James C. Grotting

Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction.

Immediate breast reconstruction using the transverse abdominal myocutaneous island (TRAM) flap was performed in 54 patients over the past 3 years at our institution. This represented approximately 59 percent of patients undergoing all types of immediate breast reconstruction. In 10 patients, the abdominal island flap was transferred as a free flap based on the deep inferior epigastric pedicle. These patients were compared with the other 44 patients, in whom the flap was transferred using the conventional technique. The TRAM flap is well suited for immediate breast reconstruction because the procedure can be carried out simultaneously with mastectomy using separate operating teams and instruments. The operation is safe and relatively free of complications. The free TRAM group compared favorably with the conventional group in terms of complications, operating time, estimated blood loss, hospitalization, and return to functional baseline. The free TRAM flap appears to be as safe as the conventional technique with the advantages of a more limited rectus muscle harvest, improved medial contour of the breast due to the lack of tunneling, and perhaps a healthier flap because of the large donor vessels.

Aeromonas hydrophila infections following use of medicinal leeches in replantation and flap surgery.

Aeromonas hydrophila infections are a recognized complication of postoperative leech application, and can occur with measurable frequency in populations of patients treated with leeches. We review 11 previously reported leech-related Aeromonas infections and analyze seven unreported cases. These infections range from minor wound complications to extensive tissue loss and sepsis. Often, these infections followed leech application to tissue with questionable arterial perfusion. Onset of clinical infection in these patients ranged from within 24 hours of leech application to 10 days or more after leech application. Late infections may represent bacterial invasion from colonized necrotic tissue. Based on these observations, we recommend that leech applications be restricted to tissue with arterial perfusion to minimize contamination of necrotic tissue. We also recommend that patients treated with leeches receive antibiotics effective against Aeromonas hydrophila before leech application. Patients treated with leeches and discharged with eschars or open wounds might benefit from oral antibiotic therapy until wound closure. These precautions may minimize or eliminate this complication of leech use.

Anatomic basis for vascularized outer-table calvarial bone flaps.

The vascularization of the scalp and calvarium was studied in cadavers to better define the design of vascularized split- or full-thickness calvarial bone flaps. Selective dye injections of the superficial temporal and internal maxillary arteries established a horizontal and vertical network of vess

Vascularized Outer-table Calvarial Bone Flaps

Based on an anatomic study of the vascularization of the calvarium in cadavers, a technique for the transfer of vascularized outer-table calvarial bone has been developed. The outer table of the calvarium receives numerous small perforators from its overlying periosteum. The periosteum is continuous with a distinct fascial layer overlying the temporal aponeurosis which we have termed the innominate fascia. Because of a network of anastomosing vessels from proximal branches of the superficial temporal artery and perforating branches of the deep temporal artery, the outer table of the calvarium can be carried on a pedicle which contains the temporal aponeurosis, innominate fascia, and periosteum. Thirty-seven vascularized outer-table calvarial bone flaps have been performed for a variety of craniofacial reconstructive deformities. Remarkable stability and lack of resorption have led the authors to favor this method of reconstruction particularly in poorly vascularized or previously infected recipient beds.

The free abdominoplasty flap for immediate breast reconstruction

As free flap breast reconstruction has become more common, we have sought to further refine donor sites. A woman is presented in whom a free flap from the low abdominal wall based on the superficial inferior epigastric artery and vein is used. This procedure results in total sparing of the rectus abdominis muscles and may be applicable in thinner women with smaller breasts, who cannot spare the larger ellipse of the conventional transverse rectus abdominis musculocutaneous (TRAM) flap. As we have sought to further refine breast reconstruction using autogenous tissue, microvascular tissue transfers are assuming a more important role. At the present time, it is possible to evaluate each individual woman for the most appropriate and available donor tissue to achieve a symmetrical reconstruction. In any given woman, it may be more appropriate to use the abdomen, hips, or buttocks, depending on the size and shape of the opposite breast and where the tissue can be most easily spared. We report here a woman in whom immediate breast reconstruction was performed using only the excess skin and fat of the lower abdominal wall pedicled on a unilateral superficial inferior epigastric artery and vein.

An Anatomic Study of the Venous Drainage of the Transverse Rectus Abdominis Musculocutaneous Flap

The authors studied the venous drainage of the abdominal wall and its application to the transverse rectus abdominis musculocutaneous flap on 12 cadavers by injecting methylene blue and methyl methacrylate to follow the venous pathways. The nonvascular tissues of the specimens injected with methyl methacrylate were corroded away to show the three-dimensional arrangement of the vessels. We describe the veins of the anterior abdominal wall in relation to the transverse rectus abdominis musculocutaneous flap. The venous drainage of the transverse rectus abdominis musculocutaneous flap when used for breast reconstruction occurs from the cutaneous part of the flap to the inferior deep epigastric veins through vertical perforators that are mainly periumbilical. From there the flow is through the deep superior epigastric veins into the internal mammary vein. The deep inferior epigastric veins were found to have valves that prevent retrograde flow. In designing the flap, its safety is increased if it includes the periumbilical perforators. Thinning the flap should be done at the deep surface to preserve Scarpas fascia and the superficial epigastric system.

