Joseph M. Serletti

Acellular dermis-assisted prosthetic breast reconstruction: a systematic and critical review of efficacy and associated morbidity.

Background: The use of acellular dermal matrix to assist in two-stage expander/implant breast reconstruction has increased over recent years. However, there are questions regarding the potential for increased morbidity when using these techniques relative to standard submuscular coverage techniques. This systematic review combines published data comparing the techniques, to compare morbidity and advantages of acellular dermal matrix relative to standard submuscular coverage techniques. Methods: An English language literature search was performed to find articles reporting outcomes of two-stage expander/implant reconstruction using acellular dermal matrix. The outcome categories analyzed were patient/treatment demographics, tissue expander characteristics, and complications. Results: Nine articles met inclusion criteria for this analysis. Six of these were matched cohort studies comparing outcomes of acellular dermal matrix techniques to standard submuscular techniques. The remaining three were case series of acellular dermal matrix techniques. The only difference found in complications was a higher rate of seroma for the acellular dermal matrix group (4.3 percent versus 8.4 percent, p = 0.03). Despite this, both groups illustrated similar rates of infection leading to explantation (3.2 percent for submuscular and 3.4 percent for acellular dermal matrix, p = 0.18). In addition, acellular dermal matrix techniques illustrated greater intraoperative fill volumes and consistently fewer fills required to reach expander capacity. Conclusions: The use of acellular dermal matrix in two-stage expander/implant reconstruction offers a safety profile similar to that of standard submuscular techniques. Both techniques have shown similar rates of infection ultimately requiring explantation. In addition, acellular dermal matrix offers the advantage of a more rapid reconstruction with less need for manipulation of the prosthetic through filling. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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 world's experience with facial transplantation: What have we learned thus far?

The objective of this review article is to summarize the published details and media citations for all seven face transplants performed to date to point out deficiencies in those reports so as to provide the basis for examining where the field of face transplantation stands, and to act as a stimulus to enhance the quality of future reports and functional outcomes. Overall long-term function of facial alloflaps has been reported satisfactorily in all seven cases. Sensory recovery ranges between 3 and 6 months, and acceptable motor recovery ranges between 9 and 12 months. The risks and benefits of facial composite tissue allotransplantation, which involves mandatory lifelong immunosuppression analogous to kidney transplants, should be deliberated by each institution’s multidisciplinary face transplant team. Face transplantation has been shown thus far to be a viable option in some patients suffering severe facial deficits which are not amenable to modern-day reconstructive technique.

Impact of Obesity on Outcomes in Breast Reconstruction: Analysis of 15,937 Patients from the ACS-NSQIP Datasets

BACKGROUNDnObesity is a growing epidemic in the United States (US) affecting more than 33% of adults. We aimed to use the World Health Organization (WHO) obesity stratification scheme to assess the overall risk of obese patients undergoing breast reconstruction using the ACS-NSQIP database from 2005 to 2010.nnnSTUDY DESIGNnWe reviewed the 2005 to 2010 ACS-NSQIP databases identifying encounters for Current Procedural Terminology (CPT) codes including either implant-based reconstruction (immediate, delayed, and tissue expander) or autologous reconstruction (pedicled transverse rectus abdominis myocutaneous [pTRAM], free TRAM, and latissimus dorsi flap with or without implant). Patients were classified and compared based on WHO obesity criteria: nonobese (body mass index [BMI] = 20 to 29.9 kg/m(2)), class I (BMI = 30 to 34.9 kg/m(2)), class II (BMI = 35 to 39.9 kg/m(2)), and class III (BMI > 40 kg/m(2)).nnnRESULTSnDuring the study period 15,937 breast reconstructions were performed. The majority of reconstructions were immediate reconstructions (85.0%) and implant-based (79.1%). The incidence of obesity was 27.1%, with 16.3% defined as class I obese, 6.9% defined as class II obese, and 4.0% defined as class III obese. The WHO-classified obese patients tended to have a progressively higher incidence of comorbid conditions, higher American Society of Anesthesiologists (ASA) physical status (p < 0.001), longer operative times (p = 0.0001), and greater lengths of hospital stay (p = 0.0001). Progressively higher BMIs were associated with higher rates of complications, including wound (p < 0.001), medical (p < 0.001), infections (p < 0.001), major surgical (p < 0.001), graft and prosthesis loss (p < 0.001), and return to the operating room (p < 0.001).nnnCONCLUSIONSnThis study characterized the effect of progressive obesity on the incidence of surgical and medical complications after breast reconstruction using a large, prospective multicenter dataset. Increasing obesity is associated with increased perioperative morbidity. Data derived from this cohort study can be used to risk-stratify patients, enhance risk counseling, and advocate for institutional reimbursement in obese patients undergoing breast reconstruction.

