Jesse C. Selber

Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review.

Background: Numerous studies compare techniques for free flap breast reconstruction techniques, with no consensus regarding differences in complication rates. This study compared the risk of fat necrosis, partial flap loss, total flap loss, abdominal bulge, laxity, or weakness, and abdominal hernia after deep inferior epigastric perforator (DIEP) and free transverse rectus abdominis myocutaneous (TRAM) flap surgery for breast reconstruction. Methods: A MEDLINE and manual search of English-language articles on DIEP and free TRAM flap surgery published up to April of 2007 yielded 338 citations. Two levels of screening identified 37 relevant studies. The Mantel-Haenszel fixed-effects and DerSimonian and Laird random-effects models were used to perform the meta-analysis. Results: Six studies reporting both DIEP and free TRAM flap outcomes were used to estimate pooled relative risks of complications and confidence intervals. There was a twofold increase in the risk of fat necrosis (relative risk, 1.94; 95 percent CI, 1.28 to 2.93) and flap loss (relative risk, 2.05; 95 percent CI, 1.16 to 3.61) in DIEP patients compared with free TRAM patients. There was no difference in the risk for fat necrosis when the analysis was limited to studies using muscle-sparing free TRAM flaps (relative risk, 0.91; 95 percent CI, 0.47 to 1.78). DIEP patients had one-half the risk of abdominal bulge or hernia (relative risk, 0.49; 95 percent CI, 0.28 to 0.86). Sixteen studies reporting DIEP outcomes and 23 studies reporting free TRAM outcomes were used to estimate pooled complication rates. Pooled flap-related complication rates were higher in DIEP patients, whereas donor-site morbidity was higher in free TRAM patients. Conclusion: This analysis suggests that the DIEP flap reduces abdominal morbidity but increases flap-related complications compared with the free TRAM flap in breast reconstruction.

Risk factors and complications in free TRAM flap breast reconstruction.

Methods: The authors retrospectively reviewed 500 free TRAM flaps performed between 1992 and 2003. This cohort was subdivided based on smoking history, obesity, preoperative chemotherapy, preoperative radiation therapy, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), and hypertension, and compared surgical complication rates. Measured complications included fat necrosis, mastectomy flap necrosis, abdominal flap necrosis, partial TRAM flap loss, wound infection, hematoma, seroma, vessel thrombosis, and abdominal hernia. &khgr;2 analysis and Fisher exact test were performed to determine differences between groups, and linear regression models were used to predict the risk factors of surgical complications. Results: Smokers were more likely to have a higher incidence of wound infection (P = 0.01), mastectomy flap necrosis (P = 0.015), abdominal flap necrosis (P = 0.033), and fat necrosis (P = 0.01). Obese patients were more likely to have higher rates of mastectomy flap necrosis (P = 0.01) and hematoma (P = 0.01). Patients with peripheral vascular disease were more likely to have a higher incidence of wound infection (P = 0.031), and patients with preoperative radiation therapy were more likely to have a higher incidence of seroma (P = 0.043). Logistic regression showed that smoking was found to be a risk factor for fat necrosis (P = 0.006), wound infection (P = 0.002), mastectomy flap necrosis (P = 0.039), and abdominal flap necrosis (P = 0.042). Obesity was a risk factor for mastectomy flap necrosis (P = 0.002). Peripheral vascular disease was a risk factor for wound infection (P = 0.032). Conclusion: Awareness of risk factors and associated complications will lead to modification and individualization of surgical techniques in an attempt to limit these complications and continually improve outcomes.

The changing epidemiologic spectrum of single-suture synostoses.