Evaluation of preoperative risk factors and complication rates in cosmetic breast surgery.

To assess the relationships between body mass index, smoking, and diabetes and postoperative complications after cosmetic breast surgery, based on patient claims made to CosmetAssure, a program which provides coverage for treatment of significant complications, which might not be reimbursed by patients health insurance carriers.Complication rates of cosmetic breast operations were reviewed from 13,475 consecutive patients between April 1, 2008 and March 31, 2009. Correlations between complication rates and risk factors of body mass index ≥30, smoking, and diabetes were analyzed.Because this insurance program reimburses patients for costs associated with the treatment of postsurgical complications, physicians are incentivized to report significant complications.A “significant” complication is defined as a postsurgical problem, occurring within 30 days of the procedure that requires admission to a hospital, emergency room, or surgery center. Minor complications that were treated in the outpatient setting are not included, as their treatment did not generate an insurance claim.According to patient claims data between April 1, 2008 and March 31, 2009, the overall complication rate for cosmetic breast surgery was 1.8%. Obese patients (body mass index ≥ 30) undergoing breast augmentation and augmentation mastopexy demonstrated higher complication rates than nonobese patients. Patients with diabetes undergoing augmentation mastopexy experienced higher complication rates than nondiabetics. Data collection is ongoing, and as the number of cases increases (approximately 1300 new cosmetic breast surgeries per month), multiple other trends in this study will likely achieve statistical significance.Analysis of CosmetAssure data can accurately and objectively track the rate of significant postoperative complications secondary to cosmetic surgical procedures. As the number of risk factors increase, the risk of complications increases. Cosmetic breast surgery is extremely safe, with low infection and overall complication rates. Plastic surgeons can further decrease complications through careful patient selection.

Ultrasound-Assisted Lipectomy Using the Solid Probe: A Retrospective Review of 100 Consecutive Cases.

Ultrasound-assisted lipectomy using the solid probe is a predictable and safe method that can yield excellent results. This method is particularly useful and is indicated when the subdermis must be approached to smooth out surface irregularities and/or to stimulate skin retraction. The authors present their method using the solid probe and a retrospective study of their first 100 consecutive cases. The indications for using the solid probe, its advantages and disadvantages, associated complications, and representative cases are presented.

Lack of evidence of systemic inflammatory rheumatic disorders in symptomatic women with breast implants

&NA; Breast implants containing silicone have been used for approximately 30 years for breast augmentation or reconstruction. In general, the implants have been well tolerated and reports have indicated a high degree of patient satisfaction. Nonetheless, there have been anecdotal reports of patients with musculoskeletal complaints that have been attributed to silicone breast implants. To investigate this further, we prospectively examined 70 women with silicone breast implants who had complaints that they or their referring physicians thought were related to their implants. On clinical examination, the majority of the patients had fibromyalgia, osteoarthritis, or soft‐tissue rheumatism. One patient had rheumatoid arthritis, which predated her implants, and one had Sjögrens syndrome. Because many of our patients had myalgic symptoms, we further evaluated these patients by measuring circulating levels of soluble factors including interleukin‐6, interleukin‐8, tumor necrosis factor‐alpha, soluble intercellular adhesion molecule‐1, and soluble interleukin‐2 receptor, which have been previously found to be elevated in patients with inflammatory diseases. We found that the levels of these molecules in women with silicone breast implants were not different from those seen in normal subjects and were significantly less than those seen when examining chronic inflammatory disorders such as rheumatoid arthritis or systemic lupus erythematosus. In summary, our clinical and laboratory evaluation of symptomatic breast implant patients argues against an association of silicone breast implants with a distinctive rheumatic disease or a systemic inflammatory disorder. Given these findings and the clinical picture, it is our impression that most symptomatic women with silicone breast implants have well‐delineated noninflammatory musculoskeletal syndromes. Moreover, these data fail to support the concept that their symptoms are due to a systemic inflammatory response related to their implants.

Pressure sore carcinoma.

The development of squamous cell carcinoma in pressure sores is a rare event, considering the high incidence of pressure sores within the elderly and paraplegic populations. The clinical courses of 10 patients with pressure sore carcinoma have been reviewed. The presence of a velvety, cauliflower-like growth on the surface of a long-standing pressure sore should alert the surgeon to the possibility of malignant degeneration. Most of these tumors are well-differentiated squamous cell carcinomas. Of the 10 patients, 8 (80%) died from massive local recurrence or distant metastases an average of 17 months after resection and flap closure despite having apparently localized disease. One patient was disease free when lost to follow-up at 2 years, and 1 patient is without evidence of recurrence or metastases 3 months postoperatively. Altered immunocompetence may play a role in the rapid progression and high mortality associated with this tumor after surgical manipulation.