1000 consecutive venous anastomoses using the microvascular anastomotic coupler in breast reconstruction.

Background: Microvascular anastomosis is one of the more critical aspects of free flap surgery. A safe, effective, and expedient method for venous anastomosis minimizes flap ischemia time, is easier on the surgical team, and saves costly operating room time. The authors report on their experience using the Synovis microvascular anastomotic coupling device in 1000 consecutive venous anastomoses in free flap breast reconstruction. Methods: The authors retrospectively reviewed 1000 consecutive venous anastomoses that were performed using the microvascular anastomotic coupler between July of 2002 and July of 2008. Data were obtained on flap type, recipient vessel, coupler size, incidence of venous thrombosis, timing of venous thrombosis, and morbidity as a result of venous thrombosis. Results: All anastomoses were performed in an end-to-end fashion. There were 460 unilateral cases and 270 bilateral cases of breast reconstruction. Flap types included muscle-sparing free transverse rectus abdominis myocutaneous, deep inferior epigastric perforator, superficial inferior epigastric artery, superior gluteal artery perforator, and inferior gluteal artery perforator. The vast majority of the recipient vessels were the internal mammary or thoracodorsal vessels. Most of the couplers that were used were either 3 or 2.5 mm in diameter. Overall, there were six instances of venous thrombosis (rate of 0.6 percent). There were no total flap losses due to venous thrombosis in this series, although two patients had partial flap necrosis. Conclusions: The patency rate for venous anastomoses performed with the microvascular coupler is excellent when compared with standard suture techniques and has the advantage of overall easier application.

Breast reconstruction after breast cancer.

Learning Objectives: After reading this article, the participant should be able to: 1. Describe the mental, emotional, and physical benefits of reconstruction in breast cancer patients. 2. Compare the most common techniques of reconstruction in patients and detail benefits and risks associated with each. 3. Outline different methods of reconstruction and identify the method considered best for the patient based on timing of the procedures, body type, adjuvant therapies, and other coexisting conditions. 4. Distinguish between some of the different flaps that can be considered for autologous reconstruction. Summary: Breast cancer is unfortunately a common disease affecting millions of women, often at a relatively young age. Reconstruction following mastectomy offers women an opportunity to mollify some of the emotional and aesthetic effects of this devastating disease. Although varying techniques of alloplastic and autologous techniques are available, all strive to achieve the same goal: the satisfactory reformation of a breast mound that appears as natural as possible without clothing and at the very least is normal in appearance under clothing. This article summarizes the various approaches to breast reconstruction and offers a balanced view of the risks and benefits of each, all of which in the end offer the opportunity for excellent and predictable results with a high degree of patient satisfaction.

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.

Comprehensive outcome and cost analysis of free tissue transfer for breast reconstruction: an experience with 1303 flaps.

Background: Free tissue transfer is standard for postoncologic reconstruction, yet it entails a lengthy operation and significant recovery. The authors present their longitudinal experience of free tissue breast reconstructions with an emphasis on predictors of major surgical and medical complications. Methods: The authors reviewed their prospectively maintained free flap database and identified oncologic breast reconstruction patients from 2005 to 2011. Factors associated with surgical and medical complications were identified using univariate analyses and logistic regression to determine predictors of complications. Results: Complications included major immediate surgical complications [n = 34 (4.0 percent)], major delayed surgical complications [n = 54 (6.4 percent)], minor surgical complications [n = 404 (47.6 percent)], and medical complications [n = 50 (5.9 percent)]. Obesity (p = 0.034), smoking (p = 0.06), flap type (p = 0.005), and recipient vessels (p < 0.001) were associated with immediate complications. Similarly, delayed surgical complications were associated with obesity (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), hypertension (p < 0.001), and prior radiation therapy (p = 0.06). Regression analysis demonstrated that flap choice (p = 0.024) was independently associated with major immediate complications, and patient comorbidities such as chronic obstructive pulmonary disease (p = 0.001) and obesity (p < 0.0001) were associated with delayed complications. Patients who developed an immediate surgical complication experienced longer hospital stays (p < 0.0001), higher operating costs (p < 0.001), and greater hospital costs (p < 0.001). Conclusions: Early major complications are related to flap selection, whereas late major complications are associated with patient comorbidities. Overall, major surgical and medical complications are associated with increased hospital length of stay and greater cost in autologous breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

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.