Ewa Komorowska-Timek

Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction.

BACKGROUND Immediate breast reconstruction results in a superior cosmetic outcome. However, immediate breast reconstruction using both prosthetic and autologous techniques is associated with significantly higher complication rates than delayed procedures. These early postoperative complications are usually related to unrecognized ischemia of mastectomy skin and/or inadequate perfusion of autologous tissue used for reconstruction. Aside from clinical experience, there are no reliable tools to assist the novice surgeon with intraoperative assessment of tissue viability. METHODS Laser-assisted indocyanine green imaging was applied to determine and map tissue perfusion. Indocyanine green perfusion mapping was used in 24 consecutive breast reconstructions to define the perfusion of both mastectomy skin and autologous tissue. Areas of inadequate perfusion were then removed at the time of surgery. Postoperative complications occurring within 90 days after surgery were reviewed. RESULTS In 24 consecutive breast reconstruction (16 tissue expanders, two latissimus dorsi flaps, and six deep inferior epigastric perforator/superficial inferior epigastric arteries), there was a 4 percent complication rate. Intraoperatively, the use of indocyanine green imaging allowed all poorly perfused skin to be removed completely in each case, minimizing the incidence of mastectomy flap necrosis, partial necrosis of autologous tissue, and impaired healing. For autologous reconstruction, patency of anastomoses could also be confirmed. This complication rate was significantly less than the 15.1 percent complication rate observed in 206 reconstructions in the previous consecutive 148 patients (p < 0.01) with similar demographics and risk factors. CONCLUSIONS This early experience demonstrates an increased accuracy in predicting tissue necrosis (mastectomy flap, autologous tissue) as guided by indocyanine green imaging. Further prospective studies are warranted to quantify whether this technology can reduce health care costs by preventing complications in immediate breast reconstruction.

The Effect of AlloDerm Envelopes on Periprosthetic Capsule Formation with and without Radiation

Background: The pathobiology of radiation-induced periprosthetic capsular formation and factors that may ameliorate its development have not been fully elucidated. The authors hypothesized that AlloDerm would diminish radiation-induced capsular formation. Methods: Two 5-ml implants were placed submuscularly in the backs of 41 rats. The right implant was wrapped with AlloDerm and the left remained bare. After 48 hours, 20 animals underwent irradiation to each implant, and 21 animals underwent no further treatment and served as controls. After 3 and 12 weeks, the capsules were harvested and submitted for tensile strength and histologic examination. Intraprosthetic pressures were measured in each implant at the time of surgery and when the animals were killed. Results: The intraprosthetic pressure decrease was uniform among all groups at 3 and 12 weeks. Between 3 and 12 weeks, capsular tensile strength increased in nonirradiated bare implants. There was considerable invasion of nonirradiated AlloDerm by inflammatory infiltrates at 3 weeks, and AlloDerm thickness decreased over time. Cellular invasion of AlloDerm was decreased with irradiation at both time points. Capsular tensile strength and thickness of the irradiated bare and AlloDerm capsules did not change between 3 and 12 weeks. Radiation increased inflammation of bare capsules at 12 weeks, but it was significantly reduced in irradiated AlloDerm capsules. The majority of irradiated bare capsules developed pseudoepithelium, whereas AlloDerm protected capsules from this transformation. Conclusion: AlloDerm decreases radiation-related inflammation and delays or diminishes pseudoepithelium formation and thus may slow progression of capsular formation, fibrosis, and contraction.

Effects of VEGF administration following ischemia on survival of the gracilis muscle flap in the rat.

The incidence of free flap transplantation failure is only 3% to 5%, yet still occurs in cases in which the flap suffers prolonged ischemia. The purpose of the current study was to determine the effects of vascular endothelial growth factor (VEGF)--a potent angiogenic agent with a suspected role in the protection of endothelium--on flap survival in a model of ischemia-reperfusion injury. The model chosen was the rat gracilis muscle flap. A total of 36 adult male Sprague-Dawley rats were divided into three groups (N = 12). One experimental group received VEGF treatment and the other received heparin. A third group was treated with saline and served as the control. The gracilis muscle flap was dissected and isolated based on a vascular pedicle originating at the femoral vessels. Following 3.75 hours of ischemia, induced by clamping the femoral vessels, either VEGF, heparin, or saline was infused directly into the pedicle of the flap via a cannula. The flaps were evaluated both grossly and histologically after 72 hours of reperfusion. Eleven of the 12 flaps from the VEGF group survived, whereas the survival rate was 6 of 12 and 5 of 12 flaps for the heparin- and saline-treated groups respectively. Flap survival was significantly greater in the VEGF-treated group compared with the heparin- and saline-treated groups (p < 0.025, p < 0.01 respectively). Furthermore, there was no significant difference between the heparin and saline groups. These results indicate that VEGF plays a role in reducing the damage that occurs in ischemia-reperfusion injury, and that the use of VEGF holds promise as a potential therapy for increasing flap survival.

