Jai-Kyong Pyon

Risk factors for donor-site seroma formation after immediate breast reconstruction with the extended latissimus dorsi flap: a statistical analysis of 120 consecutive cases.

AbstractThe extended latissimus dorsi flap has been widely used for breast reconstruction. However, seroma at the donor site is a common complication and makes it difficult for reconstructive surgeons to choose it as a primary option. We analyzed the association between seroma and reconstructions with extended latissimus dorsi flaps. A series of 120 consecutive cases were included in this study. The average body mass index (BMI) was 22.1 kg/m2, and the mean ratio of the flap weight to the extirpated breast weight was equivalent to 101.6%. The mean age of patients was 40.3 years. Donor-site seroma was reported in 69.2% (83 cases) of the total patients. With respect to BMI, flap weight, and age, the incidence and duration of donor-site seroma showed statistically significant differences (P < 0.05). Both the incidence and duration of seroma were significantly higher and longer in patients who had high BMI (>23 kg/m2), large flap (>450 g) for reconstructions, or advanced age (>45 y). In these cases, greater attention and additional adjunctive procedures would be needed to prevent seroma.

Comparison of morbidity of donor site following pedicled muscle-sparing latissimus dorsi flap versus extended latissimus dorsi flap breast reconstruction

UNLABELLED The pedicled, descending-branch muscle-sparing latissimus dorsi (MSLD) flap has been widely used for breast reconstruction following total mastectomy. However, the superiority of the MSLD flap compared to the extended latissimus dorsi (ELD) flap has not yet been described. This study compares morbidities following pedicled MSLD flap and ELD flap breast reconstruction. A total of 36 women with pedicled MSLD flaps were compared with 37 women with ELD flap breast reconstruction. The medical records were reviewed for complications and demographic data. The authors compared morbidity including donor-site seroma, limitation of shoulder movement and aesthetic contour of the donor site following MSLD flap and ELD flap breast reconstruction. The authors compared the identified parameters and set the level of significance at the 0.05 alpha level. The demographic data of the two groups were not significantly different statistically. Donor-site seroma occurred in two MSLD patients (5.6%) and in 23 ELD patients (62.2%) (p = 0.0001). Limitation of shoulder movement occurred in nine MSLD patients (25%) and in 28 ELD patients (75.7%) (p = 0.0001). Back asymmetry occurred less frequently in the MSLD group (p = 0.0297). The pedicled, descending-branch MSLD flap, with its low complication rate and associated with minimal functional and aesthetic deficits of the donor site, can be a good option for breast reconstruction. LEVEL OF EVIDENCE Therapeutic, III.

Rib-sparing and internal mammary artery-preserving microsurgical breast reconstruction with the free DIEP flap.

Background: Using an internal mammary artery as the recipient vessel in a free flap autologous breast reconstruction is common practice, but this vessel is often sacrificed for end-to-end anastomosis and is typically assessed by removing a costal cartilage segment. The authors studied the reliability of the end-to-side arterial anastomosis using a rib-sparing approach by comparing it with end-to-end anastomosis. Methods: The authors analyzed 100 consecutive medical records of patients who underwent autologous breast reconstruction with a free deep inferior epigastric artery perforator flap in which the internal mammary vessels were assessed using a rib-sparing technique. The study compared the complications between the two groups of end-to-side arterial anastomosis (50 cases) and end-to-end arterial anastomosis (50 cases). Results: Exposure of the internal mammary artery using a rib-sparing technique was performed successfully in all 100 flaps. The second and third intercostal spaces were used in 46 and 54 cases, respectively. The mean width of the used intercostal space was 18.3 ± 2.4 mm in the end-to-side group and 18.3 ± 2.9 mm in the end-to-end group (p = 0.923). All flaps survived without partial or total necrosis. One case of venous insufficiency that required exploration occurred in the end-to-side group; the flap was totally saved with venous revision. There was no significant statistical difference between the end-to-side and end-to-end groups in all other variables, including mean flap ischemic time (p = 0.431) and fat necrosis (p = 0.339). Conclusion: The rib-sparing and internal mammary artery–preserving free deep inferior epigastric artery perforator flap transfer is an efficient and safe technique for microsurgical breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Plantar reconstruction with free thoracodorsal artery perforator flaps

