L. Franklyn Elliott

Immediate Tram Flap Breast Reconstruction: 128 Consecutive Cases

The purpose of this article is to determine whether or not the transverse rectus abdominis musculocutaneous (TRAM) flap procedure is a practical operation for immediate breast reconstruction. Our series reports 128 consecutive patients who underwent immediate breast reconstruction with the TRAM flap from 1985 to 1990. Of these patients, 86 underwent conventional TRAM, while 40 underwent free TRAM breast reconstruction. Two-thirds of the patients underwent bilateral breast reconstruction. Comparison within this series of the free TRAM versus the conventional TRAM flap revealed improved statistics with regard to the free TRAM flap in a shorter hospitalization time and a decreased incidence of fat necrosis. There is no evidence to date that there is an increased chance of local recurrence with immediate breast reconstruction in this series, and chemotherapy was delayed in a single patient because of healing problems after immediate reconstruction. Operative times and the complication rate seem to be improving as compared with other series previously reported. The TRAM procedure, particularly the free TRAM procedure, is a primary choice for immediate breast reconstruction after mastectomy.

Computer-Designed Prostheses for Orbitocranial Reconstruction

Three-dimensional imaging is an adjunct to preoperative evaluation and surgical management in some patients with complex anatomic defects of various etiologies. Deformities defined by conventional computerized tomography can be viewed as accurate three-dimensional images calculated from the original scan. The images are viewed on a high-resolution video monitor and can be photographed for a permanent record. A computer-controlled milling device can use these data to fabricate prostheses. The prostheses aid reconstructive surgery through use as an alloplastic implant, as a template to fashion autogenous bone grafts, or as a model for tissue removal. We have utilized three-dimensional imaging in combination with computer-assisted prosthesis manufacture in six patients with complex orbitocranial deformities. Four patients have undergone reconstructive surgery with satisfactory results and no complications thus far. The use of computer-designed prostheses adds a new aspect to orbitocranial reconstructive surgery that facilitates increased accuracy in the correction of anatomic defects.

High leg incision fascia lata harvesting

OBJECTIVE The traditional method of harvesting fascia lata has been through an incision above the lateral knee. Problems with this method include a conspicuous scar, herniation of the muscle belly, and hematoma formation. The authors describe a new method of harvesting fascia lata in the region of the hip to minimize these complications. DESIGN Cohort study. PARTICIPANTS Twenty-three patients underwent harvesting of fascia lata by the technique described by the authors. Twenty-one patients had ptosis with poor levator function. In two patients, the fascia lata was used to wrap a hydroxyapatite implant. INTERVENTION The technique for harvesting fascia lata through an incision between the greater trochanter and anterior iliac crest is described. Long-term results were collected from chart reviews and patient interviews after surgery. MAIN OUTCOME MEASURES The patients were evaluated to determine whether any complications resulted from the new incision site. RESULTS No permanent complications were noted at the incision site. CONCLUSIONS Fascia lata can be harvested safely in the region of the iliac crest with an inconspicuous scar and with fewer complications than with the more traditional site slightly above the lateral knee.

Progressive hemifacial atrophy associated with Lyme disease

A case is described of progressive hemifacial atrophy occurring in a child with Lyme disease. Borrelial infection may have been an etiologic factor in the progressive hemifacial atrophy, which was ultimately treated with an SIEA free-flap transfer.

The 3-hour muscle-sparing free TRAM flap: safe and effective treatment review of 111 consecutive free TRAM flaps in a private practice setting.