Purpose: Classic literature indicates an infrequency of metopic craniosynostosis (3 to 10 percent) compared to other single-suture craniosynostosis. Recent observation challenges these conceptions, warranting long-term demographic analysis. Methods: Syndromic craniofacial dysostoses and multiple suture involvement were exclusion criteria, leaving only single suture synostoses treated between 1975 and 2004. A chart review was performed and patient information recorded. Chi square analysis and Fishers exact were used to determine differences in patient characteristics. A Morans I statistic was used to determine differences in spatial means and whether changes in incidence of single-suture synostoses over time are a function of regional phenomena. Results: Over 800 patients presented to The Childrens Hospital of Philadelphia with a diagnosis of single-suture synostosis. There was an outpacing of sagittal suture involvement over other sutures. Data demonstrate a decrease in unicoronal synostosis and an increase in metopic synostosis (p = 0.011). Geostatistical analysis reveals increasing separation between populations over the study period: 9.8 miles in the first 5 years to 20.8 miles in the last 5 years. Metopic maternal age increased between 1975–1989 and 1990–2004 (p = 0.002, 0.0002), while unicoronal maternal age did not. The proportion of male patients increased considerably in the metopic group compared to unicoronals from 1990–2004 (p = 0.0001), as did the proportion of syndromic metopic patients (p = 0.02). Plausible etiologies for these epidemiological shifts are discussed. Conclusions: Metopic synostosis is on the rise. Changing demographic bases and increasing proportions of syndromic patients may be clues to the etiology of this epidemiologic event.

Primary Fascial Closure with Mesh Reinforcement Is Superior to Bridged Mesh Repair for Abdominal Wall Reconstruction

BACKGROUND Many surgeons believe that primary fascial closure with mesh reinforcement should be the goal of abdominal wall reconstruction (AWR), yet others have reported acceptable outcomes when mesh is used to bridge the fascial edges. It has not been clearly shown how the outcomes for these techniques differ. We hypothesized that bridged repairs result in higher hernia recurrence rates than mesh-reinforced repairs that achieve fascial coaptation. STUDY DESIGN We retrospectively reviewed prospectively collected data from consecutive patients with 1 year or more of follow-up, who underwent midline AWR between 2000 and 2011 at a single center. We compared surgical outcomes between patients with bridged and mesh-reinforced fascial repairs. The primary outcomes measure was hernia recurrence. Multivariate logistic regression analysis was used to identify factors predictive of or protective for complications. RESULTS We included 222 patients (195 mesh-reinforced and 27 bridged repairs) with a mean follow-up of 31.1 ± 14.2 months. The bridged repairs were associated with a significantly higher risk of hernia recurrence (56% vs 8%; hazard ratio [HR] 9.5; p < 0.001) and a higher overall complication rate (74% vs 32%; odds ratio [OR] 3.9; p < 0.001). The interval to recurrence was more than 9 times shorter in the bridged group (HR 9.5; p < 0.001). Multivariate Cox proportional hazard regression analysis identified bridged repair and defect width > 15 cm to be independent predictors of hernia recurrence (HR 7.3; p < 0.001 and HR 2.5; p = 0.028, respectively). CONCLUSIONS Mesh-reinforced AWRs with primary fascial coaptation resulted in fewer hernia recurrences and fewer overall complications than bridged repairs. Surgeons should make every effort to achieve primary fascial coaptation to reduce complications.

500 Consecutive Patients with Free TRAM Flap Breast Reconstruction : A Single Surgeon's Experience

Background: This study reports on the longitudinal experience and outcomes of one surgeon performing free transverse rectus abdominis musculocutaneous (TRAM) flaps on 500 consecutive patients between 1992 and 2003. Methods: A retrospective review of hospital and outpatient records was performed. Specific risk factors for successful reconstruction were reviewed, including American Society of Anesthesiologists class, obesity, smoking, medical comorbidities, and irradiation and chemotherapy history. Outcomes measured included the length of hospital stay and the incidence of complications including both thrombotic and nonthrombotic complications. Results: Five hundred sixty-nine free TRAM breast reconstructions were performed in a total of 500 patients. Preoperative patient risk factors included obesity, smoking, hypertension, diabetes, and cardiac disease, with three-fourths of the patients being American Society of Anesthesiologists class II or III. Intraoperative or postoperative thrombosis occurred in 35 reconstructions (6.2 percent). Only one patient had a total flap loss, for a flap success rate of 99.7 percent. Significant nonthrombotic complications occurred in 67 patients (13.4 percent). The most common nonthrombotic complications included wound infection (3 percent), fat necrosis (3 percent), and delayed healing (3 percent). Revision procedures after free TRAM reconstruction were performed in 14.4 percent of cases. Conclusions: The free TRAM flap is a highly reliable method of autogenous breast reconstruction in a broad spectrum of patients. This free flap has a very low thrombotic complication rate, and abdominal donor defect problems have been limited. Finally, this method of reconstruction can be reliably offered to a wide group of patients, including those considered at high risk for a pedicled TRAM flap reconstruction.

