to synthetic mesh closure of abdominal fascial defects after transverse rectus abdominis musculocutaneous (TRAM) flap harvest, dermal autografts were removed from tissue to be discarded and used for fascial closure. Dermal grafts have been used for herniorrhaphy and fascial repair after TRAM harvest previously, but have never been systematically studied. The dermal autograft technique was used in 24 patients to repair or reinforce anterior rectus sheath or external oblique fascia after TRAM harvest for breast reconstruction. During the same period, 25 other patients underwent TRAM breast reconstruction with abdominal wall closure by other methods. All patients were followed by serial physical examinations given by the operating surgeon. Average follow‐up in the dermal autograft group was 12.6 versus 12.0 months in the second group. In the dermal autograft group, two patients complained of bulging of the anterior abdominal wall; one developed a true hernia, away from the location of the dermal autograft. In the second group, two patients experienced bulging. Wounds and infectious complications were similar in both groups. Dermal autografts are a useful alternative to mesh repair or direct closure of fascial defects after TRAM flap harvest. (Plast. Reconstr. Surg. 102: 2287, 1998.)

Comparison of clinical outcomes and patient satisfaction in immediate single-stage versus two-stage implant-based breast reconstruction.

Background: The purpose of this study was to assess the outcomes of immediate, single-stage, implant-based reconstruction compared with traditional, two-stage reconstruction (i.e., tissue expander placement followed by exchange to implant). Methods: A retrospective review of consecutive patients who underwent immediate unilateral or bilateral breast reconstruction over an 8-year period was performed. The primary predictor variable was method of reconstruction (single-stage versus two-stage). Outcome measures were postoperative complication rates, revision rates, and BREAST-Q patient satisfaction scores. Descriptive, bivariate, and multiple regression statistics were computed. Results: The study sample consisted of 346 subjects who underwent reconstruction of 582 breasts (166 single-stage and 416 two-stage reconstructions). Complication rates between the single-stage and two-stage groups were similar for minor infections, major infections, hematoma formation, seroma formation, minor necrosis, and major necrosis (p ≥ 0.20). In a multiple logistic regression model, subjects undergoing single-stage reconstruction were found to be 87 percent more likely to require revision necessitating an additional operation (p = 0.005). In an adjusted regression model, subjects undergoing two-stage reconstruction had higher BREAST-Q scores for satisfaction with medical and office staff (p ⩽ 0.02). Subjects undergoing single-stage reconstruction had higher sexual well-being satisfaction scores. Conclusions: There is no significant difference in complication rates between single-stage versus two-stage implant-based breast reconstructions. Although single-stage reconstruction is associated with higher sexual well-being satisfaction, it is more than 80 percent more likely to require additional operative revisions. Two-stage reconstruction is associated with significantly higher satisfaction with the medical and office staff. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Local fasciocutaneous flaps for olecranon coverage.

In 1989 we began to treat soft-tissue defects around the olecranon process with local fasciocutaneous flaps as our preferred method of treatment. These soft-tissue defects are complications of bursitis, degenerative joint disease, and burns. They may also result from pressure necrosis over the olecranon in patients with impaired sensation. Because of the difficulty in treating these wounds a variety of local muscle, musculocutaneous, fasciocutaneous, distant, and free flaps have been described. Fasciocutaneous flaps have the advantage of using regional tissue in a single stage. Fasciocutaneous flaps around the elbow can be categorized as proximally or distally based. Proximally based flaps include the radial and ulnar forearm flaps as well as the posterior interosseous flap. Distally based flaps are based on upper elbow collaterals including the radial collateral artery, the middle collateral artery, and the anterior and posterior ulnar recurrent arteries. Eleven fasciocutaneous flaps were used in 10 patients with a follow-up of 1 to 3 years. All flaps survived and provided primary wound closure. Complications included 1 patient with recurrent ulceration after being healed for 6 months and 1 patient with a transient neurapraxia of the posterior interosseous nerve that resolved after 2 weeks. These flaps provide long-term stable coverage of olecranon wounds by using regional tissue with an acceptable donor site morbidity.

Double fillet of foot free flaps for emergency leg and hand coverage with ultimate great toe to thumb transfer

A 42-year-old woman presented with avulsion amputation of her right leg 14 cm below the knee joint and a hemihand amputation of the opposite hand. Two free flaps, taken from the amputated foot, were used to cover the injured extremities. The sole fillet flap was used to preserve length and cover the injured leg, while the dorsal fillet flap covered the injured hand and provided ectopic storage for the great toe. The great toe was later transferred on a pedicle for thumb reconstruction. Spare parts surgery is now a well-accepted technique. This case demonstrates maximum utilization of amputated parts for functional and aesthetic reconstruction.