Reduction and Mastopexy of the Reconstructed Breast: Special Considerations in Free Flap Reconstruction.
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ABSTRACT:
SUBMITTER: Zafar SN
PROVIDER: S-EPMC4621390 | biostudies-other | 2015 May
REPOSITORIES: biostudies-other
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Project description:Breast reconstruction using contralateral autologous tissue, also known as breast sharing, is a viable option previously described in the literature, whereby flaps based on perforators of the internal mammary artery (internal mammary artery pedicle) are used. We report a postoncological breast reconstruction case using a microvascular flap taken from the lateral pole of the contralateral breast. We highlight the importance of preserving the medial pole of the donor breast for improving cosmesis, avoiding symmastia, and preserving the intermammary sulcus, as a difference with flaps based on the internal mammary artery pedicle flaps. Breast sensation could be recovered by neurotization of the lateral intercostal nerve, which may be included in the contralateral breast flap to be transferred. Contralateral breast free flaps could be an alternative to reconstruct the breast in selected patients. Oncological risk factors are discussed. Advances in genetic testing and tumor cell biology could help us to select the accurate candidates for this reconstructive technique.
| S-EPMC7253292 | biostudies-literature
Project description:Importance:Cost variation among hospitals has been demonstrated for surgical procedures. Uncovering these differences has helped guide measures taken to reduce health care spending. To date, the fiscal consequence of hospital variation for autologous free flap breast reconstruction is unknown. Objective:To investigate factors that influence cost variation for autologous free flap breast reconstruction. Design, Setting, and Participants:A secondary cross-sectional analysis was performed using the Healthcare Cost and Utilization Project National Inpatient Sample database from 2008 to 2010. The dates of analysis were September 2016 to February 2017. The setting was a stratified sample of all US community hospitals. Participants were female patients who were diagnosed as having breast cancer or were at high risk for breast cancer and underwent autologous free flap breast reconstruction. Main Outcomes and Measures:Variables of interest included demographic data, hospital characteristics, length of stay, complications (surgical and systemic), and inpatient cost. The study used univariate and generalized linear mixed models to examine associations between patient and hospital characteristics and cost. Results:A total of 3302 patients were included in the study, with a median age of 50 years (interquartile range, 44-57 years). The mean cost for autologous free flap breast reconstruction was $22?677 (interquartile range, $14?907-$33?391). Flap reconstructions performed at high-volume hospitals were significantly more costly than those performed at low-volume hospitals ($24?360 vs $18?918, P?<?.001). Logistic regression demonstrated that hospital volume correlated with increased cost (Exp[?], 1.06; 95% CI, 1.02-1.11; P?=?.003). Fewer surgical complications (16.4% [169 of 1029] vs 23.7% [278 of 1174], P?<?.001) and systemic complications (24.2% [249 of 1029] vs 31.2% [366 of 1174], P?<?.001) were experienced in high-volume hospitals compared with low-volume hospitals. Flap procedures performed in the West were the most expensive ($28?289), with a greater odds of increased expenditure (Exp[?], 1.53; 95% CI, 1.46-1.61; P?<?.001) compared with the Northeast. A significant difference in length of stay was found between the West and Northeast (odds ratio, 1.25; 95% CI, 1.17-1.33). Conclusions and Relevance:There is significant cost variation among patients undergoing autologous free flap breast reconstruction. Experience, as measured by a hospital's volume, provides quality health care with fewer complications but is more costly. Longer length of stay contributed to regional cost variation and may be a target for decreasing expenditure, without compromising care. In the era of bundled health care payment, strategies should be implemented to eliminate cost variation to condense spending while still providing quality care.
| S-EPMC5710414 | biostudies-literature
Project description:Background:Wound healing problems at the donor site in free abdominal flap breast reconstruction cause significant morbidity to patients. No studies have investigated what impact the use of the internal mammary artery in free abdominal flap breast reconstruction has on abdominal skin perfusion. We hypothesized that harvesting the internal mammary vessels (IMV) has a negative effect on abdominal skin perfusion. Methods:The abdomen and anterior thoracic wall of 17 patients scheduled for secondary free abdominal flap breast reconstruction using IMV was pre-, intra-, and postoperatively examined with dynamic infrared thermography. Qualitative and quantitative analyses of the rate and pattern of recovery in Huger's vascular zones were made with each patient being its own control. Zone III on the side where IMV were used was numbered zone IV. The contralateral zone III was used as reference. Results:Postoperative abdominal skin perfusion in zone IV was always significantly reduced compared with zone III (1-tailed t test, P < 0.05). The difference between zones II and III was statistically significant for day 1 and 3, but not for day 6 (2-tailed t test, P < 0.05). Skin perfusion in zones II and IV increased during consecutive postoperative days with an increase of hot spots in these areas. Conclusions:Using the IMV in free abdominal flap breast reconstruction had a significant effect on abdominal skin perfusion and may contribute to abdominal wound healing problems. The reperfusion of the abdominal skin was a dynamic process showing an increase in perfusion in the affected areas during the postoperative days.
