William Samson

The use of magnetic resonance angiography in vascularized groin lymph node transfer: an anatomic study.

Vascularized groin lymph node transfer (VGLNT) has been successfully used to treat lymphedema. However, lack of familiarity with the inguinal node anatomy and concerns regarding donor site morbidity have limited its widespread use. The purpose of this study was to use magnetic resonance angiography (MRA) to clarify the inguinal anatomy and provide a reliable method for identifying the location of the superficial transverse inguinal lymph nodes. In this study MRA was used to evaluate the superficial inguinal lymph nodes in 117 patients. Coordinates of lymph nodes were plotted relative to an axis from the anterior superior iliac spine (ASIS) to the pubic tubercle (PT). The nodes were also plotted relative to the superficial circumflex iliac vein (SCIV) and superficial inferior epigastric vein (SIEV). A total of 1,938 lymph nodes were identified. These lymph nodes were concentrated on one-third the distance from the PT toward the ASIS and 3 cm perpendicularly below this line. About 67% of the superficial inguinal nodes were located within the bifurcation of the SIEV and SCIV. The results from this study provide useful guidelines for locating lymph nodes targeted for VGLNT.

Comparison of irradiated versus nonirradiated DIEP flaps in patients undergoing immediate bilateral DIEP reconstruction with unilateral postmastectomy radiation therapy (PMRT).

IntroductionPatients with node positive or locally advanced breast cancer desiring deep inferior epigastric perforator (DIEP) flap reconstruction frequently require postmastectomy radiation therapy (PMRT). To avoid the deleterious effects of PMRT, surgeons will often delay reconstruction until after PMRT is complete. Drawbacks to this approach include additional surgery, recuperation, cost, and an extended reconstructive process. Even if a tissue expander is used to preserve the skin envelope during irradiation, the post-PMRT breast pocket is often distorted or constricted necessitating some skin replacement, resulting in a compromised aesthetic outcome. Therefore, a systematic approach to mitigate the deleterious effects of PMRT was developed, and primary DIEP flap reconstruction was offered to patients requiring PMRT. This study evaluates the outcome of this approach in a cohort of patients undergoing immediate bilateral DIEP flap reconstruction with unilateral PMRT, allowing comparison between irradiated and nonirradiated flaps. MethodsOne hundred twenty-five patients who underwent immediate DIEP reconstruction between 2009 and 2011 were identified. Eleven consecutive patients had bilateral DIEP reconstructions by a single surgeon and received unilateral PMRT. Preoperative, intraoperative, and postoperative steps were taken in all patients to ensure flap vascularity, prevent uncontrolled contracture, and limit radiation damage to the breast mound. Results were documented photographically and the irradiated and nonirradiated breasts were compared. The complication rates, incidence of clinically significant fat necrosis, and need for reoperation were examined. ResultsMedian follow-up was 18 months (range, 8–21 months). Complications were minor and did not require readmission to the hospital or reoperation. There was no incidence of clinically significant fat necrosis in either the irradiated or nonirradiated DIEP flaps. Four operative revisions for breast symmetry were required in 3 of 11 patients. Aesthetic outcomes were deemed satisfactory in all patients. ConclusionsPrimary reconstruction with DIEP flaps can be performed successfully in patients who require PMRT if steps are taken to ensure flap vascularity, minimize fibrosis, optimize contour, and modulate radiation dosing.

Factors influencing incidence and type of postmastectomy breast reconstruction in an urban multidisciplinary cancer center.

