Stefan O.P. Hofer

Patient satisfaction and health-related quality of life after autologous tissue breast reconstruction: a prospective analysis of early postoperative outcomes.

For this study, the authors evaluated early psychosocial adjustments and health‐related quality‐of‐life changes after breast reconstruction.

A Critical Review of Perioperative Complications in 175 Free Deep Inferior Epigastric Perforator Flap Breast Reconstructions

Background: The purpose of this study was to critically evaluate the perioperative complications for deep inferior epigastric perforator (DIEP) flap breast reconstruction. Methods: From February 2002 until February 2006, 175 consecutive abdominal free tissue breast reconstructions were performed in 131 patients. Perioperative risk factors and complications were evaluated for the entire group. Data analysis was performed to compare subsequent chronologic groups for a learning curve effect. Results: In 159 cases (90.9%) a DIEP flap could be raised. In 13 cases (7.4%), a mini-TRAM flap and in 3 cases (1.7%) a regular free TRAM flap was harvested. A learning curve was found showing a risk for flap complications in the first 30 DIEP flaps of 40% and in flaps 31 to 175 of 13.8% (P < 0.012). Microsurgical revision rate was 4% (n = 7), with a total flap failure rate of 0.6% (n = 1). Partial flap failure rate was 8.6% (n = 15), which was solved by debridement, medial advancement, and direct closure in 6.8% (n = 12) and latissimus dorsi flap transposition in 1.8% (n = 3). Multivariate analysis showed no significant influence of risk factors on development of postoperative flap complications. Conclusion: DIEP flap breast reconstruction is an excellent method, with limited donor-site morbidity. A definite learning curve was reflected in a larger number of flap complications in the beginning of our series.

High satisfaction rates in women after DIEP flap breast reconstruction.

BACKGROUND Breast reconstruction (BR) is aimed at improving quality of life (QoL) after mastectomy. Patient satisfaction is an important indicator to evaluate the success of BR. This study explored patient satisfaction and its determinants in women undergoing deep inferior epigastric artery perforator (DIEP) flap BR as well as the impact of the procedure on body image, sexuality and QoL. METHODS Patient satisfaction and QoL were studied in 72 women who underwent DIEP flap BR using a study-specific questionnaire as well as the Short Form-36 (SF-36). RESULTS Patient satisfaction was very high. Approximately 90% of the patients reported that they had been sufficiently informed about the procedure and its consequences, that their preoperative expectations had been met, that the reconstructed breast felt like their own and that they would choose the same procedure again and would recommend this procedure to a friend. Patient satisfaction was positively and significantly related to the reconstructed breast(s) feeling like their own. Women with secondary reconstructions were more positive about changes in sexuality and femininity than women with primary BRs. There were no clinically relevant differences in QoL between our study population and a random sample of Dutch females. CONCLUSIONS Women with DIEP flap BRs reported high satisfaction rates. However, to compare these satisfaction rates with other forms of BR, prospective studies in comparable groups are necessary.

Aesthetic and functional outcome following nasal reconstruction

Background: Few reports on outcome of aesthetic nasal reconstruction exist. Therefore, subjective and objective aesthetic and functional outcome following nasal reconstruction was assessed. Methods: Outcome was assessed in 38 consecutive patients treated for subtotal nasal defects using standardized semistructured interviews. Standardized physical examination forms and photographs were used. Results: In six patients, one aesthetic subunit was involved; in 14, two; and in 18, three or more. Defects were classified as skin only (13 percent), skin/cartilage (21 percent), and full thickness (66 percent). Some defects (32 percent) involved adjacent aesthetic units. Inner lining was reconstructed with local mucosa or turnover skin flaps. Support was provided with regional cartilage grafts and/or composite septal flaps. Skin defects were reconstructed with forehead, nasolabial, cheek advancement, Abbé, facial artery perforator, or free radial forearm flaps. Nasal reconstructions required 116 procedures. Thirty-three patients participated in the follow-up study. Mucosal crusting was noted in 36 percent, passage difficulties in 31 percent, and worse olfaction in 16 percent. Phonation was unchanged. Eighty-one percent were very satisfied with nasal function. Flap color match was moderate to good in 97 percent; hair growth occurred in 61 percent. At critical inspection, a thicker flap (58 percent), smaller ostium nasi (77 percent), thicker alar rim (86 percent), and minor alar rim retraction (46 percent) were noted. Seventy-nine percent were very satisfied with total nasal appearance. Conclusion: Although objective functional and aesthetic outcome following nasal reconstruction sometimes shows impairment compared with the normal situation, it gives high subjective patient satisfaction with function and aesthetics.

