Heather Erhard

Perforator Flaps: Recent Experience, Current Trends, and Future Directions Based on 3974 Microsurgical Breast Reconstructions

Summary: Perforator flap breast reconstruction is an accepted surgical option for breast cancer patients electing to restore their body image after mastectomy. Since the introduction of the deep inferior epigastric perforator flap, microsurgical techniques have evolved to support a 99 percent success rate for a variety of flaps with donor sites that include the abdomen, buttock, thigh, and trunk. Recent experience highlights the perforator flap as a proven solution for patients who have experienced failed breast implant–based reconstructions or those requiring irradiation. Current trends suggest an application of these techniques in patients previously felt to be unacceptable surgical candidates with a focus on safety, aesthetics, and increased sensitization. Future challenges include the propagation of these reconstructive techniques into the hands of future plastic surgeons with a focus on the development of septocutaneous flaps and vascularized lymph node transfers for the treatment of lymphedema.

Anatomic imaging of abdominal perforator flaps without ionizing radiation: Seeing is believing with magnetic resonance imaging angiography

The tremendous variability of the inferior epigastric arterial system makes accurate imaging of the vasculature of the anterior abdominal wall an essential component of optimal perforator selection. Preoperative imaging of the abdominal vasculature allows for preoperative perforator selection, resulting in improved operative efficiency and flap design. Abdominal wall perforators of 1-mm diameter can be reliably visualized without exposing patients to ionizing radiation or iodinated intravenous contrast through advances in magnetic resonance imaging angiography (MRA). In this study, MRA imaging was performed on 31 patients who underwent 50 abdominal flaps. For each flap, the location, relative to the umbilicus, of the three largest perforators on both the left and right sides of the abdomen was determined with MRA. Vessel diameter and anatomic course were also evaluated. Postoperatively, a survey was completed by the surgeon to assess the accuracy of the MRA with respect to the intraoperative findings. All perforators visualized on MRA were found at surgery (0% false-positive). In 2 of 50 flaps, the surgeon transferred a flap based upon a vessel not visualized on the MRA (4% false-negative). This article details our experience with MRA as a reliable preoperative imaging technique for abdominal perforator flap breast reconstruction.

Simultaneous bilateral breast reconstruction with superior gluteal artery perforator (SGAP) flaps

The superior gluteal artery perforator (SGAP) flap is a useful technique for restoration of the breast after mastectomy. If appropriately planned, the soft-tissue envelope supplied by the superior gluteal artery perforator vessels can be harvested with minimal donor site morbidity and often results in a highly esthetic restoration of the breasts. Dissection of the flap is performed with complete preservation of gluteus maximus muscle function. The resulting vascular pedicle obtained via dissection through the muscle is longer than that of gluteal musculocutaneous flaps and affords the surgeon the luxury of avoiding vein grafts in the anastomotic phase of surgery. Despite these advantages, use of the SGAP flap is not popular among reconstructive surgeons. Many practitioners are not familiar with the vascular anatomy of the gluteal area and may not be comfortable with the dissection of the parent vessels or lack the desire to practice microsurgery. On the other hand, our group has reported the largest experience to date with this method of breast reconstruction and has found the SGAP flap to be a reliable and safe method of autologous breast restoration in unilateral absence of the breast. Although the indications to perform single-stage gluteal tissue transplantation for bilateral breast restoration are uncommon, they do occasionally arise in clinical practice. We have carried out concurrent bilateral breast reconstruction using SGAP flaps on 6 patients with acceptable overall morbidity. All flaps went on to survive and resulted in highly esthetic restorations of the breast. Though a challenging undertaking, in-unison transfer of bilateral SGAP flaps serves as a useful option for a subset of patients desiring 1-stage bilateral breast reconstruction.

Bipedicle-conjoined perforator flaps in breast reconstruction

BACKGROUND For some patients seeking autologous breast reconstruction, there may be insufficient abdominal skin and soft tissue to reconstruct an adequately sized breast. Perfusion from a single-pedicle deep inferior epigastric perforator artery flap has a high degree of variability across the midline, and this further limits perfusion. We have found that bipedicle-conjoined abdominal perforator flaps are a novel and reliable technique for reconstruction in these women, and this study examines our experience. MATERIALS AND METHODS A retrospective review was performed over a 2-y period of bipedicle-conjoined abdominal perforator flaps in 28 patients. For each reconstruction, the pedicle of one flap was anastomosed to the anterograde internal mammary artery vessels and the pedicle of the second flap to a side branch of the primary flap or the retrograde internal mammary vessels. RESULTS Mean age and body mass index were 50.2 y (standard deviation, 8.0) and 25.9 kg/m(2) (standard deviation, 2.8), respectively. In total, 15 patients (53.6%) received radiation therapy before surgery. There were no flap losses; fat necrosis was found in one flap (3.2%). The large contiguous skin island of the bipedicle-conjoined deep inferior epigastric perforator flaps allowed for extensive replacement of damaged or absent breast skin when necessary. Aesthetically satisfactory results were achieved in all patients. CONCLUSIONS Bipedicle-conjoined abdominal perforator flaps represent a novel technique in select patients seeking breast reconstruction. The added complexity was safe and reliable in this series of patients. Compared to unipedicle flaps, the increased skin and volume allow greater flexibility to achieve the desired shape and projection.

