Mark A. Schusterman

Immediate breast reconstruction: why the free TRAM over the conventional TRAM flap?

Use of the transverse rectus abdominis myocutaneous (TRAM) flap for immediate breast reconstruction is controversial because of fear of flap loss and concern that a high complication rate could interfere with adjuvant therapy. One common complication of the TRAM, partial flap necrosis, can interfere with both institution of postoperative therapy and evaluation for recurrence. In an attempt to minimize this problem, we began using the free TRAM flap based on the inferior deep epigastric vessels. This study compares our experience with conventional superior-pedicled (cTRAM) flaps and free TRAM (fTRAM) flaps. A total of 68 breasts were reconstructed in 63 patients, of which 48 of 68 (71 percent) were conventional TRAM flaps and 20 of 68 (29 percent) were free TRAM flaps. Of the 48 conventional TRAM flaps, 26 (54 percent) were unipedicled and 22 (46 percent) were bipedicled. There were 39 of 48 (81 percent) conventional TRAM flaps and 17 of 20 (85 percent) free TRAM flaps with T1 or T2 lesions. Node-positive patients occurred in 14 of 48 (29 percent) conventional TRAM flaps and 2 of 20 (10 percent) free TRAM flaps. One-fourth of patients in both groups smoked cigarettes. Twenty-one of 48 patients (44 percent) with conventional TRAM flaps required postoperative chemotherapy, and 6 of 21 (29 percent) were delayed because of complications of the TRAM flap. Of the 7 of 20 (35 percent) free TRAM flap patients who required post-operative chemotherapy, only 1 of 7 (14 percent) was delayed because of TRAM flap complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Reconstruction of the Cervical Esophagus: Free Jejunal Transfer versus Gastric Pull-Up

Use of enteric grafts is a popular method for reconstruction of the cervical esophagus and hypopharynx. Free jejunal transfer (FJT) and gastric pull-up (GP) are the most popular methods used. This discussion is a retrospective review of our experience with 50 cases of free jejunal transfer and 15 cases of gastric pull-up. The graft survival rate was 94 percent (47 of 50) for free jejunal transfer and 87 percent (13 of 15) for gastric pull-up. Successful swallowing was achieved in 88 percent (44 of 50) of free jejunal transfers and 87 percent (13 of 15) of gastric pull-ups. Patients with free jejunal transfers were able to swallow and leave the hospital sooner: 10.6 versus 16.0 days and 22.3 versus 29.0 days, respectively. Fistulas occurred in 16 percent (8 of 50) of free jejunal transfers, most of which (6 of 8) healed spontaneously. Fistulas occurred in 20 percent (3 of 15) of gastric pull-ups, only one of which healed spontaneously. Stricture was the most common late complication for free jejunal transfers, 22 percent (11 of 50), whereas reflux was most common in gastric pull-ups, 20 percent (3 of 15). In patients with advanced cancer, extensive esopha-geal resection into the chest is often required, and gastric pull-up seems to be an easier and more direct form of reconstruction. In limited resection of the hypopharynx and esophagus, especially with proximal lesions, free jejunal transfer is simpler and avoids mediastinal dissection. This concept as well as other advantages and disadvantages of both techniques will be discussed.

Total Reconstruction of the Hypopharynx and Cervical Esophagus: A 20-Year Experience

We have reviewed 145 patients who underwent 148 total reconstructions of the hypopharynx and cervical esophagus between 1970 and 1989. The types and numbers of reconstruction included 45 deltopectoral (DP) flaps, 35 musculocutaneous (MC) flaps, 19 colon interpositions, 23 gastric transpositions, and 26 free jejunal transfers. Median hospitalization was 51 days for DP flaps, 24 days for MC flaps, 28 days for colon, 30 days for gastric, and 14 days for jejunum. Median resumption of oral intake was 92 days for DP flaps, 19 days for MC flaps, 12 days for colon, 13 days for gastric, and 9 days for jejunum. Functional failure, defined as the inability to maintain adequate nutrition without tube feedings, was 40% for MC flaps, 42% for colon interposition, 17% for gastric transposition, and 20% for free jejunal transfer. Microvascular free jejunal transfer has become our method of choice for reconstruction of the hypopharynx and cervical esophagus. Gastric transposition is an alternative when resection of the thoracic esophagus is necessary.