Background: On January 1, 2011, New York State amended the Public Health Law to ensure that patients receive “information and access to breast reconstruction surgery.” The purposes of this study were to investigate the early impact of this legislation on reconstruction rates and to evaluate the influence of patient variables versus physician variables on the incidence and type of breast reconstruction performed. Methods: A retrospective study was conducted on all patients who underwent mastectomy between January 1, 2010, and December 31, 2011. Reconstruction rates were analyzed in relation to timing of legislation, breast surgeon variables, plastic surgeon faculty status, type of reconstruction, and patient variables. Results: Two hundred fifty-eight patients met inclusion criteria. The overall reconstruction rate was 56.59 percent. There was no statistically significant increase in reconstruction rate after the 2011 legislation (OR, 0.45; p = 0.057). Patients whose breast surgeon was female were more likely to undergo reconstruction (OR, 5.17; p = 0.001). Patients who were Asian (OR, 0.22; p = 0.002), older than 60 years (OR, 0.09; p = 0.001), or had stage 3 and 4 cancer (OR, 0.04; p = 0.03) were less likely to undergo reconstruction. Patients reconstructed by a hospital-employed plastic surgeon were significantly more likely to undergo autologous versus implant reconstruction (OR, 6.85; p = 0.001) and to undergo microsurgical versus nonmicrosurgical autologous reconstruction (78.2 percent versus 0 percent; p = 0.001). Conclusions: Breast surgeon sex and plastic surgeon faculty status were the factors that most affected the rate and type of reconstruction, respectively. Legislation mandating the discussion of breast reconstruction options had no impact on reconstruction rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Modern Perforator Flap Imaging with High-Resolution Blood Pool MR Angiography

Advances in microsurgical techniques have improved autologous reconstructions by providing new donor site options while decreasing donor site morbidity. Various preoperative imaging modalities have been studied to assess the relevant vascular anatomic structures, with magnetic resonance (MR) angiography traditionally lagging behind computed tomography (CT) with respect to spatial resolution. Blood pool MR angiography with gadofosveset trisodium, a gadolinium-based contrast agent with extended intravascular retention, has allowed longer multiplanar acquisitions with resultant voxel sizes similar to or smaller than those of CT and with improved signal-to-noise ratio and soft-tissue contrast while maintaining the ability to depict flow with time-resolved imaging. The resultant vascular detail enables precise evaluation of the relevant vascular anatomic structures, including the vessel course, size, and branching pattern, as well as the venous arborization pattern. In addition, any architectural distortion, vessel alteration, or injury from prior surgery can be depicted. The reporting radiologist should be aware of pertinent and incidental findings relevant to the planned surgery and the patients disease so that he or she can assist the microsurgeon in flap design as a member of the multidisciplinary team. Given the lack of ionizing radiation exposure in patients who often have an elevated body mass index, high-spatial-resolution blood pool MR angiography has become the imaging reference standard for the preoperative assessment of perforator flap vascular and soft-tissue morphology in our practice.

Revision of Wise pattern breast reductions with vertical procedures.

AbstractA small percentage of patients who undergo Wise pattern mammaplasties request revisions to address recurrent macromastia or poor breast shape. Reuse of the Wise pattern method at times results in disappointing aesthetic results. Recently, in a series of 15 consecutive patients, we used vertical techniques with glandular reshaping to perform these revisions. Advantages include the ability to significantly improve breast shape and to avoid reopening of potentially problematic inframammary scars. No major complications occurred. Patients have been uniformly pleased with the significant improvement in their breast contour, width, and size. In summary, despite the use of the Wise pattern method for the original procedure, consideration should be given to use vertical techniques for revisions in that they are safe and can better address patient goals. Gratifying results can be achieved.

Transversus Abdominis Plane Blocks with Single-dose Liposomal Bupivacaine in Conjunction with a Nonnarcotic Pain Regimen Help Reduce Length of Stay following Abdominally Based Microsurgical Breast Reconstruction

