Gregory P. Reece

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.

A single center’s experience with 308 free flaps for repair of head and neck cancer defects

Since its inception at our institution in 1988, microvascular reconstructive surgery has become an integral part of the treatment of head and neck cancer patients. This review of 308 free flaps performed over the last 4 years was done to evaluate the complication and flap loss rates and to investigate which factors may contribute to these rates. The overall complication rate was 36.1 percent, the vessel thrombosis rate was 6.8 percent, the flap loss rate was 5.5 percent, and the flap salvage rate was 19.0 percent. Multifactorial analysis of delayed reconstruction, tobacco use, alcohol consumption, previous radiation therapy, previous surgery, and use of vein grafts showed that only previous surgery and the use of vein grafts led to significantly higher rates of flap loss (p < 0.01 for both).

Effect of obesity on flap and donor-site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction

&NA; The purpose of this study was to assess the effect of obesity on flap and donor‐site complications in patients undergoing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. All patients undergoing breast reconstruction with free TRAM flaps at our institution from February 1, 1989, through May 31, 1998, were reviewed. Patients were divided into three groups based on their body mass index: normal (body mass index <25), overweight (body mass index 25 to 29), obese (body mass index =30). Flap and donor‐site complications in the three groups were compared. A total of 936 breast reconstructions with free TRAM flaps were performed in 718 patients. There were 442 (61.6 percent) normal‐weight, 212 (29.5 percent) overweight, and 64 (8.9 percent) obese patients. Flap complications occurred in 222 of 936 flaps (23.7 percent). Compared with normal‐weight patients, obese patients had a significantly higher rate of overall flap complications (39.1 versus 20.4 percent; p = 0.001), total flap loss (3.2 versus 0 percent; p = 0.001), flap seroma (10.9 versus 3.2 percent; p = 0.004), and mastectomy flap necrosis (21.9 versus 6.6 percent; p = 0.001). Similarly, overweight patients had a significantly higher rate of overall flap complications (27.8 versus 20.4 percent; p = 0.033), total flap loss (1.9 versus 0 percent p = 0.004), flap hematoma (0 versus 3.2 percent; p = 0.007), and mastectomy flap necrosis (15.1 versus 6.6 percent; p = 0.001) compared with normal‐weight patients. Donor‐site complications occurred in 106 of 718 patients (14.8 percent). Compared with normal‐weight patients, obese patients had a significantly higher rate of overall donor‐site complications (23.4 versus 11.1 percent; p = 0.005), infection (4.7 versus 0.5 percent; p = 0.016), seroma (9.4 versus 0.9 percent; p < 0.001), and hernia (6.3 versus 1.6 percent; p = 0.039). Similarly, overweight patients had a significantly higher rate of overall donor‐site complications (19.8 versus 11.1 percent; p = 0.003), infection (2.4 versus 0.5 percent; p = 0.039), bulge (5.2 versus 1.8 percent; p = 0.016), and hernia (4.3 versus 1.6 percent; p = 0.039) compared with normal‐weight patients. There were no significant differences in age distribution, smoking history, or comorbid conditions among the three groups of patients. Obese patients, however, had a significantly higher incidence of preoperative radiotherapy and preoperative chemotherapy than did patients in the other two groups. A total of 23.4 percent of obese patients had preoperative radiation therapy compared with 12.3 percent of overweight patients and 12.4 percent of normal‐weight patients; 34.4 percent of obese patients had preoperative chemotherapy compared with 24.5 percent of overweight patients and 17.7 percent of normal‐weight patients. Multiple logistic regression analysis was used to determine the risk factors for flap and donor‐site complications while simultaneously controlling for potential confounding factors, including the incidence of preoperative chemotherapy and radiotherapy. In summary, obese and overweight patients undergoing breast reconstruction with free TRAM flaps had significantly higher total flap loss, flap hematoma, flap seroma, mastectomy skin flap necrosis, donor‐site infection, donor‐site seroma, and hernia compared with normalweight patients. There were no significant differences in the rate of partial flap loss, vessel thrombosis, fat necrosis, abdominal flap necrosis, or umbilical necrosis between any of the groups. The majority of overweight and even obese patients who undertake breast reconstruction with free TRAM flaps complete the reconstruction successfully. Both such patients and surgeons, however, must clearly understand that the risk of failure and complications is higher than in normal‐weight patients. Patients who are morbidly obese are at very high risk of failure and complications and should avoid any type of TRAM flap breast reconstruction. (Plast. Reconstr. Surg. 105: 1640, 2000.)

