Mark R. Kobayashi

Current options in head and neck reconstruction.

Learning Objectives: After studying this article, the participant should be able to: 1. Understand current trends in the treatment of head and neck cancer. 2. Discuss the challenges of reconstructing head and neck defects 3. Understand the different reconstructive options available for specific anatomical regions of the head and neck. Background: Reconstructive surgery of the head and neck is both technically challenging and rewarding. In the past 20 years, significant advances in this field have improved surgical outcomes and patient function. The development and subsequent refinement of microvascular techniques, in particular, have been a major reason for this progression. Methods: In this article, the authors review the current options available in head and neck reconstruction. Because a large number of major craniocervicofacial defects result from oncologic resection, the authors have focused their review on this particular subject. By dividing their discussion into different anatomical sites, the authors hope to cover all major aspects of this broad topic. Results: Free tissue transfer has revolutionized head and neck reconstruction. The most widely used free flaps include the fibula, radial forearm, anterolateral thigh, and rectus abdominis. Restoration of both form and function is the ultimate goal. Conclusions: Although defects of the head and neck region present a challenge, successful cosmetic and functional results have been achieved with both local and free tissue flaps. The flexibility of free tissue transfer, however, has dominated this area and continues to be the method of choice for reconstruction of sizable defects.

Mandibular reconstruction: Are two flaps better than one?

This study compared the combined iliac and ulnar forearm flaps with the osteomusculocutaneous fibular free flap for mandibular reconstruction. A retrospective study of 40 patients who had oromandibular reconstruction was performed, of whom 23 patients had a combined iliac crest without skin and ulnar forearm free flap. Seventeen patients had an osteomusculocutaneous free fibular flap. Ten women and 30 men with a mean age of 57.5 years comprised this study population. Ninety percent of the cases were squamous cell carcinoma (55%, T4), of which 11% were recurrent tumors. Anterolateral mandibular defects constituted 52.9% of the fibular reconstructions and 60.9% accounted for the iliac/ulnar reconstructions. The mean bone gaps were 8.79 cm and 8.95 cm respectively. Functional evaluation was based on the University of Washington Questionnaire through phone calls and personal communication. The mean hospital stay was 15.43 days and 10.09 days for the fibular and iliac/ulnar flaps respectively. The facial artery (64.7%) and facial vein (60%) were the main recipient vessels for the fibular reconstructions whereas the external carotid artery (95.6%) and the internal jugular vein (66.7%) were the main recipient vessels for the iliac/ulnar reconstruction. Overall flap survival was 96.8% (100% of fibular flaps and 95.65% of iliac/ulnar flaps). Two flaps were lost in the iliac/ulnar series because of unsalvageable venous thrombosis. Local complications for the iliac/ulnar flaps were 30.4% but were 5.9% for the fibular reconstructions. Function such as speech, swallowing, and chewing were notably better in the fibular than the iliac/ulnar group in 23 of the patients tested. The cosmetic acceptance of 77.8% of the fibular flaps was judged to be excellent and good, whereas 71.4% of the iliac/ulnar flaps were rated good. It appears that within this study population the free osteomusculocutaneous fibular flap had fewer local complications and a higher flap survival rate than the combined iliac/ulnar forearm flaps. Overall functional outcome was also improved. The use of the double flap may be appropriate in massive oromandibular defects, but may be less appropriate in more modest functional reconstructions of mandibular defects.

Institutional review of free TRAM flap breast reconstruction.

Introduction:A 10-year experience with breast reconstruction in a university hospital was recently reviewed. The purpose of this study was to determine the subtypes of breast reconstructive procedures and to evaluate the frequency and change in technique over time of free TRAM (transverse rectus abdominis muscle) flap breast reconstruction performed at one institution. Trends in the development of the procedure over this period were also reviewed. Materials & Methods:Between November 1994 and September 2004, a 10-year retrospective chart review was conducted. The indications for mastectomy and reconstruction were determined. The median age was 48 (range 31–66). The range of follow-up was 2 to 71 months, with a median of 19.5 months. The mean follow-up was 23.5 months. Outcome data were grouped into 2 consecutive 5-year periods (period 1: 1994–1998; period 2: 1999–2004) and evaluated for changes over time in techniques and outcome. Statistical analysis (Decision Analyst, Inc., STATS Statistics software, version 1.1, 1998) was performed using the difference between 2 proportions module to assess the probability of a significant difference in the data for period 1 and period 2 parameters. Results:Over a 10-year period, 117 patients underwent breast reconstruction. This consisted of 12 pedicle procedures (11.3%), including 1 bipedicle flap (0.9%) and 2 bilateral pedicle procedures (1.8%). There were 3 latissimus dorsi pedicle flaps (2.8%). Sixteen patients (15.1%) received tissue expander or implant reconstructions. Of the 117 patients, 79 underwent free flap breast reconstruction. Of the 79 free-flap patients, 22 (27.8%) had bilateral procedures, for a total of 101 free flaps performed in these 79 patients. Fifty-two patients underwent immediate reconstruction (65.8%) and 25 were delayed (31.6%) reconstructions using either deep inferior epigastric artery perforator (DIEP) flaps (4 = 3.9%) or free TRAM flaps (97 = 96.0%). A muscle-sparing technique was used in 43 of the 97 free TRAM flaps (44.3%). The preferred vascular inflow was the internal mammary artery, which was used in 66 out of 101 flaps (65.3%). The rate of anastomotic revision (arterial and venous) was 4.9%. The majority of cases used a 2.5-mm venous coupler (65.3%). In 2 of the free TRAM cases, there was insufficient volume to establish the patients preexisting volume. Therefore, at the patients request, immediate implants were used to augment the reconstruction. The average hospital stay was 8.13 days, and the average intensive care stay was 4.59 days. When assessed for trends over time, we noted a reduction in our hospital length of stay and our ICU length of stay. Conclusion:The experience with free tissue breast reconstruction reveals predominant use of the TRAM flap. This is justified by the reliability of this flap and the advances in achieving esthetic breast reconstruction. Additionally, we have begun performing DIEP free-flap reconstructions. Our clinical practice has evolved concurrent with standards of care, as noted by the increase in use of muscle-sparing techniques and the reduction in the use of dextran. We do not routinely use therapeutic anticoagulation in our cases. Our hospital length of stay and average intensive care length of stay have also decreased over time, consistent with a system-wide effort to increase the efficiency of healthcare delivery.