Background: The muscle-sparing free transverse rectus abdominis muscle (TRAM) flap is a reliable technique that provides great versatility, with potentially decreased donor-site morbidity. However, because of the inherent nature of microvascular techniques, it is still regarded as a time-consuming and technically difficult procedure. The goal of this retrospective study was to document the validity of this technique in the private practice setting. Methods: Data were reviewed retrospectively and included patient demographics, total operative time, choice of recipient vessels, outcome, and perioperative morbidities. Results: One hundred one consecutive patients underwent 111 muscle-sparing free TRAM flap procedures for breast reconstruction (immediate, 89 patients; delayed, 12 patients).The internal mammary artery was used in 75 cases and the thoracodorsal artery was used in 36 cases. Average operative time was 185 minutes (3 hours 5 minutes). Average blood loss was 195 cc. There was no total flap loss. Revision of the microvascular anastomosis was performed in four patients, with flap salvage in all of them. Thirteen patients (13 percent) required primary mesh for abdominal wall closure. Fourteen (14 percent) had fat necrosis. Two patients had hematoma that required surgical evacuation. Abdominal wall weakness was detected in two patients (2 percent) and required mesh repair. Conclusions: The technical difficulties associated with the free TRAM flap have been ameliorated using a well-designed surgical plan and consistent technique performed by a team familiar with the procedure to achieve an acceptable average 3-hour operating time, with minimal complications. The authors advocate the muscle-sparing free TRAM flap as the operation of choice for unilateral breast reconstruction using autogenous tissue. The technique is expeditious and relatively safe.

The significance of intraabdominal compartment pressure after free versus pedicled TRAM flap breast reconstruction

The significance of intraabdominal compartment pressures following 77 pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstructions was previously reported in the Journal.1 We demonstrated that a transient elevation in intraabdominal pressure occurs, especially in those patients with bipedicled TRAM flaps or elevated body mass indices. Tension free mesh closure appeared to have a protective effect. Symptomatic trends (decreased urine output, increased respiratory rate, and a positive fluid balance) and certain complications were associated with, and possibly explained by an elevated intraabdominal compartment pressure. Given that the study only examined pedicled TRAM flaps, we found it of interest to study free TRAM flap procedures with regard to intraabdominal pressures. The purpose of this report was to evaluate a series of patients and to compare their intraabdominal compartment pressures following free TRAM flap breast reconstructions. The intent was not to compare outcomes in free versus pedicled TRAMs, as this has already been done. Nor was the intent to demonstrate an association among intraabdominal compartment pressures, symptomatic trends, and complications, as this was discussed in our previous article.1 We were merely interested in documenting intraabdominal compartment pressures following free TRAM flaps and comparing them with those following pedicled TRAM procedures. METHODS

The Scarless Latissimus Dorsi Flap for Full Muscle Coverage in Device-Based Immediate Breast Reconstruction: An Autologous Alternative to Acellular Dermal Matrix

Background: Thin patients have fewer autologous options in postmastectomy reconstruction and are frequently limited to device-based techniques. The latissimus dorsi flap remains a viable option with which to provide autologous coverage, although for certain patients the donor scar can be a point of contention. The scarless latissimus dorsi flap is a way of mitigating these concerns. The authors present their 6-year single-surgeon experience with scarless latissimus dorsi flap reconstruction. Methods: A retrospective review of scarless latissimus dorsi flap reconstruction was performed. Charts from 2003 to 2009 were queried for demographic characteristics, nonoperative therapies, and short- and long-term complications. Results were compared with historical data. Results: Thirty-one patients with 52 flaps were identified. Fifty-one flaps were immediate reconstructions, with an average age of 47 years and body mass index of 22.8 kg/m2. Thirteen patients were treated with chemotherapy and four were irradiated, two preoperatively. The single drain was removed on average at 21 days. Complications included three hematomas (5.8 percent), two capsular contractures (3.8 percent), and two infections (3.8 percent). Average time to secondary reconstruction was 143 days. There were five unplanned revisions (9.6 percent). There were no flap failures or tissue expander losses. Conclusions: The scarless latissimus dorsi flap is an effective method for providing durable homogenous device coverage in the thinner patient (body mass index <24). With the advent of acellular dermal matrices, device coverage has been made simpler, but this comes at a cost. Coverage is thin, the matrix is not initially vascularized, and products are expensive. For these reasons, use of the scarless latissimus dorsi flap is an excellent alternative, particularly in the patient with a low body mass index. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. Figure. No caption available.