Prolonged perivascular use of verapamil or lidocaine decreases skin flap necrosis.

During this experiment the authors investigated whether prolonged local use of verapamil or lidocaine prevents vasoconstriction and establishes better blood supply to the rat epigastric skin flap, hence reducing the necrosis that occurs otherwise. Abdominal wall skin flaps of 45 Sprague-Dawley rats, based on a single pedicle of the femoral vessels, were elevated. A subcutaneous pocket for the microport valve was created, and the adjacent catheter tip was sewn next to the femoral vessels. In the control and the two treatment groups, 0.5 ml saline or vasodilator solution respectively was injected through the microport every 12 hours for 5 days. On postoperative day 5 there was no statistical difference between the flap surfaces in all groups. The area of flap necrosis was significantly lower in the verapamil- (p = 0.001) and the lidocaine-treated (p = 0.012) groups vs. the control group as determined by analysis of variance with Bonferronis post hoc test. In conclusion, topical application of verapamil and lidocaine solutions for 5 postoperative days decreased flap marginal necrosis significantly. Prolonged injection of vasodilators in the vicinity of the vascular pedicle prevents vasospasm and improves blood supply to the flap.

Outcomes of Prosthetic Reconstruction of Irradiated and Nonirradiated Breasts with Fat Grafting

Background: Fat grafting may be beneficial in prosthetic reconstruction of irradiated tissues, but there is a paucity of data on the complication rates associated with this clinical scenario. Methods: All consecutive patients who had undergone fat grafting and prosthetic reconstruction from 2010 to 2013 were enrolled. Variables obtained related to fat grafting and history of irradiation. Implant-related complications in relation to irradiation status were also noted. Results: Eighty-five patients (age 49 ± 10 years) underwent 117 fat grafting procedures. The mean follow-up was 2.6 ± 0.7 years. Fat grafting was predominantly performed to correct soft-tissue deficiency [112 of 117 (95.7 percent)] or to alter skin after irradiation [five of 117 (4.3 percent)]. Thirty-two procedures (27.4 percent) were associated with a complication, with the most common being palpable fat necrosis (23.1 percent). Volume of transferred fat averaged 151.2 ± 76.6 ml per breast. Fat grafting complications did not depend on donor site, technique of fat processing, volume of transferred fat, number of procedures, or irradiation. Implant-related complications were observed after 26 of 117 overall procedures (22.2 percent). No association between implant-related complications and irradiation was observed (OR, 1.3; 95 percent CI, 0.4 to 4.1; p = 0.63). Overall complications following fat grafting in nonirradiated [37 of 82 (45.1 percent)] and irradiated [16 of 35 (45.7 percent)] breasts were not statistically different (OR, 1.02; 95 percent CI, 0.41 to 2.57; p = 0.96). Conclusion: Similar outcomes of irradiated and nonirradiated prosthetic breast reconstruction can be achieved with additional fat grafting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Oral administration of L-Arginine decreases necrosis of the epigastric skin flap in the rat

Background:We investigated the effect of prolonged oral arginine administration on tissue necrosis and perfusion in the rat skin flap. Methods:Twenty-five Sprague-Dawley rats had an 8 × 8-cm epigastric skin flap elevated and were divided in 2 groups, l-Arginine and Control, which respectively received oral 6% l-arginine solution or water for 8 days postoperatively. On postoperative day 8, area of flap necrosis was measured, and the animals were perfused systemically with 15-μm colored fluorescent microspheres before (blue) and after (yellow-green) ligation of the flap pedicle. Results:l-Arginine reduced total flap necrosis (6.53 ± 3.76 cm2 versus 11.91 ± 4.12 cm2; P < 0.01). After pedicle ligation, total flap perfusion remained unchanged in Control but diminished in the l-Arginine group (Control: 0.47 ± 0.23 and 0.42 ± 0.06; P = nonsignificant versus l-Arginine: 0.58 ± 0.29 and 0.27 ± 0.19; P < 0.01). Serum levels of l-arginine were higher in the l-arginine-treated animals (504 ± 154 versus 152 ± 34 μmol/l; P < 0.0001). Conclusions:Postoperative oral administration of l-arginine decreased flap necrosis in the rat epigastric skin flap. Flap perfusion following oral l-arginine was more dependent on the main vascular pedicle.