PURPOSE The plantar region presents unique challenges for reconstructive surgeons. Reconstruction using a thoracodorsal artery perforator (TDAP) flap yields favourable results in various fields of microsurgical reconstruction, but reports on the reconstruction of plantar defects are sparse. Here, the authors present their experience in the reconstruction of various defects in the plantar region using free TDAP flaps. METHODS From January 2005 to July 2011, 40 free TDAP flaps were transferred for reconstructive purposes to restore skin and soft-tissue defects in the plantar region. Hospital and outpatient records were reviewed independently for all patients. A patient questionnaire including five questions was administered to subjectively evaluate reconstructive results. RESULTS A total of 24 male and 16 female patients were enrolled in this study. The mean age was 47.8 years and ranged from 7 to 77 years. The most common cause of defect was oncology related (n=21), followed by trauma-related (n=11), diabetes-related (n=6) and other causes. The average flap size was 63.7 cm2 and ranged from 25 to 212 cm2. All flaps survived except for one, resulting in a below-knee amputation. The mean follow-up period was 20.4 months. Four patients underwent secondary revisional procedures, including simple defatting in two patients and excision of redundant skin due to flap instability in two patients. The satisfaction surveys were completed by 34 (85%) patients. Patients reported high levels of satisfaction in terms of pain, limitation of daily activities, donor site satisfaction and overall satisfaction. Most patients were satisfied and reported that they would recommend the procedure to others. CONCLUSION An appropriately thinned free TDAP flap with thick skin provided favourable outcomes with high patient satisfaction and is a valuable option for the restoration of skin and soft-tissue defects in the plantar region.

Merkel cell carcinoma: Our experience with seven patients in Korea and a literature review

BACKGROUND Merkel cell carcinoma (MCC) is a rare but malignant cutaneous neuroendocrine carcinoma. As MCC has primarily been reported in Caucasians, MCC cases in Korea have not yet been reported. The purpose of this study was to retrospectively review our experience with the surgical treatment of MCC in Korea and to study its management and outcome. METHOD We retrospectively reviewed seven MCC case files between 2000 and 2008 from a single institution. We analysed patient characteristics, tumour location and size, staging, treatment methods and outcomes. We performed polymerase chain reaction (PCR) to detect Merkel cell polyomavirus (MCPyV) from formalin-fixed paraffin-embedded tissue specimens. RESULTS Two patients had stage I tumours, four patients had stage II tumours and one patient had a stage III tumour. Wide local excision with a clear resection margin was the primary modality of treatment in all cases. Adjuvant radiotherapy and chemotherapy were performed for selected patients. Recurrence was observed in two out of the seven cases during the follow-up period. MCPyV was detected by PCR in all seven cases. CONCLUSION MCC is an aggressive skin cancer, and pathologic lymph node evaluation is important for staging. Wide excision is the primary modality of treatment, but adjuvant radiotherapy could be positively considered if the tumour is large and the lesion is not confined to the dermis. MCPyV was detected by PCR in all cases, which suggests that MCPyV is also a putative aetiological agent in the carcinogenesis of MCC in Korea.

The impact of immediate breast reconstruction on post-mastectomy lymphedema in patients undergoing modified radical mastectomy

The aim of this study was to assess the impact of immediate breast reconstruction (IBR) with autologous tissue on the development of post-mastectomy lymphedema in patients undergoing modified radical mastectomy (MRM). A retrospective chart review was performed for early-stage breast cancer patients who underwent MRM between January 2001 and December 2009. Patients were categorized into two groups based on whether or not they underwent IBR. The incidence of lymphedema was assessed and compared. A total of 712 patients underwent MRM, which included 117 patients undergoing IRB. There were no significant differences between two groups except for a lower body mass index in the reconstruction group. Comparing the incidence of lymphedema using multivariate logistic regression analysis, the reconstruction group had a significantly lower incidence of lymphedema (p-value = 0.023). Breast cancer patients who underwent MRM with IBR had a significantly lower incidence of lymphedema than those in the non-reconstruction group.

Reliable harvesting of a large thoracodorsal artery perforator flap with emphasis on perforator number and spacing.

Background: Thoracodorsal artery perforator flaps are useful for covering extensive defects because of their generous donor-site dimensions. However, large flaps increase the risk of partial flap necrosis, and a reliable means of sizing thoracodorsal artery perforator flaps has not been devised. The authors reviewed a series of large thoracodorsal artery perforator flap transfers performed under various reconstructive conditions to evaluate surgical outcomes and placed emphasis on flap design and harvesting technique. Methods: A consecutive series of large thoracodorsal artery perforator flaps (>20 cm long) performed between November of 2005 and March of 2010 were included in this study. Patient charts, operative records, and photographs were reviewed. Results: A total of 20 flaps with an average size of 25 × 11 cm in 20 patients were identified; the largest flap measured 32 × 13 cm. The average number of perforators included was 2.6 per flap (range, one to four). Four different harvesting techniques were used, depending on perforator numbers and locations. All large flaps survived without sizable partial flap necrosis. Complications included wound dehiscence in one donor and two recipient sites; all healed after wound repair. Tip necrosis of a small area developed but healed with conservative wound care. Conclusions: This study reports the clinical safety of large thoracodorsal artery perforator flaps with customized thickness control, which can be reliably harvested beyond 20 cm in length by carefully considering perforator numbers and locations. To optimize tissue perfusion in these large flaps, effort is required to capture multiple perforators from various sources and to obtain an ideal arrangement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The influence of pedicle length on the viability of twisted perforator flaps in rats.

