Breast Tissue Expanders with Magnetic Ports: Clinical Experience at 1.5 T.

BACKGROUND: The purpose of this study was to evaluate breast tissue expanders with magnetic ports for safety in patients undergoing abdominal/pelvic magnetic resonance angiography before autologous breast reconstruction. METHODS: Magnetic resonance angiography of the abdomen and pelvis at 1.5 T was performed in 71 patients in prone position with tissue expanders with magnetic ports labeled "MR Unsafe" from July of 2012 to May of 2014. Patients were monitored during magnetic resonance angiography for tissue expander-related symptoms, and the chest wall tissue adjacent to the tissue expander was examined for injury at the time of tissue expander removal for breast reconstruction. Retrospective review of these patients' clinical records was performed. T2-weighted fast spin echo, steady-state free precession and gadolinium-enhanced spoiled gradient echo sequences were assessed for image artifacts. RESULTS: No patient had tissue expander or magnetic port migration during the magnetic resonance examination and none reported pain during scanning. On tissue expander removal (71 patients, 112 implants), the surgeons reported no evidence of tissue damage, and there were no operative complications at those sites of breast reconstruction. CONCLUSION: Magnetic resonance angiography of the abdomen and pelvis in patients with certain breast tissue expanders containing magnetic ports can be performed safely at 1.5 T for pre-autologous flap breast reconstruction perforator vessel mapping. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Autologous breast reconstruction: preoperative magnetic resonance angiography for perforator flap vessel mapping.

BACKGROUND: Selection of a vascular pedicle for autologous breast reconstruction is time consuming and depends on visual evaluation during the surgery. Preoperative imaging of donor site for mapping the perforator artery anatomy greatly improves the efficiency of perforator selection and significantly reduces the operative time. In this article, we present our experience with magnetic resonance angiography (MRA) for perforator vessel mapping including MRA technique and interpretation. METHODS: We have performed over 400 MRA examinations from August 2008 to August 2013 at our institution for preoperative imaging of donor site for mapping the perforator vessel anatomy. Using our optimized imaging protocol with blood pool magnetic resonance imaging contrast agents, multiple donor sites can be imaged in a single MRA examination. Following imaging using the postprocessing and reporting tool, we estimated incidence of commonly used perforators for autologous breast reconstruction. RESULTS: In our practice, anterior abdominal wall tissue is the most commonly used donor site for perforator flap breast reconstruction and deep inferior epigastric artery perforators are the most commonly used vascular pedicle. A thigh flap, based on the profunda femoral artery perforator has become the second most used flap at our institution. In addition, MRA imaging also showed evidence of metastatic disease in 4% of our patient subset. CONCLUSION: Our MRA technique allows the surgeons to confidently assess multiple donor sites for the best perforator and flap design. In conclusion, a well-performed MRA with specific postprocessing provides an accurate method for mapping perforator vessel, at the same time avoiding ionizing radiation.

Microlymphatic surgery for the treatment of iatrogenic lymphedema.

Lymphedema is a chronic and progressive condition that occurs after cancer treatment. Autologous lymph node transplant, or microsurgical vascularized lymph node transfer (ALNT), is a surgical treatment option that brings vascularized vascular endothelial growth factor-C-producing tissue into the operated field to promote lymphangiogenesis and bridge the distal obstructed lymphatic system with the proximal lymphatic system. Operative techniques for upper- and lower-extremity ALNT are described with 3 donor lymph node flaps (inguinal, thoracic, cervical). Surgical technique is described for the combination of ALNT with abdominal flaps and nonabdominal flaps. Imaging showing restoration of lymphatic drainage after ALNT is shown.

Nipple-sparing mastectomy and immediate free-flap reconstruction in the large ptotic breast.

Because of increased risk for nipple necrosis, many surgeons believe large ptotic breasts to be a relative contraindication to nipple-sparing mastectomy (NSM). A retrospective review was performed on 85 consecutive patients who underwent NSM with 141 immediate perforator free-flap breast reconstructions. We analyzed the subset of patients with large ptotic breasts, defined as cup size C or greater, sternal notch to nipple distance greater than 24 cm and grade 2 or 3 breast ptosis. Of the 85 patients, 19 fit the inclusion criteria. Breast cup size ranged from 34C to 38DDD. There was 1 case of nipple necrosis in the patient with previous breast radiation (5%), 1 hematoma (5%), and no flap losses. Five (26%) patients underwent subsequent mastopexy or breast reduction, a mean of 6.6 months after the primary procedure. We demonstrate that NSM and free-flap breast reconstruction can be safely and reliably performed in selected patients.