| S-EPMC5889442 | biostudies-literature
Project description:BackgroundHospital volume has been correlated with improved outcomes in oncologic care and complex surgical procedures. The authors sought to determine the relationship between overall annual hospital volume and perioperative outcomes following free flap breast reconstruction.MethodsFree flap breast reconstruction patients (n = 7991) were identified at 1907 centers using the Healthcare Cost and Utilization Project National Inpatient Sample database. Logistic regression characterized the association of hospital volume (total discharges per year) with systemic, surgical, and microsurgical complications. Patients were categorized as being treated at low- versus high-volume hospitals based on identified threshold volumes, and the association with the incidence of complications was estimated.ResultsInitially, restricted cubic spline analysis suggested potential threshold volumes of 13,018 (95 percent CI, 7468 to 14,512) and 7091 (95 percent CI, 5396 to 9918) discharges per year, at which the risk for developing systemic and microsurgical complications may change, respectively. However, further patient-level evaluation of treatment at low- versus high-volume hospitals demonstrated that hospital volume did not predict the risk of developing perioperative systemic (OR, 1.28; 95 percent CI, 0.75 to 2.18; p = 0.36) or microsurgical complications (OR, 1.06; 95 percent CI, 0.78 to 1.44; p = 0.73).ConclusionsPerioperative complications after free flap breast reconstruction did not differ between patients treated at low- versus high-volume hospitals after in-depth multiprong analysis. Patient outcomes are more likely associated with surgeon and programmatic experience. Overall annual hospital volume should not serve as a proxy for high-quality breast free flap care. .Clinical question/level of evidenceRisk, III.
| S-EPMC7876366 | biostudies-literature
Project description:IntroductionHistorically, there were concerns vasopressors impair free flap outcomes, but recent studies suggest vasopressors are safe. Here we investigate this controversy by (1) evaluating vasopressors' effect on head and neck free-flap survival and surgical complications, and (2) performing soft tissue and bony subset analysis.Patients and methodsPost hoc analysis was performed of a single-blinded, prospective, randomized clinical trial at a tertiary care academic medical center involving patients ≥18 years old undergoing head and neck free flap reconstruction over a 16-month period. Patients were excluded if factors prevented accurate FloTrac™ use. Patients were randomized to traditional volume-based support, or goal-directed support including vasopressor use. Primary data was obtained by study personnel through intraoperative data recording and postoperative medical record review.ResultsForty-one and 38 patients were randomized to traditional and pressor-based algorithms, respectively. Flap survival was 95% (75/79). There was no significant difference between the pressor-based and traditional protocols' flap failure (1/38 [3%] vs. 3/41 [7%], RR 0.36, 95% CI of RR 0.04-3.31, p = .63) or flap-related complications (12/38 [32%] vs. 18/41 [44%], RR 0.72, 95% CI 0.40-1.29, p = .36) Soft tissue flaps had surgical complication rates of 12/30 (40%) and 9/27 (33%) for traditional and pressor-based protocols, respectively. Bony flaps had surgical complication rates of 6/11 (55%), and 3/11 (27%) for traditional and pressor-based protocols, respectively.ConclusionsIntraoperative goal-directed vasopressor administration during head and neck free flap reconstruction does not appear to increase the rate of flap complications or failures.
| S-EPMC8396078 | biostudies-literature
Project description:Dental rehabilitation with osseointegrated implants in reconstructed mandibles is a common procedure, but the technique still requires improvement, especially in its reliability and technical simplification. We herein report dental rehabilitation of a free fibula-reconstructed mandible with scar contracture. A vestibuloplasty technique with application of a polyglycolic acid (PGA) sheet is described. The implants were inserted into a viable fibula flap with severe scar contracture of the overlying epithelium resulting from vascular instability in skin paddle. Only the fibula periosteum was sutured after implant insertion; exposed surfaces were covered with a combination of PGA sheet and fibrin sealant. The area with PGA sheet coverage gradually healed with moderate contracture. The epithelium around the almost implants became immobilized. The implant-supported removable partial denture with custom titanium bar was acceptable. Dental rehabilitation is possible for reconstructed mandibles with severe scar contracture. Application of a PGA sheet may be useful for vestibuloplasty in patients with reconstructed mandibles.
