Kyeong-Tae Lee

A Systematic Review of Functional Donor-site Morbidity after Latissimus Dorsi Muscle Transfer

Background: The authors performed a comprehensive literature review regarding functional impairment after latissimus dorsi muscle transfer, to investigate functional changes in the donor site and the potential impact on patients’ daily lives. Methods: The PubMed database was searched for articles regarding functional donor-site morbidity following latissimus dorsi muscle flap harvest. Articles discussing the thoracodorsal artery perforator flap, which shares the same donor sites with the latissimus dorsi muscle flap, were also included. Functional morbidity was analyzed based on questionnaire of subjective symptoms, Disabilities of the Arm, Shoulder and Hand questionnaire, shoulder range of motion, and shoulder strength. Results: Twenty-two articles representing 719 cases in 644 patients were reviewed, including seven prospective and 15 retrospective cohort studies. As a questionnaire summary from eight articles, 94 of 232 patients (41 percent) experienced any kind of discomfort at the donor site. In the Disabilities of the Arm, Shoulder and Hand questionnaire from seven articles, little difficulty in daily activities but significant difficulties in sports and art activities were observed. Nine of 13 articles reported some limitations of shoulder motion, particularly during the early postoperative period, and four other articles detected little limitation. Eight of 12 articles reported some shoulder strength weakness over time, and shoulder extension, adduction, and internal rotation were commonly involved. The muscle-sparing latissimus dorsi and thoracodorsal artery perforator flaps showed low functional morbidity. Conclusions: Functional impairment of the shoulder could develop after latissimus dorsi muscle flap transfer. Knowledge of the flap’s functional morbidity will allow surgeons to inform patients regarding donor-site expectations and to accomplish better surgical outcomes.

Ischaemic time and fat necrosis in breast reconstruction with a free deep inferior epigastric perforator flap

PURPOSE Fat tissue can be injured by ischaemia in free flap surgeries, leading to the development of fat necrosis. The aim of this study was to evaluate the association between ischaemic time and fat necrosis in microsurgical breast reconstruction using a deep inferior epigastric perforator (DIEP) flap. METHODS A retrospective chart review was performed for patients who underwent breast reconstruction with free DIEP flaps between June 2009 and November 2011. Data regarding patient demographics, potential risk factors and fat necrosis were collected. Fat necrosis was diagnosed with ultrasound imaging between 3 and 6 months postoperatively. Univariate and multivariate analyses were used to assess the correlation between ischaemic time and fat necrosis rate. Receiver operating characteristic curve analysis was used to determine a cut-off value for the ischaemic time at which differential fat necrosis rates were maximal. RESULTS A total of 86 patients were included in this study. The mean ischaemic time was 89 min, and fat necrosis was diagnosed in 15 patients (17.4%). A significant association was found between ischaemic time and fat necrosis rate on univariate (p-value=0.001) and multivariate analyses (p-value=0.017). The trend analysis of ischaemic time as a categorical variable relative to fat necrosis rate was also significant (p-value<0.001). A threshold value was found whereby patients with an ischaemic time longer than 99.5 min appeared to experience a significantly higher fat necrosis rate than patients with shorter times (p-value=0.005, odds ratio=9.449). CONCLUSION Ischaemic time appears to be significantly associated with increased fat necrosis rate in breast reconstruction using DIEP flaps. A long ischaemia time may be a risk factor for the development of fat necrosis.

Effects of Obesity on Postoperative Complications After Breast Reconstruction Using Free Muscle-Sparing Transverse Rectus Abdominis Myocutaneous, Deep Inferior Epigastric Perforator, and Superficial Inferior Epigastric Artery Flap: A Systematic Review and Meta-analysis.

Background Although several studies have found obesity to increase the risk of postoperative morbidity in autologous breast reconstruction, there remains some controversy over the influence of obesity for muscle-conserving abdominal flaps, including muscle-sparing transverse rectus abdominis myocutaneous (msTRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps. This review evaluates the effects of obesity on complications in breast reconstruction using muscle-conserving abdominal flaps and compares them to those for conventional free transverse rectus abdominis myocutaneous (TRAM) flaps. Methods A literature search was conducted using MEDLINE, Ovid, and Cochrane databases for studies reporting complication rates for obese and nonobese patients undergoing breast reconstruction using msTRAM, DIEP, and SIEA flaps and conventional free TRAM flaps. The pooled relative risks (RRs) of the obesity for flap-related and donor complications were estimated in the muscle-conserving flaps by meta-analytic methodology and the pooled complication rates in obese patients were compared between muscle-conserving flaps and conventional TRAM flaps. Here, only those studies following the World Health Organization definition of obesity (body mass index ≥ 30 kg/m2) were included. Results A total of 17 articles were analyzed. Eight studies were used to compute the obesity-related risks of flap-related and donor complications for msTRAM, DIEP, and SIEA flaps. Obesity increased the risk of total flap loss [RR, 1.68; 95% confidence interval (CI), 0.85–3.33], partial flap loss (RR, 2.26; 95% CI, 1.01–5.02), abdominal bulge or hernia (RR, 1.72; 95% CI, 1.00–2.95), and overall abdominal complications (RR, 1.53; 95% CI, 1.10–2.14). The results of a pooled analysis with 15 studies are consistent with those of the meta-analysis. In comparison to free TRAM flaps, muscle-conserving abdominal flaps showed a lower pooled incidence of flap loss, fat necrosis, and abdominal bulge or hernia in obese patients. Conclusions This review suggests that obesity increases the risk of both flap-related and donor-site complications in breast reconstruction using msTRAM, DIEP, and SIEA flaps. In comparison to conventional TRAM flaps, however, muscle-conserving abdominal flaps may have an advantage in reducing the morbidity in obese patients.