A 15-year review of midface reconstruction after total and subtotal maxillectomy: part I. Algorithm and outcomes.

BACKGROUND: Reconstruction of complex midfacial defects is best approached with a clear algorithm. The goals of reconstruction are functional and aesthetic. METHODS: Over a 15-year period (1992 to 2006), a single surgeon (P.G.C.) performed 100 flaps to reconstruct the following midfacial defects: type I, limited maxillectomy (n = 20); type IIA, subtotal maxillectomy with resection of less than 50 percent of the palate (n = 8); type IIB, subtotal maxillectomy with resection of greater than 50 percent of the palate (n = 8); type IIIA, total maxillectomy with preservation of the orbital contents (n = 22); type IIIB, total maxillectomy with orbital exenteration (n = 23); and type IV, orbitomaxillectomy (n = 19). Free flaps were used in 94 cases (94 percent), and pedicled flaps were used in six (6 percent). RESULTS: One hundred flaps were performed in 96 patients (69 males, 72 percent; 27 females, 28 percent); four patients underwent a second flap reconstruction due to recurrent disease (n = 4, 4 percent). Average patient age was 49.2 years (range, 13 to 81 years). Free-flap survival was 100 percent, with one partial flap loss (1 percent). Five patients suffered systemic complications (5.2 percent), and four died within 30 days of hospitalization (4.2 percent). Over 50 percent of patients returned to normal diet and speech. Almost 60 percent were judged to have an excellent aesthetic result. CONCLUSIONS: Free-tissue transfer offers the most effective and reliable form of reconstruction for complex maxillectomy defects. Rectus abdominis and radial forearm free flaps in combination with immediate bone grafting or as osteocutaneous flaps consistently provide the best functional and aesthetic results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A 15-year review of midface reconstruction after total and subtotal maxillectomy: part II. Technical modifications to maximize aesthetic and functional outcomes.

BACKGROUND: Midface reconstruction of oncologic defects is one of the most challenging problems in plastic surgery. Over time, the senior author (P.G.C.) has developed modifications in his technique for oncologic midface reconstruction to minimize complications and maximize outcomes. METHODS: Over a 15-year period (1992 to 2006), 100 flaps for midface oncologic reconstruction were performed at Memorial Sloan-Kettering Cancer Center. The first 50 flaps were performed from 1992 to 2000, and the second 50 flaps were performed from 2001 to 2006. Over time, technical improvements were made in the following areas: palate, dental implants and prosthesis, orbital floor, eyelid, nasal sidewall, lips, cranial base and dura, and pedicle anastomosis. Using a prospectively maintained database, the authors compared the functional and aesthetic outcomes of the first 50 flaps and the second 50 flaps. RESULTS: Improvements in palatal reconstruction increased the proportion of patients who achieved normal speech from 38.9 percent in the first half of the series (1992 to 2000) to 50 percent in the second half of the series (2001 to 2006). The percentage of patients who were able to tolerate an unrestricted diet increased from 44.4 to 52 percent. The use of new methods to reconstruct the orbital floor also lowered the ectropion rate from 71.4 to 47.6 percent. The percentage of patients whose aesthetic results were judged as "excellent" increased from 12 to 58.6 percent. CONCLUSIONS: Over the last 15 years, the senior author has refined methods of midface reconstruction that have improved functional and aesthetic outcomes. These technical advancements have made it possible to obtain better and more consistent results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Introducing the septocutaneous gluteal artery perforator flap: a simplified approach to microsurgical breast reconstruction.