Timing of pedicle thrombosis and flap loss after free-tissue transfer.

&NA; A series of 990 consecutive free flaps was reviewed to determine how often pedicle thrombosis occurred, when it occurred, and if the timing of thrombosis detection had any relationship to the probability of flap salvage. The overall thrombosis rate was 5.1 percent, and the flap loss rate was 3.2 percent. The majority (80 percent) of thrombi occurred within the first 2 postoperative days. Only 5 thrombi (10 percent) were known to have occurred after the third postoperative day. No flaps that developed thrombosis after the third postoperative day were salvaged successfully. Had flap monitoring been discontinued after the first 3 postoperative days, our results in this series would have been unchanged. Thrombosis of the vein (54 percent) was more common than arterial thrombosis (20 percent) or thrombosis of both artery and vein (12 percent). Almost all purely arterial thrombi (90 percent) occurred before the end of the first postoperative day, whereas 41 percent of all venous thrombi occurred later. We conclude that arterial monitoring is most critical immediately after surgery. Beginning on the second postoperative day, venous monitoring becomes progressively more important to flap success. The cost‐effectiveness of postoperative monitoring of free flaps is greatest during the first 2 days, after which it decreases significantly.

Choice of flap and incidence of free flap success

&NA; A review of 854 consecutive free flaps was performed to determine whether the choice of flap used for the reconstruction influenced the probability of a successful outcome. Flaps were grouped into nine categories: rectus abdominis, free transverse rectus abdominis myocutancous, radial forearm, jejunum, latissimus dorsi, fibula, scapula, iliac crest, and other. There were significant differences among the success rates of different flaps (p < 0.0001). Rectus abdominis‐based flaps used for breast or head and neck reconstruction had lower failure rates (0.9 percent) than did non‐rectus abdominis Haps (6.6 percent; p < 0.0001). Flaps requiring vein grafts had a higher rate of flap loss (18.4 percent) than did flaps that did not require vein grafts (2.9 percent; p < 0.0001). There was a strong trend favoring survival of flaps without a bone component (compared with osteocutaneous flaps), and a weaker trend favoring survival of flaps in nonobese patients (compared with flaps in obese patients). Smoking, age. and previous irradiation had no significant effect on flap failure rales. Surgeons should consider the flap success rate as one (but not necessarily the most important) factor in choosing the best reconstruction for any individual patient.

Successes and failures of the teachable moment: Smoking cessation in cancer patients

Successful cancer treatment can be significantly compromised by continued tobacco use. Because motivation and interest in smoking cessation increase after cancer diagnosis, a window of opportunity exists during which healthcare providers can intervene and assist in the quitting process.

Reconstruction and the radiated breast: Is there a role for implants?

The use of breast implants in irradiated patients is controversial. Recently, 39 irradiated implants were compared with 338 nonirradiated implants in 297 patients between January of 1975 and October of 1994 at The University of Texas M. D. Anderson Cancer Center. Tissue expanders and follow-up time of less than 6 months excluded patients from the study. Five groups of patients were identified. Group 1 consisted of 7 patients and 7 implants who received postoperative adjuvant radiotherapy after implant placement. Group 2 consisted of 5 patients and 7 implants who received preoperative adjuvant radiotherapy prior to implant placement. Groups 3 and 4 consisted of 2 and 12 patients (2 and 19 implants) placed beneath latissimus dorsi flaps who had postoperative and preoperative adjuvant radiotherapy, respectively. Group 5 contained 4 patients with 4 implants placed beneath a transverse rectus abdominis myocutaneous (TRAM) flap who had preoperative radiotherapy. All implants were placed submuscularly or beneath autogenous flaps. The average irradiated breast received 50 Gy. For statistical purposes, two categories were identified. Capsular contracture (Baker III or greater), pain, exposure, and implant removal in 6 of 14 implants that received radiotherapy were compared with similar complications in 33 of 266 implants without irradiation (p = 0.001). The second category contained 10 complications in 25 implants placed beneath autogenous reconstructions with radiotherapy compared with 6 of 72 similar complications in implants placed beneath autogenous reconstructions without radiotherapy (p = 0.000). Results showed that irradiation has significant negative effects on the reconstructive outcome with implants. Autogenous reconstruction did not appear to offer a protective role when placed over implants.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Wall Strength, Bulging, and Hernia After Tram Flap Breast Reconstruction