Acellular dermal matrices in abdominal wall reconstruction: a systematic review of the current evidence.

Background: Reconstruction of the anterior abdominal wall is a complex procedure that can be complicated by contamination, loss of domain, previous scarring or radiotherapy, and reduced availability of local tissues. With the introduction of acellular dermal matrices to clinical use, it was hoped that many of the problems associated with previous synthetic materials could be overcome. With their enhanced biocompatibility, acellular dermal matrices are believed to integrate with surrounding tissues while demonstrating resistance to infection, extrusion, erosion, and adhesion formation. Methods: The MEDLINE database was reviewed, including all publications as of December 31, 2011, using the search terms “dermal matrix” or “human dermis” or “porcine dermis” or “bovine dermis,” applying the limits “human” and “English language.” Prospective and retrospective clinical articles were identified. Results: A total of 40 eligible articles were identified and included in this review. Thirty-five of the studies were level IV; the remaining studies were level III. Acellular dermal matrix was used to reconstruct the abdominal wall in a wide range of clinical settings, including trauma, tumor resection, sepsis, and hernia repairs. The operative methods varied widely among clinical studies. While the heterogeneity of the patient populations and techniques limited interpretation of the data, concerns were identified regarding high rates of hernia recurrence with acellular dermal matrix use. Conclusion: High-quality data derived from level I, II, and III studies are necessary to determine the indications for acellular dermal matrix use and the optimal surgical techniques to maximize outcomes in abdominal wall reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Prevascular Structures Promote Vascularization in Engineered Human Adipose Tissue Constructs upon Implantation

Vascularization is still one of the most important limitations for the survival of engineered tissues after implantation. In this study, we aim to improve the in vivo vascularization of engineered adipose tissue by preforming vascular structures within in vitro-engineered adipose tissue constructs that can integrate with the host vascular system upon implantation. Different cell culture media were tested and different amounts of human adipose tissue-derived mesenchymal stromal cells (ASC) and human umbilical vein endothelial cells (HUVEC) were combined in spheroid cocultures to obtain optimal conditions for the generation of prevascularized adipose tissue constructs. Immunohistochemistry revealed that prevascular structures were formed in the constructs only when 20% ASC and 80% HUVEC were combined and cultured in a 1:1 mixture of endothelial cell medium and adipogenic medium. Moreover, the ASC in these constructs accumulated lipid and expressed the adipocyte-specific gene fatty acid binding protein-4. Implantation of prevascularized ASC/HUVEC constructs in nude mice resulted in a significantly higher amount of vessels (37 ± 17 vessels/mm2) within the constructs compared to non-prevascularized constructs composed only of ASC (3 ± 4 vessels/mm2). Moreover, a subset of the preformed human vascular structures (3.6 ± 4.2 structures/mm2) anastomosed with the mouse vasculature as indicated by the presence of intravascular red blood cells. Our results indicate that preformed vascular structures within in vitro-engineered adipose tissue constructs can integrate with the host vascular system and improve the vascularization upon implantation.

Impact of vasopressors on outcomes in head and neck free tissue transfer

Objectives/Hypothesis: The primary objective of the study was to determine the frequency of intraoperative vasopressor administration among patients undergoing free tissue transfer for head and neck reconstruction, and the secondary objective was to determine the impact of intraoperative vasopressor on free tissue transfer outcomes, including the impact of cumulative vasopressor dose and timing of intraoperative vasopressor administration. Study design/Methods: A retrospective review was performed of all patients undergoing free tissue transfer for head and neck reconstruction at the University Health Network between 2004 to 2008. Results: From 2004 to 2008 inclusive, 485 patients underwent 496 free tissue transfers for head and neck reconstruction. The complete failure rate was 2.2% (11 of 485 patients). The partial failure rate was 1.4%, and the operative take‐back rate for venous congestion or arterial thrombosis was 1.6%. This gave a total major flap complication rate of 5.2%, which was used as the primary free tissue transfer outcome measure. Of the 485 patients who underwent free tissue transfer, 320 (66.0%) received intraoperative vasopressor. Of these patients, the majority (97.5%) received phenylephrine and/or ephedrine. There was no significant relationship between receiving intraoperative vasopressor and major free flap complications, which were defined as complete failure, partial failure, or operative take‐back for venous congestion or arterial thrombosis. Conclusion: Intraoperative vasopressors are used routinely in free tissue transfer for the reconstruction of head and neck defects. The use of intraoperative vasopressors does not appear to adversely affect free tissue transfer outcomes.