BACKGROUND: Consistent septocutaneous perforators exist between the gluteus maximus and medius muscles. The existence of these septocutaneous perforators obviates the need for any intramuscular dissection when elevating a gluteal artery perforator flap. In this study, the authors present their experience with the septocutaneous gluteal artery perforator (sc-GAP) flap for microsurgical breast reconstruction. METHODS: The authors retrospectively reviewed 11 consecutive sc-GAP flaps performed for postmastectomy breast reconstruction in nine patients between February and July of 2008. Patient demographics, risk factors, perforator characteristics, operative technique, operative time, and outcome were analyzed. Preoperative imaging was used for all patients. RESULTS: Mean patient age was 52 years (range, 44 to 60 years). Mean body mass index was 22.2 (range, 17.2 to 29.1). Of the 11 flaps, five sc-GAP flaps were immediate (45 percent) and six were delayed reconstruction (55 percent); seven were unilateral (64 percent) and four were bilateral (36 percent). Mean operative time was 8.2 hours (range, 6.5 to 11 hours). All patients stayed in the hospital for 5 days. Mean pedicle length was 7.9 cm (range, 5 to 10 cm) and mean flap weight was 499 g (range, 360 to 640 g). Vessel size ranged from 1.8 to 3 mm. Complications included one take-back, one axillary seroma, one donor-site seroma, and one donor-site hematoma. There were no flap losses. CONCLUSIONS: The sc-GAP flap is a viable technique for microsurgical breast reconstruction that may be easier to master than traditional musculocutaneous gluteal artery perforator flap procedures. The authors recommend the sc-GAP flap as a simplified approach to gluteal artery perforator flaps for microsurgical breast reconstruction.

Measuring quality of life in oncologic breast surgery: a systematic review of patient-reported outcome measures.

Multiple randomized trials demonstrate equivalent survival between BCT and mastectomy, but clinical outcomes research must also evaluate patient satisfaction and quality of life. This review analyzes existing patient-reported outcome (PRO) measures in oncologic breast surgery to assess utility and make recommendations for future research. We performed a systematic literature review to identify PRO measures used in oncologic breast surgery patients. After applying inclusion and exclusion criteria, qualifying instruments were assessed for adherence to international guidelines for health outcomes instrument development and validation. Ten measures underwent development and psychometric evaluation in an oncologic breast surgery population. Five of ten measures (EORTC QLQ BR-23, FACT-B, HBIS, BIBCQ, and BREAST-Q) reported an adequate development and validation process. Three of these 5 measures (EORTC QLQ BR-23, FACT-B, HBIS) focused on non-surgical treatment issues. A fourth instrument (BIBCQ) did not address aesthetic concerns after breast reconstruction. The fifth instrument (BREAST-Q) was developed for use in patients undergoing mastectomy ± reconstruction, but did not address breast-conserving therapy. Overall, two key limitations were noted: 1) surgery-specific issues of breast-conserving surgery patients were not well represented and 2) measures were largely developed without the aid of newer psychometric methods that may improve their clinical utility. Reliable and valid PRO measures in breast cancer patients exist, but even the best instruments do not address all important surgery-specific and psychometric issues of oncologic breast surgery patients. Newer psychometric methods would facilitate development of scales for use in individual patient care as well as group level comparisons.

The effect of providing information about lymphedema on the cognitive and symptom outcomes of breast cancer survivors.

BACKGROUND: Despite recent advances in breast cancer treatment, breast cancer related lymphedema (BCRL) continues to be a significant problem for many survivors. Some BCRL risk factors may be largely unavoidable, such as mastectomy, axillary lymph node dissection (ALND), or radiation therapy. Potentially avoidable risk factors unrelated to breast cancer treatment include minor upper extremity infections, injury or trauma to the arm, overuse of the limb, and air travel. This study investigates how providing information about BCRL affects the cognitive and symptomatic outcome of breast cancer survivors. METHODS: Data were collected from 136 breast cancer survivors using a Demographic and Medical Information interview instrument, a Lymphedema Education Status interview instrument, a Knowledge Test for cognitive outcome, and the Lymphedema and Breast Cancer Questionnaire for symptom outcome. Data analysis included descriptive statistics, t tests, chi-square (chi(2)) tests, and regression. RESULTS: BCRL information was given to 57% of subjects during treatment. The mean number of lymphedema-related symptoms was 3 symptoms. Patients who received information reported significantly fewer symptoms and scored significantly higher in the knowledge test. After controlling for confounding factors, patient education remains an additional predictor of BCRL outcome. Significantly fewer women who received information about BCRL reported swelling, heaviness, impaired shoulder mobility, seroma formation, and breast swelling. CONCLUSIONS: Breast cancer survivors who received information about BCRL had significantly reduced symptoms and increased knowledge about BCRL. In clinical practice, breast cancer survivors should be engaged in supportive dialogues so they can be educated about ways to reduce their risk of developing BCRL.