Functional results of dental restoration with osseointegrated implants after mandible reconstruction.

&NA; We reviewed the cases of 20 cancer patients (mean age 47.4 years) in whom osseointegrated implants were used for dental restoration after mandibular reconstruction between January of 1988 and December of 1994. Seventyone implants were placed into bone flaps (n = 60) or native mandible (n = 11), an average of 3.55 per patient (range, 2 to 5). Successful integration occurred in 91.5 percent (65 of 71); there were five early failures and one late failure, with no significant difference between the number lost in microvascular flaps (5 of 60) and native mandible (1 of 11) (as determined by Fishers exact test). Functional evaluation included assessments of diet, speech, and cosmesis. Based on our review, we concluded that (1) implants enhance dental restoration in selected patients, and (2) microvascular bone flaps, including the fibula and iliac crest, are well suited for dental implant restoration.

Bilateral Breast Reconstruction: Conventional versus Free Tram

Free TRAM flap transfer is now routinely offered to patients requiring breast reconstruction. This study compares results of conventional superior-pedicled TRAM flaps and free TRAM flaps in bilateral breast reconstructions. A total of 92 breasts were reconstructed in 46 patients. Eighteen patients had free TRAM flap reconstructions, and 28 patients were reconstructed with conventional TRAM flaps. Comparison of average operative blood loss and average operative time for the two techniques showed blood loss of 575 cc and an operative time of 9.6 hours for the free TRAM reconstructions and a blood loss of 313 cc and an operative time of 6.6 hours for the conventional TRAM reconstructions. For free TRAM flap reconstructions, both blood loss and operative time decreased significantly between the first and second group of nine patients: from 819 to 360 cc of blood loss and from 10.5 to 8.9 hours of operative time. Partial flap loss (skin and fat necrosis) and fat necrosis only occurred in 13 and 7 percent, respectively, of conventional TRAM flaps, but neither occurred in free TRAM flaps. However, early in the series, three free flaps were lost in two patients, requiring implant placement. Bilateral breast reconstruction using the free TRAM flap may offer a lower complication rate than the conventional TRAM flap by virtue of improved blood supply and less abdominal wall disruption. Surgeons, however, are forewarned that this procedure has a steep learning curve, and surgeons lacking microsurgical expertise may be better served by the conventional TRAM flap. (Plast. Reconstr. Surg. 93: 1410, 1994.)

Hypopharyngeal reconstruction: A comparison of two alternatives

Gastric pull‐up or free jejunal interposition was used for reconstruction after total laryngopharyngectomy in 31 patients. Complications and functional outcomes of the two methods are compared. Primary swallowing was achieved in 86% of patients after gastric pull‐up and in 82% of patients after jejunal interposition. Patients who underwent jejunal interposition were able to swallow sooner and had a shorter hospital stay than patients who underwent gastric pull‐up. Esophageal tumor recurrence after jejunal interposition was not observed. Hepatic failure occurred in two gastric pull‐up patients, leading to perioperative death in one. Flap necrosis occurred in two jejunal interposition patients and one gastric pull‐up patient. Two additional fistulas occurred in jejunal interposition patients as a result of microvascular complications. Stricture developed in four jejunal interposition patients, requiring revision surgery in two. Minor complications were more common in the gastric pull‐up group. Long‐term speech and swallowing function are compared. Our current choice of jejunal interposition or gastric pull‐up for reconstruction after total laryngopharyngectomy primarily depends on the location of the tumor.

Immediate breast reconstruction with the TRAM flap after neoadjuvant therapy.