Angiogenic capacity of human adipose-derived stromal cells during adipogenic differentiation: an in vitro study.

BACKGROUND Improving vascularization of engineered adipose tissue constructs is a major challenge in the field of plastic surgery. Although human adipose-derived stromal cells (hASCs) are known to release factors that stimulate new blood vessel formation, detailed information about the effects of adipogenic differentiation on the angiogenic potential of hASCs remains largely unknown. In the present study, we studied the expression and secretion of a large panel of angiogenic factors during hASC differentiation and evaluated the effects of hASC-conditioned medium (hASC-CM) on endothelial cells. METHODS hASCs were cultured on adipogenic medium or basal medium. Conditioned medium was collected, and cells were harvested following 0, 3, 7, 14, and 22 days of culture. The stage of adipogenic differentiation of hASC was assessed using Oil Red O staining, fatty acid binding protein-4 gene expression, and glycerol-3-phosphate dehydrogenase activity. RESULTS Gene expression of vascular endothelial growth factor (VEGF), placental growth factor, angiopoietin-1 (ANGPT1), angiopoietin-2 (ANGPT2), and protein secretion of VEGF significantly increased during short-term adipogenic differentiation of hASCs. Moreover, conditioned medium from differentiated hASCs strongly enhanced endothelial cell numbers compared to conditioned medium from undifferentiated hASCs. CONCLUSION In vitro adipogenic differentiation of hASCs improves their ability to support endothelial viable cell numbers and suggests that hASCs differentiated for a short period potentially improve angiogenic responses for in vivo implantation.

Closure of the donor site of the free radial forearm flap: a comparison of full-thickness graft and split-thickness skin graft.

Introduction:Donor-site complications of free radial forearm flaps (FRFF) after closure with a split-thickness skin graft (STSG) have been reported repeatedly. Different types of closure of the donor site have been advocated to reduce donor-site complications. In our practice, a V-Y closure with a local full-thickness skin graft (FTG) is performed generally. Purpose:A retrospective follow-up study was performed comparing subjective and objective outcomes of FTG versus STSG closure. FRFF donor site closure in 34 head and neck cancer patients (15 STSG, 19 FTG) was studied. Results:Both methods of closure showed good function, sensibility, and esthetic outcome. No statistical differences between the 2 methods could be shown. Conclusion:V-Y local donor site closure is a good technique which prevents an additional donor site scar and discomfort when performing an STSG closure.

Functional and aesthetic outcome and survival after double free flap reconstruction in advanced head and neck cancer patients

Background: Extensive composite defects in the head and neck area may require the use of double free flap reconstructions. These reconstructions are not only surgically challenging but also challenging to patients. A realistic perspective on general outcome for the patient seems important. Methods: From January of 2002 to August of 2003, double free flap reconstructions were used in 12 patients with extensive composite head and neck defects following malignant tumor (n = 7) and osteoradionecrosis (n = 5) resection. Six patients had a standardized interview, physical examination, and clinical photographs. Results: All reconstructions were performed using an osteocutaneous fibula flap in combination with an anterolateral thigh flap (n = 8), a radial forearm flap (n = 1), or a lateral thigh flap (n = 1). The total flap survival rate was 96 percent. Mean mandibular bone defects were 10 cm. Mean skin island sizes of osteocutaneous fibula flaps were 67 cm2. Mean external skin reconstruction flap sizes were 117 cm2. Mean overall survival time was 20 months in patients with malignant tumors. Patients with osteoradionecrosis reconstruction survived free of disease for an average period of 38 months. Three patients (50 percent) were very satisfied, one was neutral, and two were very dissatisfied with their functional and aesthetic results. Objective evaluation of function showed mainly deteriorated speech (83 percent) and oral incontinence (67 percent). Objective evaluation of aesthetics showed mainly color mismatch (67 percent) and flap contracture of external flaps (50 percent). Conclusions: Reconstruction of these major composite through-and-through defects will often result in a modest functional and aesthetic outcome. Because selected patients require these procedures, the authors give information that matches with realistic expectations.