Nipple-sparing mastectomy and immediate tissue expander/implant breast reconstruction.

BACKGROUND: The nipple is an uncommon site for breast cancer development, but the nipple-areola complex is routinely excised in breast cancer treatment. The authors evaluated the risks and benefits of nipple- or areola-sparing mastectomy with breast reconstruction. METHODS: The authors analyzed data on 115 consecutive nipple- or areola-sparing mastectomies with immediate tissue expander breast reconstruction performed in 66 patients from 1998 to 2008 at a single tertiary-care cancer center. Nipple-sparing mastectomies were performed for prophylaxis (n = 75) or treatment of disease (n = 40). RESULTS: Mean patient age was 45 years (range, 24 to 61 years) and mean follow-up time was 22 months (range, 2 weeks to 91 months). There were 115 nipple- or areola-sparing mastectomies (48 bilateral and 19 unilateral), including 111 nipple-sparing and four areola-sparing mastectomies. On pathologic review, 20 breasts had ductal carcinoma in situ, 20 breasts had invasive cancer, 11 breasts had lobular carcinoma in situ, one breast had phyllodes tumor, one breast had mucinous carcinoma, and 62 breasts were cancer-free. Incision placement was periareolar and radial (n = 61), inframammary (n = 25), omega type (n = 14), customized to include a previous scar (n = 10), or transareolar (n = 5). Of all 115 nipple- or areola-sparing mastectomies, six nipples were lost because of occult disease (5.2 percent), and four nipples were lost because of wound-healing problems (3.5 percent). CONCLUSIONS: In the authors' series of nipple- and areola-sparing mastectomies performed for risk reduction or breast cancer, there was a low incidence of occult disease (5.2 percent). Nipple- and areola-sparing mastectomy may be feasible in selected patients and should be the subject of additional investigation.

The incidence of venous thromboembolism after oncologic head and neck reconstruction.

This study evaluates the incidence of symptomatic deep venous thrombosis and pulmonary embolism after head and neck reconstruction at a single tertiary care cancer center. From 1997 to 2006, 6,759 surgical procedures were performed. There were 1,591 head and neck reconstructions (n = 1,591) and 5,168 non-head and neck reconstructions (n = 5,168). Free flaps, regional flaps, and other procedures were included. Although the incidence of venous thromboembolism (VTE) was less than 1% in both patient populations, there was a significantly greater incidence of VTE among patients undergoing head and neck reconstruction than non-head and neck reconstruction (P < 0.05). When compared with patients undergoing non-head and neck reconstruction, patients undergoing oncologic head and neck procedures were older, underwent longer anesthesia times, spent more days in the hospital, and were more likely to need free flaps. When possible, appropriate prophylaxis against VTE in cancer patients under going head and neck reconstruction is recommended.

Is the use of intraoperative heparin safe?

BACKGROUND: Despite the reliability of microvascular free tissue transfer, flap loss remains a significant concern. To improve outcome, various pharmacologic agents have been used to prevent microvascular thrombosis. The authors review their experience with intraoperative heparin therapy, specifically addressing the risks of hematoma, pedicle thrombosis, and flap loss rate. METHODS: Results from consecutive free flaps performed over a 3-year period were reviewed using a prospectively maintained database. Patients were divided into two groups: group A received a bolus of 3000 units of intraoperative heparin 10 minutes before flap pedicle ligation; group B did not receive intraoperative heparin. Patient demographics, procedure type, diagnosis, adjuvant treatment, and complications were recorded. Outcome variables included microvascular thrombosis, total and partial flap loss, hematoma, seroma, pulmonary embolism, and death. RESULTS: Four hundred seventy patients underwent 505 microvascular free flaps for reconstruction of oncologic defects. Reconstructed areas included head and neck (n = 288), trunk and breast (n = 151), upper extremity (n = 12), and lower extremity (n = 19). Of these, 260 flaps (group A) received an intraoperative heparin bolus, and 245 flaps (group B) received no intraoperative heparin bolus. There were no statistically significant differences in major and minor complications between the two groups (power = 0.85). CONCLUSIONS: Intraoperative systemic heparin use has no statistically significant effect on the incidence of microvascular thrombosis. In addition, administration of a single dose of intraoperative heparin does not increase the rate of hematoma formation or prevent microvascular thrombosis. Thus, critical factors for flap survival are likely independent of the use of intraoperative anticoagulation.