Neoadjuvant therapy is a relatively new weapon in the chemotherapeutic arsenal against breast carcinoma. However, there has been concern that preoperative chemotherapy might lead to an increased incidence of complications and delays in postoperative treatment. A retrospective study was performed at M.D. Anderson Cancer Center of all patients with locally advanced breast cancer who had undergone neoadjuvant therapy followed by mastectomy and immediate reconstruction with the transverse rectus abdominis musculocutaneous (TRAM) flap. Patients were evaluated for the incidence of complications and any delays in resumption of postoperative chemotherapy. Thirty-one patients underwent immediate reconstruction with the TRAM flap. Twenty-two patients were reconstructed with free TRAM flaps whereas 9 patients were reconstructed with pedicled TRAM flaps. Seventeen patients (55%) had complications postoperatively, but only 2 patients (6%) had a delay in the resumption of chemotherapy. Seven patients were smokers, five (71%) of whom had complications, which was not a significant difference from the rate in nonsmokers (50%). Although delays in postoperative chemotherapy occurred in smokers (29%, vs. 0% in nonsmokers), the number of patients was too small to attain statistical significance. Based on this study it is felt that immediate reconstruction with the TRAM flap can be performed safely in patients on a neoadjuvant protocol. Although not contraindicated, immediate reconstruction with the TRAM flap in smokers in this setting may be associated with higher morbidity.

Immediate microvascular reconstruction of combined palatal and midfacial defects

We describe a method for immediate one-stage reconstruction of combined palatal and midfacial defects using latissimus dorsi musculocutaneous free-tissue transfer. It has consistently provided healed wounds, restoration of palatal function, and preservation of facial contour while obviating the need for a palatal prosthesis. This reconstructive method, which uses only autogenous tissue, may offer a significant advantage in cases where more than a hemimaxillectomy is required, for compound defects resulting from the sacrifice of facial structures along with the maxillectomy, and in situations where the resection involves cranial base structures with a resultant need to separate the cranial contents from the oral and nasal cavities. Finally, it provides an alternative to prosthetic rehabilitation for the elderly patient with decreased or absent vision.

Jejunal Interposition for Repair of Stricture or Fistula after Laryngectomy

Complications following total laryngectomy may include pharyngocutaneous fistula or pharyngeal stricture. Traditional techniques of repair of fistula and stricture with local or regional flaps lead to a high rate of failure. In this study, we report 18 patients treated by secondary jejunal interposition (JI) to rehabilitate swallowing following recalcitrant postlaryngectomy stricture or fistula. All patients had undergone total laryngectomy with or without partial pharyngectomy for treatment of squamous cell carcinoma of the larynx (8) or hypopharynx (10). Four were stage II; 5, stage III; and 9, stage IV. Thirteen patients (72%) regained swallowing function. Complications of secondary JI included perioperative death (2), flap loss (1), and persistent fistulas (3). Jejunal interposition may be the best modality in the rehabilitation of swallowing in patients with persistent fistula or stricture that fails to respond to traditional management.

The internal oblique repair of abdominal bulges secondary to TRAM flap breast reconstruction.

The internal oblique repair, a new method for repair of abdominal bulging following TRAM flap breast reconstruction, involves identification and repair of the internal oblique fascia. To assess the usefulness of this repair and to compare it with simple plication of the deep abdominal fascia, we retrospectively reviewed all abdominal bulge repairs performed by the first author over the past 7 1/2 years. Of 30 abdominal bulge repairs, the internal oblique repair was used in 14 patients and plication in 16 others. The bulge recurrence rate was lower after the internal oblique repair (21 percent) than after the plication repair (69 percent; p = 0.028). When synthetic mesh reinforcement was added to the internal oblique repair, the bulge recurrence rate dropped to 13 percent. We conclude that the internal oblique repair is the preferred technique for the correction of abdominal bulges secondary to TRAM flap breast reconstruction.