The incidence of postoperative abdominal bulge, hernia, and the ability to do sit-ups was reviewed in a series of 268 patients who had undergone free TRAM (FTRAM) or conventional TRAM (CTRAM) flap breast reconstruction. Minimum follow-up was 6 months. Patients were divided into four groups: unilateral FTRAM (FT1P; n = 123), double-pedicle bilateral FTRAM (FT2P; n = 45), single-pedicle CTRAM (CT1P; n = 40), and double-pedicle or bilateral CTRAM (CT2P; n = 60). The incidence of abdominal bulges (3.8 percent) and hernia (2.6 percent) was similar in the four groups. Synthetic mesh, however, was required for reinforcement of donor site closure twice as often in the CTRAM patients. The ability to perform sit-ups was greatest in the FT1P group (63.0 percent), slightly lower in the CT1P group (57.1 percent), still lower in the FT2P group (46.2 percent), and lowest in the CT2P group (27.1 percent; p = 0.0005). Patients reconstructed with an FTRAM flap were more likely to be able to do sit-ups (58.3 percent) than were those reconstructed with a CTRAM flap (38.2 percent; p = 0.0074). Patients who had only one muscle pedicle used were more likely to be able to do sit-ups (61.7 percent) than were those who had two muscle pedicles used (35.6 percent; p = 0.0003). We conclude that the incidence of abdominal bulge or hernia is relatively independent of the type of TRAM flap used and the number of muscle pedicles harvested. On the other hand, postoperative abdominal strength, as measured by the ability do sit-ups, is influenced significantly by both of these factors.

Long-Term Implantation of Preadipocyte-Seeded PLGA Scaffolds

Studies were performed in a long-term effort to develop clinically translatable, tissue engineered adipose constructs for reconstructive, correctional, and cosmetic indications. Rat preadipocytes were harvested, isolated, expanded ex vivo, and seeded within PLGA scaffolds. Preadipocyte-seeded and acellular (control) scaffolds were implanted for 1-12 months. Explanted scaffolds were stained with osmium tetroxide, processed, and counterstained using H&E. Quantitative histomorphometric analysis was performed on all tissue sections to determine the amount of adipose tissue formed. Analyses revealed maximum adipose formation at 2 months, followed by a decrease at 3 months, and complete absence of adipose and PLGA at 5-12 months. These results extend a previous short-term study (Tissue Engineering 1999;5:134) and demonstrate that adipose tissue can be formed in vivo using tissue engineering strategies. However, the long-term maintenance of adipose tissue remains elusive.

Postoperative adjuvant irradiation: effects on tranverse rectus abdominis muscle flap breast reconstruction.

The use of postoperative irradiation following oncologic breast surgery is dictated by tumor pathology, margins, and lymph node involvement. Although irradiation negatively influences implant reconstruction, it is less clear what effect it has on autogenous tissue. This study evaluated the effect of postoperative irradiation on transverse rectus abdominis muscle (TRAM) flap breast reconstruction. A retrospective review was performed on all patients undergoing immediate TRAM flap breast reconstruction followed by postoperative irradiation between 1988 and 1998. Forty-one patients with a median age of 48 years received an average of 50.99 Gy of fractionated irradiation within 6 months after breast reconstruction. All except two received adjuvant chemotherapy. Data were obtained from personal communication, physical examination, chart, and photographic review. The minimum follow-up time was 1 year, with an average of 3 years, after completion of radiation therapy. Nine patients received pedicled TRAM flaps and 32 received reconstruction with microvascular transfer. Fourteen patients had bilateral reconstruction, but irradiation was administered unilaterally to the breast with the higher risk of local recurrence. The remaining 27 patients had unilateral reconstruction. All patients were examined at least 1 year after radiotherapy. No flap loss occurred, but 10 patients (24 percent) required an additional flap to correct flap contracture. Nine patients (22 percent) maintained a normal breast volume. Hyperpigmentation occurred in 37 percent of the patients, and 56 percent were noted to have a firm reconstruction. Palpable fat necrosis was noted in 34 percent of the flaps and loss of symmetry in 78 percent. Because the numbers were small, there was no statistical difference between the pedicled and free TRAM group. However, as a group, the findings were statistically significant when compared with 1443 nonirradiated TRAM patients. Despite the success of flap transfer, unpredictable volume, contour, and symmetry loss make it difficult to achieve consistent results using immediate TRAM breast reconstruction with postoperative irradiation. TRAM flap reconstruction in this setting should be approached cautiously, and delayed reconstruction in selected patients should be considered. Patients should be aware that multiple revisions and, possibly, additional flaps are necessary to correct the progressive deformity from radiation therapy.