Predictive risk factors of venous thromboembolism in autologous breast reconstruction surgery.

BackgroundVenous thromboembolism (VTE) can be a significant cause of morbidity and mortality in autologous breast reconstruction surgery. The aim of this study was to evaluate the effect of patient characteristics, comorbidities, payer type, reconstruction type, reconstruction timing, radiation, chemotherapy, and teaching status of hospital on VTE (deep venous thrombosis and/or pulmonary embolism) in autologous breast reconstructive surgery. MethodsUsing the Nationwide Inpatient Sample (NIS) database, we examined the clinical data of patients who underwent autologous breast reconstructive surgery in 2009 to 2010 in the United States. Univariate and multivariate regression analyses were performed to identify factors predictive of in-hospital VTE. ResultsA total of 35,883 patients underwent autologous breast reconstructive surgery during this period. Overall rate of VTE was 0.13%. The highest rate of VTE (0.26%) was observed in pedicled transverse rectus abdominis myocutaneous flap. Patients who experienced VTE had significantly longer mean hospital stay (11.6 vs 3.9 days; P < 0.001) and higher mean total hospital charges (

Incidental positive internal mammary lymph nodes: a multiple international institutional investigation.

146,432 vs

Long-Term Outcomes after Primary Breast Reconstruction Using a Vertical Skin Pattern for Skin-Sparing Mastectomy

61,794; P < 0.001) compared with non-VTE patients; however, there was no significant difference observed in mortality rate (VTE, 0.0% vs non-VTE, 0.04%; P = 0.886). Using multivariate regression analysis, immediate reconstruction after mastectomy (adjusted odds ratio [AOR], 5.4), older than 65 years (AOR, 4.2), obesity (AOR, 3.7), history of chemotherapy (AOR, 3.5), and chronic lung disease (AOR, 2.5) were associated with higher risk of VTE. There was no association between race, payer type, diabetes, hypertension, liver disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, smoking, reconstruction type, radiation, or teaching status of hospital on VTE. ConclusionsIn patients undergoing autologous breast reconstruction surgery, immediate reconstruction, older than 65 years, obesity, history of chemotherapy, and chronic lung disease are all independent predictors of higher VTE. Surgeons should consider these factors and use appropriate prophylaxis to minimize the risk of VTE development.

Pharmacologic enhancement of rat skin flap survival with topical oleic acid.

The internal mammary lymph node is the second most frequent site of nodal metastasis. With an increase in breast free flap reconstruction utilization of the internal mammary vessels, identification of these internal mammary lymph node metastases will become more prevalent. A chart review documented 75 free transverse rectus abdominis myocutaneous flaps cases performed at Kaiser Bellflower from 1998 to 2004. Between March 2000 and January 2006 there were 157 autologous breast reconstructions (122 DIEP flaps, 10 GAP flaps, 15 SIEA flaps, 7 free transverse rectus abdominis flaps, and 1 SCIA flap) using internal mammary vessels as the recipient site at the Chang Gung Memorial Hospital. A literature review was conducted to survey the current protocols in the surgical, oncological, and radiological communities. A population of 232 patients with breast reconstruction via free flaps was identified. The age range was 29 to 65 years. With the exception of the five cases presented, no other incidence of positive internal mammary lymph nodes was identified. Failure to account for the status of the internal mammary lymph nodes may risk understaging and preclude appropriate treatment stratification. With more frequent utilization of the internal mammary vessels, discussions regarding breast reconstruction should take this new oncological focus into consideration.