Use of Irradiated Cartilage in Rhinoplasty of the Non-Caucasian Nose

BACKGROUND Aesthetic correction of the non-Caucasian nose may require a high volume of graft material to achieve an aesthetically pleasing shape and contour while maintaining characteristics in keeping with the patients ethnicity. OBJECTIVE We report our experience with the long-term use of irradiated homograft costal cartilage (IHCC) in 17 non-Caucasian patients. METHODS Individually packaged specimens of IHCC were obtained from government-approved tissue banks for intraoperative use in the augmentation of the dorsum as an onlay graft and, when necessary, to create maxillary-columellar-tip (MCT) struts and crural and spreader grafts. A V-shaped cut was made at the base of the MCT graft to accommodate the anterior maxillary ridge. The dorsal-only cartilage grafts were sutured to the underlying periosteum and framework to prevent tipping or shifting of the cartilage. Small tip grafts were not used, and defatting of the tip skin was avoided. RESULTS Patients were monitored for periods ranging from 7 months to 14 years. No immediate complications were noted, and only 1 late complication (>30 days after surgery) occurred; it involved the shifting of a dorsal graft that had not been sutured. Patient satisfaction was excellent. CONCLUSIONS The use of IHCC for augmentation rhinoplasty of the non-Caucasian nose saves operative time, eliminates both the need to harvest cartilage and the morbidity that can result from this procedure, and provides excellent, long-lasting aesthetic results with few complications.

Unilateral Autologous Breast Reconstruction with Bi-pedicled, Conjoined Deep Inferior Epigastric Perforator Flaps

Background The abdomen remains the most popular and reliable donor site for autologous breast reconstruction. Some patients, however, lack sufficient tissue to recreate an aesthetic breast mound using a single‐pedicle, deep inferior epigastric perforator (DIEP) flap, particularly when matching a contralateral native breast. The amount of abdominal skin and/or soft tissue reliably supplied by one vascular pedicle is frequently insufficient to adequately restore the breast skin envelope and “footprint.” This study summarizes our experience with using bipedicled DIEP flaps to improve the aesthetic results of unilateral breast reconstruction in such patients. Methods Consecutive patients undergoing unilateral breast reconstruction with bi‐pedicled, conjoined DIEP flaps over a 4‐year period were retrospectively reviewed. Primary and secondary flap microvascular anastomoses were performed to the antegrade internal mammary (IM) vessels and to either the retrograde IM vessels or a primary DIEP pedicle side branch, respectively. Clinical characteristics and outcomes were recorded. Results Sixty‐three patients underwent immediate (n = 29) or delayed (n = 34) reconstruction, with age and body mass index of 54.1 ± 8.4 years and 26.6 ± 4.7, respectively. Mean follow‐up was 14.1 months. Twenty‐eight (44.4%) patients received prereconstruction radiation therapy. All patients had preoperative abdominal imaging, including 57 (90.5%) using magnetic resonance angiography. There were no flap losses with three operative interventions for flap salvage. Conclusion Unilateral breast reconstruction with bipedicled, conjoined DIEP flaps is safe and reliable. These procedures can be performed with a complication profile similar to single‐pedicle DIEP flaps. The additional skin and soft tissue available with bi‐pedicled flaps allows for greater flexibility in matching the shape and projection of a womans contralateral breast, and in some cases is necessary to achieve an aesthetically acceptable reconstruction. With growing expectations among breast reconstruction patients, conjoined bi‐pedicled flaps represent a tool for meeting their reconstructive needs and exceeding the status quo for aesthetic outcomes.

Risk Factors for Postoperative Venous Thromboembolic Complications after Microsurgical Breast Reconstruction

Background Venous thromboembolism (VTE) is a significant cause of postoperative morbidity and a focus of patient safety initiatives. Despite giving appropriate prophylaxis in accordance with the Caprini risk assessment model, we observed a high incidence of VTE in patients undergoing microsurgical breast reconstruction at our institution. To explore factors contributing to these events, we compared patients undergoing microsurgical breast reconstruction who sustained postoperative VTEs to those who did not. Methods A retrospective review of all patients who underwent microsurgical free flap breast reconstruction at Montefiore Medical Center from January 2009 to January 2016 was conducted. Patients were divided into two cohorts; those sustaining postoperative VTE and those who did not. Patients were compared based on demographics, comorbidities, operative time, estimated intraoperative blood loss, need for transfusion, volume of transfusion, and discharge on postoperative aspirin. Results A total of 133 patients underwent microsurgical breast reconstruction during the study period. Nine patients (6.8%) had postoperative VTE and there was one (0.8%) death. Patients having VTE were more likely to be Hispanic (33.3%, n = 3) in the VTE group versus 8.1% (n = 6) in the control group (p = 0.011), more likely to have an increased mean transfusion volume (455.5 ± 367.8 vs. 139.51 ± 221.7 mL, p = 0.03), and were more likely to be discharged without aspirin (77.8%, n = 7 and 58.1%, n = 72; p = 0.003). Conclusion Patients sustaining postoperative VTE after microsurgical breast reconstruction are more likely to have an increased volume of blood transfusions and lack of discharge on postoperative aspirin.

Abstract: The Impact of Implementing a Standardized Postoperative Pathway on Underserved Patients Undergoing Microsurgical Breast Reconstruction

PURPOSE: There is paucity of knowledge regarding the impact of variation in postoperative care for microsurgical breast reconstruction patients. Currently, both optimizing patient outcomes and decreasing the cost of healthcare are of prime concern. Caring for underserved populations presents greater challenges in this realm for many reasons. Our aim was to understand the impact of initiating a standardized postoperative pathway for underserved patients undergoing microsurgical reconstruction.