The pedicled perforator flap is now regarded as a valuable tool in the reconstructive armamentarium, but variable degrees of perforator twisting upon flap transposition are frequently encountered intraoperatively. The aim of this study was to investigate the effect of pedicle length on twisted perforator flap viability. Forty Sprague-Dawley rats were randomly divided into four groups of 10 animals each: group I (short pedicle, no rotation), group II (short pedicle, 720 degrees rotation), group III (long pedicle, no rotation), and group IV (long pedicle, 720 degrees rotation), and cranial epigastric artery perforator flaps were elevated. Mean group flap survival ratios were 88.47 +/- 13.87% (group I), 60.23 +/- 28.95% (group II), 87.06 +/- 13.85% (group III), and 84.28 +/- 31.76% (group IV). Viable flap ratios in group II were significantly lower than in groups I, III, and IV, respectively (p < 0.05). Our findings suggest that when perforator twisting is unavoidable, longer pedicles are significantly more likely to result in secure flap survival.

Preoperative rib cartilage imaging in 3-dimensional chest computed tomography for auricular reconstruction for microtia.

BackgroundThere are several methods that may be used to confirm the status of rib cartilage, such as physical examinations or chest radiography, for subjects with microtia. However, these methods are limited because of clinicians’ inability to gain accurate information about the rib cartilage. We performed 3-dimensional chest computed tomography to preoperatively evaluate the accuracy of rib cartilage imaging. MethodsA total of 37 patients preparing for auricular reconstruction using a rib cartilage graft underwent preoperative 3-dimensional rib cage computed tomography (3-D rib CT). The 3-D rib CT was performed in cases of secondary revisional reconstruction, those with a history of surgery using rib cartilage, in those with a history of trauma related to the rib cage, older patients with question of calcification of rib cartilage, or those with a suspected rib cartilage anomaly on physical examination. Preoperatively, the appropriateness of using the rib cartilage were evaluated. ResultsWith the aid of the 3-D rib CT, successful autogenous auricular reconstruction was achieved in 36 patients. Framework fabrication in combination with a porous polyethylene implant and autogenous rib cartilage was performed in the remaining patient as planned preoperatively. By analyzing the 3-D rib CT image preoperatively, auricular reconstruction using a recycled rib cartilage graft with newly harvested rib cartilage was performed successfully in 13 of 14 secondary revisional cases. Based on preoperative CT images, modified surgical planning in terms of cartilage harvest and framework fabrication was needed in 8 of 11 patients who had a history of operation using rib cartilage and in 3 of 5 subjects with suspected rib cage anomalies on physical examination. Successful reconstruction was achieved using the modified surgical plan. ConclusionsA preoperative 3-D rib CT helps in surgical planning for autogenous auricular reconstruction for microtia, especially in patients with suspicious rib cartilage status.

Does the reconstruction method influence development of mastectomy flap complications in nipple-sparing mastectomy?

PURPOSE There has been an increase in the use of nipple-sparing mastectomy (NSM) with immediate breast reconstruction for the treatment of early-stage breast cancer patients. Mastectomy flap complication including nipple loss is a major concern and usually associated with the surgical technique. The authors evaluated potential risk factors of mastectomy flap complications, especially focussing on the impact of reconstructive variables. METHODS Using a prospectively collected database, we reviewed 130 cases of NSM between January 2009 and December 2012. Only cases using lateral incision were included. Potential patient- and procedure-related risk factors were analysed using logistic regression analysis to investigate associations with the development of mastectomy flap necrosis. RESULTS Among the 130 cases, 70 underwent autologous tissue reconstruction and 60 underwent two-stage prosthesis reconstruction using a tissue expander. All patient- and procedure-related characteristics were similar between the two groups. Mastectomy flap complications occurred in 21 cases (16.2%), including total nipple necrosis in 5 (3.8%) and mastectomy flap necrosis in 10 (7.7%). The autologous tissue group showed a significantly lower rate of complications than the prosthesis group (10.0% vs. 23.3%, p = 0.034), and the difference remained significant after adjusting for other factors on multivariate logistic regression analysis (p = 0.024, odds ratio = 3.259). The rate of revision surgery was also significantly lower in the autologous tissue group (1.4% vs. 15.0%, p = 0.004). CONCLUSIONS In our study, the reconstruction method was associated with the development of necrotic complications of the mastectomy flap. Careful selection of patients and reconstruction methods may reduce the risk of mastectomy flap complications in NSM.