| S-EPMC6784466 | biostudies-literature
Project description:BackgroundExtensive through-and-through oromandibular defects after advanced oral carcinoma excision pose a reconstructive challenge for the head and neck surgeon. These complex oromandibular wounds often involve the mandible, oral and/or aerodigestive mucosa, and the external skin. As a result, these defects are often not amenable to reconstruction with a single flap due to the volume of soft tissue needed and the three-dimensional reconstructive requirement. The use of two free flaps has often been suggested to overcome this reconstructive challenge. A simpler and less technically demanding way to deal with this may involve the use of a free flap in combination with a pedicled regional flap. We present our experience of the use of a simultaneous microvascular fibula free flap (FFF) with a pectoralis major myocutaneous flap (PMMC) for addressing these defects.MethodsA retrospective chart review was performed of patients treated with a FFF and PMMC combination for the reconstruction of oromandibular defects at the University of Mississippi Medical Center (Jackson, MS) between October 2013 and February 2016. A minimum follow-up of 12 months was required. Data collected included the extent and location of tumor involvement, size of the postablative defect, tumor histology, clinical and pathological staging, length of follow-up, functional outcomes, and associated complications.ResultsA total of three patients were identified to have been treated with the above technique. Defects repaired involved through-and-through mandibular defects with associated oral mucosa and external skin defects. In all cases, the FFF was used for restoring bony continuity with the skin paddle used to reconstruct the intraoral lining. The PMMC was used for reconstruction of the external skin defect and for providing soft tissue bulk. The average size of the fibula skin paddle used for intraoral reconstruction was 7.7 cm × 11.7 cm. The average size of the PMMC paddle was 7.3 × 9 cm. The mean follow-up was 21.7 months. Both the FFF and PMMC survived in all cases, although postoperative wound healing complications occurred in two of the three patients. There was one partial flap loss. Two patients regained good oral intake while one patient tolerated oral intake but was PEG tube-dependent.ConclusionsThe combination of pectoralis major myocutaneous flap and a vascularized free fibular flap is a viable option for the reconstruction of complex through-and-through oromandibular defects. This technique may be useful when a single microvascular free flap is not sufficient for reconstruction of such defects.
| S-EPMC6458920 | biostudies-literature
Project description:This article portrays the authors' clinical experience of a complex case of lower extremity reconstruction using a recycled pedicle from 10 years old free latissimus dorsi musculocutaneous flap to supply a new free anterolateral thigh flap for proximal tibia wound defect reconstruction. It provides clinical evidence that muscle neovascularization occurs and supports the dogma peripheral tissue neovascularization. This case stipulates that recycling of pedicle is feasible, when used with appropriate strategy and safety and also provides evidence for the long-term survival of greater saphenous vein grafts in lower extremity reconstruction.
| S-EPMC7700852 | biostudies-literature
Project description:Osteoradionecrosis is a delayed complication from radiation therapy which causes chronic pain, infection and constant deformity after necrosis. Most of the osteoradionecrosis occurs spontaneously or after the primary oncologic surgery, dental extraction or by trauma of prosthesis. The treatment of osteoradionecrosis relies on both conservative measures and surgical measures. The fibular osteocutaneous free flap has become more popular choice for reconstruction of maxillofacial defects as a treatment of osteoradionecrosis.We presented our experiences from 7 patients with osteoradionecrosis who have had reconstruction surgery with fibular osteocutaneous free flap at National Cancer Center during the recent 5 years. We performed segmental mandibular resection with fibular osteocutaneous free flap for all 7 patients of advanced osteoradionecrosis who were not controlled by conservative treatment such as wound irrigation, debridement, and antibiotics.A wide range of techniques were available for the reconstruction of composite defects resulted from the treatment of advanced mandibular osteoradionecrosis. Significant improvement was noted in relieving pain and treating trismus after the surgery however difficulty in swallowing and xerostomia showed less improvement.We concluded that fibular osteocutaneous free flap can be performed safely in patients with osteoradionecrosis and yields positive outcomes with significantly increased success rate. The fibular osteocutaneous free flap was our preferred choice for the mandibular reconstruction due to its versatility and predictability.
| S-EPMC4322236 | biostudies-literature
Project description:PurposeTo assess the availability, success rate and complications of microvascular iliac crest free flap for reconstruction of mandibular segmental defects.MethodsIn this retrospective-descriptive study, we report patients who had undergone segmental mandibular resection for pathologic lesions and received reconstruction with iliac crest microvascular free flap between 2016 and 2019. Clinical and demographic data of all the cases were collected. Success was regarded as complete consolidation of the bone graft in panoramic radiograph. Postoperative complications were defined as major or minor based on the need for intervention. T-test, Kolomogorov_Smirnov, and multivariate analysis were used and the p-value<0.05 was considered to be statistically significant.ResultsOf all 30 patients, 16 were women and 14 were men with an average age of 27.2 years (range 14-40). Patients were followed for 12-60 month (mean: 38.4). One flap was lost due to unsalvageable venous thrombosis. Six other cases had post-op complications while smoking and diabetes were associated with more complications (P = 0.036). Twenty-three patients received primary reconstruction which was more successful than secondary ones (P = 0.003). Osteogenic sarcoma was associated with greater risk of complications (P < 0.01).ConclusionsThe results of this study suggest that iliac crest microvascular free flap serves as a promising option for the reconstruction of mandibular defects, providing excellent contour and acceptable success rate with low donor site morbidity. Future studies will focus on the role of systemic diseases in post-op complications and flap failures.
| S-EPMC8121997 | biostudies-literature