Randall J. Yetman

Complications of postmastectomy breast reconstructions in smokers, ex-smokers, and nonsmokers

Smoking results in impaired wound healing and poor surgical results. In this retrospective study, we compared outcomes in 155 smokers, 76 ex‐smokers, and 517 nonsmokers who received postmastectomy breast reconstructions during a 10‐year period. Ex‐smokers were defined as those who had quit smoking at least 3 weeks before surgery. Transverse rectus abdominis musculocutaneous (TRAM) flap surgery was performed significantly less often in smokers (24.5 percent) than in ex‐smokers (30.3 percent) or nonsmokers (39.1 percent) (p < 0.001). Tissue expansion followed by implant was performed in 112 smokers (72.3 percent), 50 (65.8 percent) ex‐smokers, and 304 nonsmokers (58.8 percent) (p = 0.002). The overall complication rate in smokers was 39.4 percent, compared with 25 percent in ex‐smokers and 25.9 percent in nonsmokers, which is statistically significant (p = 0.002). Mastectomy flap necrosis developed in 12 smokers (7.7 percent), 2 ex‐smokers (2.6 percent), and 8 nonsmokers (1.5 percent) (p < 0.001). Among patients receiving TRAM flaps, fat necrosis developed in 10 smokers (26.3 percent), 2 ex‐smokers (8.7 percent), and 17 nonsmokers (8.4 percent). Abdominal wall necrosis was more common in smokers (7.9 percent) than in ex‐smokers (4.3 percent) or nonsmokers (1.0 percent). In this large series, tissue expansion was performed more often in smokers than was autogenous reconstruction. Complications were significantly more frequent in smokers. Mastectomy flap necrosis was significantly more frequent in smokers, regardless of the type of reconstruction. Breast reconstruction should be done with caution in smokers. Ex‐smokers had complication rates similar to those of nonsmokers. Smokers undergoing reconstruction should be strongly urged to stop smoking at least 3 weeks before their surgery. (Plast. Reconstr. Surg. 107: 342, 2001.)

Nipple-sparing mastectomy update: one hundred forty-nine procedures and clinical outcomes.

OBJECTIVES To describe our experience with patients who underwent the nipple-sparing mastectomy procedure developed and standardized at our institution and to report clinical outcomes for those patients with a breast cancer diagnosis. DESIGN Prospective study for consecutive nipple-sparing mastectomy procedures. SETTING Multidisciplinary breast center at a large tertiary care facility. PATIENTS One hundred ten consecutive patients underwent nipple-sparing mastectomy between July 2001 and June 2007. INTERVENTION Nipple-sparing mastectomy was offered to carefully screened patients; the nipple-areola tissue was cored and sent for histologic frozen-section analysis intraoperatively. MAIN OUTCOME MEASURES Assessment of nipple-areola cored tissue for neoplastic involvement; postoperative stability of retained nipple-areola complex; and clinical outcomes. RESULTS Data were available for 149 nipple-sparing mastectomies performed on 110 patients. No procedure performed for prevention had neoplastic involvement of the cored nipple-areola tissue, while 9 procedures performed for breast cancer treatment were found to have neoplastic involvement. Postoperatively, 2 patients had partial loss of the nipple-areola complex due to sloughing and a third patient developed an infection that required surgical removal of the nipple-areola complex. Among patients with breast cancer, none with ductal carcinoma in situ has developed a recurrence, while 4 patients with infiltrating breast cancer have, including 2 patients with distant metastases only, a third with a chest wall recurrence, and a fourth with an axillary recurrence. CONCLUSION A low incidence of neoplastic involvement of the nipple-areola cored tissue leads to successful completion of nipple-sparing mastectomy for most patients.

The Submental Artery Flap: An Anatomic Study

&NA; Coverage of facial defects is frequently challenging. Despite the numerous flaps described, the search for additional flaps with good color match and minimal donorsite morbidity continues. We present a flap based on the submental vessels. The anatomy based on 24 fresh cadaver dissections injected with Microfil is outlined. The submental artery is a branch of the facial artery after it exits from the submandibular gland. It runs over the mylohyoid and below the mandible. It continues either superficial or deep to the anterior belly of the digastric muscle. It supplies the skin of almost the entire triangle of the neck and a variable area across the midline. The facial artery diameter is 2.0 to 2.8 mm, and that of the submental artery is 1.0 to 1.5 mm. The facial vein provides venous drainage. From the anatomic study, the submental artery flap appears to have a long vascular pedicle and should be useful in facial and intraoral reconstructions. The size of the pedicle also makes it attractive as a free‐tissue transfer. We feel that this flap has great clinical potential. (Plast. Reconstr. Surg. 97: 56, 1996.)