The Number of Operations Required for Completing Breast Reconstruction

Background: Preservation of the breast skin envelope in skin-sparing mastectomy is the key component for superior aesthetic results. Breast mound disproportions in primary breast reconstruction caused by a mismatch between retained skin envelope and donor-tissue volume provokes breast shape asymmetries. A skin-sparing mastectomy using a vertical pattern can address these breast mound imperfections by adjusting this mismatch in a vertical direction. Methods: A retrospective chart review was conducted over a 10-year period for patients who underwent skin-sparing mastectomy using a vertical pattern for malignant, premalignant, benign, and deformational disease of the breast. Reconstruction was performed primarily with free muscle-sparing transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flaps. Results: Seventy-two patients, aged 31 to 69 years (mean, 51.5 years), underwent 106 skin-sparing mastectomies using a vertical pattern and primary reconstruction with 38 unilateral and 34 bilateral free flaps (muscle-sparing transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flaps). The mean follow-up period was 42 months, without any local or systemic recurrences of the breast cancer. The complication rates of 8.49 percent at the donor site and 6.60 percent at the flap site show a direct correlation to smoking but no correlation to body mass index, cancer stage, or diabetes. Conclusions: Skin-sparing mastectomy using a vertical pattern improves the aesthetic outcome in primary breast reconstruction without compromising oncologic safety and demonstrates low morbidity. Elimination of the disharmony between skin flap and breast volume in the vertical direction while respecting the inframammary crease produces a youthful, symmetrical conical breast shape with medial fullness.

The Effects of Perioperative Tamoxifen Therapy on Microvascular Flap Complications in Transverse Rectus Abdominis Myocutaneous/Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

This study was instituted to investigate in a rat model the effect of topical coadministration of the penetration enhancer oleic acid (10% by volume) and RIMSO-50 (medical grade dimethyl sulfoxide, 50% by volume) on rat skin flap survival. A rectangular abdominal skin flap (2.5 × 3 cm) was surgically elevated over the left abdomen in 40 nude rats. The vein of the flaps neurovascular pedicle was occluded by placement of a microvascular clip, and the flap was resutured with 4-0 Prolene to its adjacent skin. At the end of 8 hours, the distal edge of the flap was reincised to gain access to the clips and the clips were removed. After resuturing of the flaps distal edge to its adjacent skin, the 40 flaps were randomly divided into four groups. Group 1 (control) flaps were treated with 5 g of saline, group 2 (dimethyl sulfoxide) flaps were treated with 2.7 g of dimethyl sulfoxide (50% by volume), group 3 flaps (oleic acid) were topically treated with 0.45 g of oleic acid (10% by volume), and group 4 (dimethyl sulfoxide plus oleic acid) flaps were treated with a mixture of 0.45 g of oleic acid (10% by volume) and 2.7 g of dimethyl sulfoxide (50% by volume) diluted in saline. Each flap was topically treated with 5 ml of drug-soaked gauze for 1 hour immediately after clip removal to attenuate reperfusion injury. Thereafter, drug was applied topically once daily for 4 more days. Digital photographs of each flap were then taken on day 6 and the flaps were then harvested. The percentage of skin survival in each flap was determined by computerized morphometry and planimetry. The mean surviving area of group 3 (oleic acid–treated flaps) was 23.60 ± 4.19 percent and was statistically higher than that in group 1 (control, saline-treated flaps) at 7.20 ± 2.56 percent. The mean surviving area of group 2 (dimethyl sulfoxide–treated flaps) at 18.00 ± 5.23 percent and group 4 (oleic acid–and dimethyl sulfoxide-treated flaps) at 9.90 ± 3.44 percent did not achieve statistically higher mean surviving areas than controls. A topical solution of oleic acid (10% by volume) caused a statistically significant increase in the survival of rat abdominal skin flaps relative to controls. Dimethyl sulfoxide and the two experimental drugs together did not increase the percentage of flap survival when given as a single 5-ml dose released from a surgical sponge at reperfusion for 1 hour and then daily for a total of 5 days. The reasons for the lack of response are unknown but may have included the technical difficulty of delivering an adequate dose of dimethyl sulfoxide topically and immiscibility between dimethyl sulfoxide and oleic acid. Further studies may be warranted.

Free tensor fasciae latae flap for abdominal wall reconstruction: overview and new innovation.

Background: Breast reconstruction often requires multiple surgeries, which demands additional expense and time and is often contrary to the patient’s expectation. The aim of this study was to review the number of operations that were needed for completion of breast reconstruction and to determine patient and clinical factors that influenced this number. Methods: We retrospectively reviewed the medical records of 254 cases of breast reconstructions (in 185 patients) that were performed between February 2005 and August 2009. We investigated the numbers of operations that were performed for individual case of breast reconstruction and analyzed the influence of variable factors. The purpose of the additional operations was also analyzed. Results: The mean number of operations per breast was 2.37 (range, 1–9). The mean number of operations for mound creation was 2.24. Factors associated with an increased number of operation were use of an implant, contralateral symmetrization, complications, and nipple reconstruction. Considering the reconstruction method, either the use of a primary implant or the use of free abdominal tissue transfer demonstrated fewer surgeries than the use of an expander implant, and the number of operations using free transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flaps was less than the number of operations using pedicled transverse rectus abdominis musculocutaneous flaps. Conclusions: These data will aid in planning breast reconstruction surgery and will enable patients to be more informed regarding the likelihood of multiple surgeries.