Optimal timing of delayed free lower abdominal flap breast reconstruction after postmastectomy radiation therapy

Background: The purpose of this study was to determine the optimal timing of delayed abdominal free flap breast reconstruction following postmastectomy radiation therapy. The authors evaluated the association between timing of delayed abdominal free flap breast reconstruction following postmastectomy radiation therapy and postoperative complications. Methods: The authors reviewed a prospectively maintained database of delayed abdominal free flap breast reconstruction performed between July of 2005 and December of 2009. Data regarding demographics, operative variables, and clinical outcomes were collected. Patients were classified as having undergone reconstruction less than 12 months after postmastectomy radiation therapy (group I) or 12 months or more after postmastectomy radiation therapy (group II). Complications were compared between groups, including microvascular thrombosis, flap loss, reoperation, wound dehiscence, and fat necrosis. Results: One hundred eighty-nine patients were identified, 82 (43.4 percent) in group I and 107 (56.6 percent) in group II. The total flap loss rate was 2.6 percent, with all flap losses occurring in group I (p = 0.014). The reoperation rate was higher in group I (14.6 percent versus 4.7 percent; p = 0.022). In addition, group I patients trended toward a higher incidence of microvascular thrombosis, infection, and wound dehiscence. Conclusions: Patients who underwent delayed abdominal free flap breast reconstruction after 12 months from the completion of postmastectomy radiation therapy developed fewer complications, including microvascular thrombosis and total flap loss, than those who underwent delayed abdominal free flap breast reconstruction within 12 months of completing postmastectomy radiation therapy. Allowing an interval of 12 months between the completion of postmastectomy radiation therapy and delayed abdominal free flap breast reconstruction will likely minimize complications and optimize outcomes in free flap breast reconstruction in patients receiving postmastectomy radiation.

A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: Part I. Unilateral reconstruction

Background: The purpose of this study was to demonstrate the impact of bilateral free flap breast reconstruction on the abdominal wall. This is the second installation of a two-part series. Presented here are bilateral combinations of three techniques: the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap, deep inferior epigastric perforator (DIEP) flap, and superficial inferior epigastric artery (SIEA) flap. Methods: A blinded prospective cohort study was performed involving 234 patients. Patients were evaluated preoperatively and for 1 year postoperatively. At each encounter, patients underwent objective abdominal strength testing using the Manual Muscle Function Test and Functional Independence Measure and psychometric testing using the Short Form 36 questionnaire. At postoperative visits, patients also completed a questionnaire specific to breast reconstruction. Statistical analysis included the Kruskal-Wallis, Mann-Whitney, Friedman, and Wilcoxon signed rank tests. Results: A total of 234 patients were enrolled. Of these, 157 underwent reconstruction, 82 of which were bilateral. There was a significant decline in upper (p = 0.02) and lower (p = 0.05) abdominal strength from bilateral free TRAM flaps compared with bilateral DIEP flaps. Likewise, there was a significant decline in upper (p = 0.055) and lower (p = 0.04) abdominal strength from bilateral free TRAM flaps compared with bilateral SIEA flaps. For combinations, the most muscle impairment to least was as follows: free TRAM/free TRAM, free TRAM/DIEP, DIEP/DIEP, DIEP/SIEA, and SIEA/SIEA. The free TRAM/SIEA data were not significant. Although psychometric testing showed trends, there was no significant difference among treatment groups. Conclusion: Abdominal wall strength following various combinations of bilateral free flap breast reconstruction techniques closely adheres to theoretical predictions based on the degree of surgical muscle sacrifice.

Transoral robotic reconstruction of oropharyngeal defects: a case series.