Treatment of dermatofibrosarcoma protuberans with Mohs micrographic surgery.

Ten patients with dermatofibrosarcoma protuberans, all of whom had been treated previously by conventional excisional surgery without success, were treated with Mohs micrographic surgery. A team approach utilizing margin control by Mohstrained physicians and reconstruction by surgical specialists was employed. Average follow-up exceeds 3 1/2 years, with no recurrences. Microscopically controlled excision appears to be the treatment of choice for dermatofibrosarcoma protuberans.

Transposition of the greater omentum for recalcitrant median sternotomy wound infections

During a 3-year period, 25 patients underwent transposition of the greater omentum, either alone or in combination with muscle flaps, for treatment of recalcitrant median sternotomy wound infections. Most patients underwent radical sternectomy for deep and extensive sternal wounds; the others had significant defects involving the lower third of the sternum. The most common combination of flaps was omentum and bilateral pectoralis major musculocutaneous flaps (14 patients). Delay to reconstruction after the recognition of median sternotomy infection ranged from 2 to 36 days (average, 13.9 days) except for one patient treated outside by the “open method” for 18 months. Definitive closure was performed after an average of 1.8 debridements (range, 1-4). Hospitalization averaged 28.5 days (range, 13-42 days) in 16 of the 19 surviving patients. The majority of these patients had far more extensive sternal defects than those usually treated by muscle flaps alone. Healing was ultimately achieved in 95% of infected sternotomy wounds. Seventy-four percent of patients healed their sternal wounds uneventfully without subsequent problems. Flap site complications in the remaining patients included recurrent chondritis (16%) and partial (4%) or complete (4%) flap loss. Donor-site complications included abdominal wall herniation (21%), hematoma (8%), and seroma (4%). There were no problems with chest wall instability or intra-abdominal morbidity. Six patients (24%) succumbed to multisystem failure unrelated to sternal infection. We present our experience—including indications, technique, and outcome—with transposition of the greater omentum for recalcitrant median sternotomy wound infections. Pedicled omental flaps provide reliable coverage especially after radical sternectomy for deep infection, including osteomyelitis, chronic chondritis, and mediastinitis, as well as for extensive and lower third sternal wounds. To the best of our knowledge, this is the largest series of omental transposition flaps for coverage of infected sternal wounds reported in the literature.

Relationship of obesity and specimen weight to complications in reduction mammaplasty

Obesity and specimen weight have both been associated with a higher incidence of complications for patients undergoing reduction mammaplasty. However, obesity has been arbitrarily and inconsistently defined, and the degree of obesity has not been considered in these previous studies. Because insurance companies are increasingly demanding weight loss before authorizing surgery, the relationship of obesity and breast size to complications is of great importance. Upon critical review of the literature, a number of fundamental questions remain unanswered. If complications are more frequent in the obese patient, are these complications directly proportional to the degree of obesity? Also, if the patient is required to lose weight before surgery, is weight loss effective in reducing complication rates? In an attempt to clarify these issues, 395 patients who underwent reduction mammaplasty over a 10-year period were reviewed retrospectively. Patients were arbitrarily divided into five groups in which, depending on their degree of relative obesity, they were classified as less than 5 percent, 5 to 10 percent, 10 to 15 percent, 15 to 20 percent, or greater than 20 percent above average body weight. To evaluate the relationship of specimen weight to complications, patients were also arbitrarily divided into five groups according to weight of the breast reduction specimen, which was classified as less than 300 g, 300 to 600 g, 600 to 900 g, 900 to 1200 g, and greater than 1200 g reduction per breast. Complications were then divided into local and systemic and major and minor. When bilateral reductions alone were analyzed (n = 267), there was a statistically significant increase in complication rate in the obese (p = 0.01). However, when the obese population was further subdivided according to their degree of obesity (less than 5 percent, 5 to 10 percent, 10 to 15 percent, 15 to 20 percent, and greater than 20 percent above average body weight), no further correlation was found. However, the relationship between specimen weight per breast and complications was much stronger with a direct correlation existing between increasing specimen weight and the incidence of complications. Although this study has shown that patients who are average body weight have fewer complications than obese patients after breast reduction surgery, it has not shown an increasing incidence of complication with increasing degrees of obesity. The implications of these findings and their relationship for denying patients surgery on the basis of weight alone are discussed in detail.