The efficacy of postoperative antithrombotics in free flap surgery: a systematic review and meta-analysis.

Background: Although the efficacy of postoperative antithrombotics in free flap survival is well demonstrated through animal studies, debate remains in the clinical literature. This review estimates the benefits and risks of each antithrombotic drug and evaluates whether antithrombotics can produce better outcomes than nonantithrombotic treatment. Methods: English-language articles evaluating the efficacy of antithrombotics in free flap surgery through comparisons with control groups were analyzed. The outcome measures were total flap failure, pedicle thrombosis, and hematoma formation. Results: Twelve articles representing 4984 cases were analyzed. None of the antithrombotics showed significant benefits for flap survival. Heparin reduced the risk of flap loss by 35 percent, but the difference was not significant (relative risk, 0.65; 95 percent CI, 0.25 to 1.69). Dextran and aspirin showed little protective effects on pedicle thrombosis and flap failure. All antithrombotics showed increased risks of hematoma, and aspirin raised the risk of hematoma significantly (relative risk, 1.91; 95 percent CI, 1.05 to 3.47). In an analysis combining six studies comparing outcomes between the antithrombotic group and the nonantithrombotic group, antithrombotic administration did not reduce the risk of total flap loss (relative risk, 0.99; 95 percent CI, 0.72 to 1.35) or thrombosis (relative risk, 1.00; 95 percent CI, 0.74 to 1.36) but significantly increased the risk of hematoma (relative risk, 1.78; 95 percent CI, 1.20 to 2.63). Conclusions: There is little evidence suggesting that the use of antithrombotics reduces the risk of thrombosis and total flap failure. Although randomized controlled studies would be required, the risks of routine administration of antithrombotics may outweigh the benefits. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Prosthetic breast reconstruction in previously irradiated breasts: A meta-analysis

The present review evaluated the impacts of pre‐reconstruction radiotherapy on outcome of prosthetic breast reconstruction and compared the safety of prosthetic reconstruction with that of other modalities, including autologous tissue reconstruction and the combination of flap and implant in the setting of pre‐reconstruction radiation.

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.

Interstitial granulomatous dermatitis associated with autoimmune hepatitis

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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.

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.

Free latissimus dorsi muscle-chimeric thoracodorsal artery perforator flaps for reconstruction of complicated defects: does muscle still have a place in the domain of perforator flaps?

PurposeThe reconstruction of complicated defects with 3-dimensional deficits remains challenging. The reconstruction of these defects requires not only coverage of surface but also appropriate obliteration of dead space, and muscle–chimeric perforator flaps can be a valuable option. Here, we present our experience with free latissimus dorsi (LD) muscle–chimeric thoracodorsal artery perforator (TDAP) flaps for the treatment of complicated defects. MethodsA retrospective chart review was performed for patients who underwent a free LD muscle–chimeric TDAP flap procedure for the treatment of complicated wounds with 3-dimensional tissue deficits between March 2005 and October 2012. The surgical technique, clinical outcomes, and postoperative complications were evaluated. ResultsA total of 24 cases were included. All flaps survived and no partial flap losses were encountered. Large skin flaps of 115 cm2 average size were elevated, with an average of 38-cm2 muscle segments. The total length of pedicle was 12.2 cm on average, with 7.3 cm of common pedicle, 4.9 cm of skin paddle, and 3.4 cm of muscle segments. Muscle segments could be inset in the underlying dead space with spatial freedom. The mean follow-up period was 34.1 months. Wounds successfully healed in all cases without significant postoperative complications. The donor-site complication rate of the chimeric flap group was similar to that of the simple TDAP group. ConclusionsThe use of LD muscle–chimeric TDAP flaps with Y-pedicle configurations allowed efficient positioning of both skin and muscle components for their specific purposes and successful healing of complicated wounds. The muscle components of chimeric flaps acted as “filler flaps” and were an effective addition to the perforator flap technique for the reconstruction of complicated defects without the addition of significant donor-site morbidity.