Immediate permanent implant reconstruction following mastectomy with capsule preservation in patients with prior augmentation mammoplasty

AbstractPrior breast augmentation in patients desiring post-mastectomy reconstruction provides a unique opportunity for capsular preservation and immediate, single-step implant reconstruction. We report a case series of a single-surgeon experience with immediate implant reconstruction after skin-sparing mastectomy in patients with prior subpectoral augmentation. Final implant volumes, complications, and outcomes were examined. Twenty patients (15 bilateral, total 35 breasts) were included. Eighteen (90%) patients were treated for cancer. Mean augmentation-to-reconstruction interval was 9 years (range, 3–19 years). Mean patient age was 45.1 years (range, 37–64 years). Eight patients (40%) received postoperative chemotherapy and two (10%) radiation. Mean mastectomy weight was 321 g. Mean weight of the implants removed was 346 g. Mean volume of new implants was 487 mL. All patients underwent capsulotomy (100% superior, 85% medial, 30% inferior, 5% lateral). Mean operative time was less than 1 hour for bilateral reconstruction. With average follow-up of 25.6 months, 2 patients were re-operated on for asymmetry (implant malposition, synmastia). Thirty-day complications included 1 implant loss due to infection, 1 drain placement with implant salvage, 1 hematoma requiring evacuation, and 1 cellulitis treated with antibiotics. There were no late complications and no capsular contractures. None have required further oncologic surgery. No cancer recurrences have been detected. In patients who desire prosthetic reconstruction similar to their original submuscular augmentation, capsule preservation and implant replacement with a larger prosthetic inserted within the old capsule is safe, fast, and aesthetically pleasing without compromising oncologic principles.

The use of autologous platelet-leukocyte-enriched plasma to minimize drain burden and prevent seroma formation in latissimus dorsi breast reconstruction.

Introduction: Seromas and drains are major sources of morbidity associated with latissimus dorsi breast reconstruction. Our goal was to look at an autologous platelet-leukocyte-enriched plasma spray and to assess its efficacy in reducing drain burden and seroma formation. Methods: We performed a single surgeon, patient-controlled, blinded study on bilateral latissimus dorsi breast reconstruction patients in which we applied autologous platelet-leukocyte-enriched plasma to one side and measured drain amounts, time to drain removal, and seroma rate. Results: Twelve patients were included in this study. The average age was 41.1 years, and the average body mass index was 21.6 kg/m2. Average volume of drain output showed neither difference (789 mL spray side vs. 790 mL control side) nor average time to drain removal (11.83 days spray side vs. 11.5 days control side). There were 2 complications reported: 1 hematoma (8.33%) and 1 seroma (8.33%) that required aspiration in a postoperative visit. Conclusions: It appears after 12 patients that there is no demonstrable difference regarding drain output, time to drain removal, or seroma incidence between the study and the control group. We feel a larger study population would add power and confirm these findings.

The role of sponsored supplements in a peer-reviewed journal: a reply to an editorial.

This letter is in response to the well-written discussion by Dr Foad Nahai1 entitled “The Role of Sponsored Supplements in a Peer-Reviewed Journal” in Aesthetic Surgery Journal ( ASJ ). It is clearly evident that Dr Nahai has considered this subject in detail both from an ethical as well as an informational standpoint to create an editorial that offers an in-depth analysis of sponsored supplements. Dr Nahai’s discussion of the overall indication for and benefit of sponsored supplements is quite good. I doubt that any of us disagree that focused supplements have significant clinical value, particularly when a subject or product is relatively new—such as with acellular dermal matrix (ADM), nonsurgical facial rejuvenation, or Dysport (Medicis, Inc, Scottsdale, Arizona) dosing, all of which have been topics of recent supplements in ASJ . These publications have the potential to be quite successful in bringing to the reader an overview of each subject in a relatively unbiased manner, even when sponsored by one of the companies in the field. Dr Nahai explains in great detail the Editorial Board’s …