Prospective analysis of the outcome of subpectoral breast augmentation: Sensory changes, muscle function, and body image

This study is a prospective analysis of the outcome of subpectoral breast augmentation. Forty-seven patients undergoing breast augmentation were studied. They were assessed for pectoralis muscle function, breast sensation, and body image before and after subpectoral breast augmentation with saline implants. The patients were evaluated as follows: Pectoralis function was determined by measuring maximal voluntary isometric force. Sensation was evaluated by two means: vibration and pressure. The patient’s body image was assessed using the Multidimensional Body-Self Relations Questionnaire. Results indicated a significant change in breast sensation at 3 months postoperatively but not at 6 months. Pectoralis muscle function did not significantly change during the study period. Body image was significantly improved at both postoperative measuring periods. The authors conclude that breast augmentation results in improved body image with negligible effect on muscle or nerve function.

T-cell adoptive immunotherapy of metastatic renal cell carcinoma

OBJECTIVES To determine the feasibility and toxicity of the adoptive transfer of ex vivo-activated T lymphocytes that have been sensitized to autologous tumor vaccine in vivo. METHODS Twenty patients with extensive metastatic renal cell carcinoma received systemic adoptive immunotherapy with autologous T cells in the absence of conjunctional interleukin-2 (IL-2) administration. Patients were vaccinated intradermally with irradiated autologous tumor cells and granulocyte-macrophage colony-stimulating factor as an adjuvant to stimulate an immune response. Inguinal lymph nodes draining the vaccine site were surgically removed, and the cells were stimulated with staphylococcal enterotoxin A followed by expansion in 60 IU/mL IL-2, and in some cases additionally stimulated with anti-CD3 monoclonal antibody and IL-2, to obtain a large number of cells. RESULTS The staphylococcal enterotoxin A/IL-2 activation induced vigorous proliferation of T cells (median expansion 26-fold) that were a mixture of CD4 and CD8 T lymphocytes. Activated cells were infused intravenously at doses ranging from 2x10(9) to 9.5x10(10). There was minimal toxicity consisting of grade 1 or 2 fever and nausea, and the entire treatment was delivered as outpatient therapy. One patient had a partial response, one had a mixed response, and 8 had stable disease lasting at least 5 months. CONCLUSIONS Adoptive transfer of ex vivo-activated, tumor vaccine-primed lymph node cells is feasible and is associated with minimal toxicity when used alone. These results warrant further study in a Phase II trial.

The acute effects of postoperative radiation therapy on the transverse rectus abdominis myocutaneous flap used in immediate breast reconstruction

PURPOSE To analyze the acute effects of postoperative radiation therapy on the transverse rectus abdominis myocutaneous (TRAM) flap reconstruction following modified radical mastectomy for breast cancer. METHODS AND MATERIALS Twenty-five consecutive patients were treated with postoperative radiation therapy after TRAM flap reconstruction between 1985 and 1999. The radiation records for these patients were retrospectively reviewed. Information regarding treatment techniques, timing, and dose was obtained and correlated with the extent of erythema, desquamation, and the need for treatment break. RESULTS The median age was 48 years. The median dose of chest wall radiation was 5040 cGy. Additional boost doses were delivered in 13 patients. Twelve patients (48%) developed mild erythema in the treatment field during the course of treatment and 13 patients (52%) developed moderate (40%) or brisk (12%) erythema. Only 10 patients (40%) developed any kind of desquamation; 5 patients (20%) developed dry desquamation and another 5 patients (20%) developed moist desquamation. No patients required a break in the course of treatment because of acute side effects. None of the parameters evaluated (the use of chemotherapy prior to radiation, the interval between surgery and radiation, smoking, prior incidence of fat necrosis, the use of bolus during radiation, and the use of a boost) were predictive of an increased incidence of either the extent of erythema or the development of desquamation in the treatment field. CONCLUSION Postmastectomy radiation for TRAM flap reconstruction is well tolerated and is not associated with an increased incidence of acute side effects. Radiation technique and the use of preradiation chemotherapy do not appear to be correlated with an increased incidence of acute side effects.

The AO system for primary mandibular reconstruction

We reviewed the records of 27 patients who underwent primary mandibular reconstruction with AO plates to investigate the outcome and complications of this procedure. Immediate soft-tissue flap coverage was required in 26 patients. Early complications were seen in 44% of the patients, with the highest incidence after irradiation (P = 0.02). Late complications were mostly related to tumor recurrence (12). Late complications not associated with recurrence were persistent pain (2), minor infections (3), plate exposure (3), and plate fracture (1). Good to excellent cosmetic results were obtained in all but 1 patient. Full mastication was not possible for any of our patients, and therefore function was not fully restored. Speech and deglutition were mostly influenced by the amount of soft-tissue resection. Mean follow-up was 20 months (range 3 to 52). At last evaluation, 12 patients were alive and free of disease, and 15 were dead of disease or other causes. Our results show that primary mandibular reconstruction with rigid plates is a safe, effective, and reliable technique to restore mandibular continuity and cosmesis. For lateral defects, this method is a viable alternative to free vascularized osseocutaneous flaps.