Saphenous neurocutaneous island flap model in the rat : Evaluation of vascular supply

Neurocutaneous flaps are utilized routinely in reconstructive surgery and even more so during the past decade. In this study, the vascular supply of the neurocutaneous flap in the rat model is presented and evaluated. Thirty-six flaps (3.5x3 cm2) were dissected on the medial aspect of the leg based on a pedicle of the saphenous nerve, saphenous artery, great saphenous vein, and the surrounding fascial tissues. Animals in the experiment were divided into five groups with different circulatory patterns of pedicle dissections. In group I (N = 12), the pedicle artery, vein, nerve, and fascia were preserved. In group II (neurocutaneous flap model, N = 24), the saphenous artery was transected and the vein, nerve, and fascia were preserved. In group III (intraneural vascular plexus circulation pattern, N = 12), the saphenous artery and the fascia were transected. In group IV (extraneural vascular plexus circulation pattern, N = 12), the saphenous artery and nerve were transected. In group V (N = 12), the entire pedicle was transected completely. Flap survival was evaluated grossly on postoperative day 7. All flaps survived in group I, but in group II 19 of 24 flaps survived completely, 3 of 24 had partial necrosis, and 2 of 24 were completely necrotic. Complete necrosis was observed in all group III flaps. In group IV, 6 of 12 flaps survived completely, 3 of 12 flaps survived partially, and 3 of 12 flaps were necrotic (p<0.05 vs. group I). Only one flap with partial necrosis survived in group V. In group II, the average survival area was not significantly different from group I (p>0.05). In conclusion, the saphenous neurocutaneous flap in the rat is a reliable microsurgical model. The saphenous neurocutaneous flap is commonly supplied by both the intraneural and extraneural vascular plexus, and although the latter is more important, neither provides sufficient vascular supply on its own.

Successful reattachment of a nearly amputated ear without microsurgery.

Traumatic ear loss is functionally and aesthetically disabling. Replantation of an amputated ear, with1–7 or without8,9 microsurgical techniques, has been reported before and offers the best reconstructive results. In contrast, ear salvage using the modified pocket technique,10–12 coverage with temporoparietal fascia flap and skin graft,13 or recreation of the cartilaginous framework using autologous tissues14 is inferior to primary ear repair with regard to shape and color mismatch. However, the outcome of primary ear salvage is limited by reestablishment and/or preservation of the existing perfusion to the severed tissue, which may be complicated by partial or complete tissue loss. Few existing reports describing the survival of avulsed yet still connected ear fragments underscore the uncertainty of successful nonmicrosurgical auricle replantation. To illustrate, Tomono and Hirase described reattachment of an ear based on a 3 x 1.5-cm pedicle at the lobule resulting in necrosis of the concha.15 Yotsuyanagi et al. reported successful survival of an auricle based on a 1-cm skin pedicle at the helical crus after resection of the congested lobule.16 According to another report, a 3-mm pedicle at the helical rim provided adequate circulation to the nearly amputated middle and inferior auricle yielding necrosis of the lobule.17 Similarly, Bill and colleagues noted satisfactory recovery of a partly detached ear with inferior pole ischemia after hyperbaric oxygen application.18 Adjunctive therapies, such as hyperbaric oxygen, dextran-40, aspirin, and leeches, have been described in the literature to augment survival of tissues with compromised perfusion, but the combination of all these modalities has not been previously applied in nonmicrosurgical ear rescue. In the current report, a case of complete nonmicrosurgical salvage of a nearly amputated ear with adjunctive multimodal therapy is described.

The Use of Seprafilm as a Biological Barrier in Flap Delay

MethodS: Two implants were placed in each of eight Spraque-Dawley rats, one of these wrapped with Seprafilm. Animals were sacrificed at 3 weeks. The periprosthetic capsules were sent for microscopic analysis including capsular thickness and extent of inflammatory infiltrate. Clinically, Seprafilm was utilized as a barrier to adhesion formation in two patients undergoing surgical delay of reverse sural (Figure 1) and trapezius myocutaneous flaps.

Abstract 126: complication rates of fat grafting associated with various modalities of breast reconstruction.

Methods: All breast fat grafting procedures conducted by a single surgeon from 2010 to 2013 were included in the study. The patients’ demographics, comorbidities, indications for fat grafting, technique of fat preparation, volume of transferred fat, and complications resulting from each procedure were noted. Indications for fat grafting were defined as follows: 1. contour deficiency over prosthetic or autologous flap 2. Breast reconstruction after mastectomy and/or implant failure 3. Post lumpectomy 4. Attempt to alter the skin after radiation 5. Congenital or cosmetic. Complications included infection, fat necrosis, cyst formation, wound dehiscence, sterile collection of necrotic fat, and abscess formation.