Background: Side effects associated with use of postoperative narcotics for pain control can delay recovery after abdominally based microsurgical breast reconstruction. The authors evaluated a nonnarcotic pain control regimen in conjunction with bilateral transversus abdominis plane blocks on facilitating early hospital discharge. Methods: A retrospective analysis was performed of consecutive patients who underwent breast reconstruction using abdominally based free flaps, with or without being included in a nonnarcotic protocol using intraoperative transversus abdominis plane blockade. During this period, the use of locoregional analgesia evolved from none (control), to continuous bupivacaine infusion transversus abdominis plane and catheters, to single-dose transversus abdominis plane blockade with liposomal bupivacaine solution. Demographic factors, length of stay, inpatient opioid consumption, and complications were reported for all three groups. Results: One hundred twenty-eight consecutive patients (182 flaps) were identified. Forty patients (62 flaps) were in the infusion–liposomal bupivacaine group, 48 (66 flaps) were in the single-dose blockade–catheter group, and 40 (54 flaps) were in the control group. The infusion–liposomal bupivacaine patients had a significantly shorter hospital stay compared with the single-dose blockade–catheter group (2.65 ± 0.66 versus 3.52 ± 0.92 days; p < 0.0001) and the control group (2.65 ± 0.66 versus 4.05 ± 1.26 days; p < 0.0001). There was no significant difference in flap loss or major complications among groups. Conclusions: When used as part of a nonnarcotic postoperative pain regimen, transversus abdominis plane blocks performed with single injections of liposomal bupivacaine help facilitate early hospital discharge after abdominally based microsurgical breast reconstruction. A trend toward consistent discharge by postoperative day 2 was seen. This could result in significant cost savings for health care systems. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Bilateral breast reconstruction from a single hemiabdomen using angiosome-based flap design.

Summary: Performing bilateral autologous breast reconstruction using the abdominal donor site usually entails harvesting one flap from each hemiabdomen. However, the overlapping vascular territories of the superior epigastric, deep inferior epigastric, superficial inferior epigastric, and superficial circumflex iliac vessels make it theoretically possible to harvest two flaps based on vessels from one hemiabdomen. This may be useful in the obese patient, where one hemiabdomen may provide adequate tissue to reconstruct two breasts. The authors describe three clinical scenarios where they have used this principle, including the first reports in the literature of metachronous and synchronous bilateral breast reconstructions using two flaps based on pedicles from a single hemiabdomen. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Abstract: Transversus Abdominis Plane (TAP) Blocks with Single-Dose Liposomal Bupivacaine Reduce Length of Stay Following Abdominally-Based Microsurgical Breast Reconstruction

INTRODUCTION: Microsurgical abdominally-based breast reconstruction (MABR) typically entails an inpatient length of stay between three to five days. However, most payors reimburse for only the first two hospital days after routine mastectomy regardless of the breast reconstruction method. Moreover, free flap take-back and salvage rates both drop drastically after 48 hours resulting in rapidly rising incremental hospital costs for flap monitoring beyond the second post-operative day. In this study, we examined the effect of bilateral single-dose TAP nerve blockade using long-acting liposomal bupivacaine (BTBLB) on length of stay after MABR to see if it facilitated safe discharge by post-operative day two.

Performing Vascularized Groin Lymph Node Transfer with Confidence: The Use of Four Anatomic and Physiologic Modalities for Safe and Effective Flap Harvest

INTRODUCTION: Vascularized groin lymph node transfer (VGLNT) involves transfer of superfi cial inguinal lymph nodes supplied by the superfi cial circumfl ex iliac artery (SCIA) to the affected extremity. While VGLNT has been successfully used to treat lymphedema, lack of familiarity with the anatomy and concern regarding donor site lymphedema have limited its widespread use. The purpose of this study was to demonstrate the use of four separate modalities to localize the lymph nodes draining the abdomen and avoid lymph nodes draining the lower extremity.

Combined Nerve to Masseter and Mini-Hypoglossal Nerve Transfers in the Oncologic Patient with Proximal Facial Nerve Sacrifice: Maximizing Reliability and Minimizing Synkinesis in the Primary Setting

INTRODUCTION: Proximal facial nerve sacrifi ce during tumor extirpation poses a challenge in restoring dynamic facial expression. Primary nerve grafting is an option, but nerve grafts may require a long time to reinnervation with the likelihood of signifi cant synkinesis and variable outcomes. Additionally, a proximal facial nerve stump may not be available in advanced cases. In the oncologic setting where life expectancy may be limited, rapid and reliable dynamic reconstruction is ideal. This study describes a new approach using combined nerve to masseter and mini-hypoglossal nerve transfers to the separate distal facial nerve target branches in order to achieve rapid reanimation while minimizing synkinesis.