Background: Large resections of oropharyngeal tumors in the absence of a mandibulotomy create a reconstructive challenge, because flaps are often necessary, and inset requires contouring and suturing in a confined space with limited line of sight. Transoral robotically assisted reconstruction is the logical solution. Methods: The DaVinci Surgical System was used in five cases of oropharyngeal reconstruction. All oropharyngeal tumors were resected without a mandibulotomy, using either a transoral robotic approach or a lateral pharyngotomy. Robotic reconstruction was performed using a radial forearm, an anterolateral thigh flap, a facial artery myomucosal flap, and primary closure. The robot was also used to perform an arterial anastomosis. Results: All cases were performed with an intact mandible. This resulted in complex oropharyngeal defects with limited access. The robot was used to inset free flaps or local flaps, or to close primarily by improving access and precision in the oropharynx. The robot was used to perform a microvascular anastomosis between two, 2-mm arteries without hand-sewn revision. There were no surgical complications, flap failures, take-backs, or fistulas. All patients have been decannulated and are tolerating an oral diet without tube feeding. Conclusions: Minimally invasive resections provide locoregional control without the morbidity of mandibulotomy or high-dose chemoradiation. Transoral robotic reconstruction allows access and precision within the oropharynx. It is safe and effective, and may expand minimally invasive resections where reconstruction is not possible through traditional approaches.

Long-term results following fronto-orbital reconstruction in nonsyndromic unicoronal synostosis.

Background: Fronto-orbital reconstruction is the standard of care for repair of unilateral coronal synostosis. This study examined the relationship between age at initial surgery and need for secondary surgery, to determine the optimal age for reconstruction. Methods: The series comprised 81 patients with unicoronal synostosis who underwent reconstruction over a 30-year period by a single surgeon. Measured outcomes included reoperation rate, relapse/defect rate, relapse interval, and problem rate. Results: Average age at surgery was 11.3 months (range, 1.5 to 71 months). The problem rate was 27.2 percent. Mean follow-up was 69 months (range, 6 to 234 months). The postoperative defect rate was 73 percent. Sixteen patients (20 percent) underwent reoperation to correct secondary deformities. Whitaker category I or II results were achieved in 90.1 percent. Problem rates for patients aged 0 to 6 months, 6 to 12 months, and older than 12 months were 13.3, 28, and 35, respectively. Secondary surgery was performed in 40 percent of patients whose first surgery was at 0 to 6 months, 7 percent aged 6 to 12 months, and 30.4 percent older than 12 months. After surgery, 87 percent of patients aged 0 to 6 months, 95 percent aged 6 to 12 months, and 87 percent older than 12 months had Whitaker category I or II results. Conclusions: Fronto-orbital advancement at younger than 6 months had the highest incidence of readvancement. Patients treated at 6 to 12 months had the least need for any secondary surgery; however, patients older than 12 months had the lowest incidence of readvancement. These results indicate that fronto-orbital advancement should be delayed until at least age 6 months to avoid relapse.

Transoral robotic surgery: Role in the management of upper aerodigestive tract tumors†‡

The toxicity associated with concomitant chemoradiation for the management of laryngeal and pharyngeal carcinoma has been well documented. Minimally invasive surgical techniques offer the potential to extirpate the malignancy as a single‐modality therapy and provide essential information that may direct subsequent treatment. In selected patients, radiation doses may be reduced and systemic chemotherapy may be withheld after tumor extirpation. Transoral laser microsurgery has proven effective, although inability to manipulate and suture tissue by this modality limits ablation and reconstruction of extensive defects. Transoral robotic surgery is a relatively new technique that provides several unique advantages, which include a 3‐dimensional magnified view, ability to see and work around curves or angles, and the availability of 2 or 3 robotic arms that can be used to reconstruct extensive defects using either local, regional, or free flaps. Preliminary data suggest that transoral robotic surgery may provide a technique for ablation and reconstruction of pharyngeal defects that may be superior to other transoral techniques. It may also provide a means for personalizing therapy for oropharyngeal and supraglottic carcinoma. Head Neck, 2011