Surgical management of a dermal lymphatic malformation of the lower extremity.

Dermal lymphatic malformations are rare congenital hamartomas of superficial lymphatics characterized by high recurrence rates after excision. The standard therapy for a single lesion is surgical excision with wide margins, which reduces recurrence but can have a potentially unacceptable aesthetic outcome. A case of a 24-year-old woman with a 6 cm x 5 cm dermal lymphatic malformation on her right thigh, diagnosed by clinical history, physical examination, magnetic resonance imaging and pathological findings, is reported. The patient underwent wide local excision with split-thickness skin grafting. After pathological examination revealed negative margins, the patient underwent tissue expander placement and excision of the skin graft with primary closure. The lesion did not recur, and the patient achieved a satisfactory aesthetic result. The present case represents the first report of the use of tissue expanders to treat dermal lymphatic malformations in the lower extremity and demonstrates a safe, staged approach to successful treatment.

Immediate postoperative complications in DIEP versus free/muscle-sparing TRAM flaps.

BACKGROUND: The deep inferior epigastric perforator (DIEP) flap is a major advance in breast reconstruction, but many surgeons are reluctant to use it because of concerns about a higher flap loss rate when compared with free/muscle-sparing transverse rectus abdominis myocutaneous (TRAM) flaps. Previous studies, however, have not statistically analyzed the relationship of patient characteristics to outcome. This study evaluates the authors' institutional experience with immediate postoperative complications following DIEP and free/muscle-sparing TRAM flaps. METHODS: Results of 200 consecutive free/muscle-sparing TRAM and DIEP flaps performed by two surgeons at a single institution between 2003 and 2005 were reviewed using a prospectively maintained database. The incidence of flap complications was compared. Patient demographics, procedure type, diagnosis, adjuvant treatment, and complications were recorded. Outcome variables included total and partial flap loss, infection, seroma, hematoma, wound-healing problems, fat necrosis, and mastectomy flap necrosis. RESULTS: One hundred forty-three patients were treated with 159 free/muscle-sparing TRAM flaps and 41 DIEP flaps. The demographics of the two groups were statistically similar. No statistically significant differences were noted in total or partial flap loss. CONCLUSIONS: In the authors' series, the use of the DIEP flap did not result in more postoperative flap-related complications when compared with the free/muscle-sparing TRAM flap. Furthermore, no patient characteristics were statistically associated with a more successful result. The authors conclude that in patients whose anatomy reveals perforators of adequate size, the DIEP flap is a safe and reliable procedure for breast reconstruction.

Measuring quality of life in cosmetic and reconstructive breast surgery: a systematic review of patient-reported outcomes instruments.

BACKGROUND: Patient-reported outcomes in cosmetic and reconstructive breast surgery are increasingly important for clinical research endeavors. Traditional surgical outcomes, centered on morbidity and mortality, remain important but are no longer sufficient on their own. Quality of life has become a crucial research topic augmenting traditional concerns focused on complications and survival. Given this, reliable and valid patient questionnaires are essential for aesthetic and reconstructive breast surgeons. METHODS: The authors performed a systematic literature review to identify patient-reported outcome measures developed and validated for use in cosmetic and reconstructive breast surgery patients. Qualifying instruments were assessed for adherence to international guidelines for health outcomes instrument development and validation. RESULTS: The authors identified 227 health outcomes questionnaires used in breast surgery studies. After 135 generic instruments, 65 ad hoc instruments, seven oncologic instruments, 11 education questionnaires, and two non-English-language questionnaires were excluded, seven measures remained. Detailed analysis revealed that six of the seven measures had undergone limited development and validation. Only one measure, the Breast-Related Symptoms Questionnaire, demonstrated adequate development and validation in its target population. It had, nevertheless, significant content limitations. CONCLUSIONS: Valid, reliable, and responsive instruments to measure patient-reported outcomes in cosmetic and reconstructive breast surgery are lacking. To demonstrate the benefits of aesthetic and reconstructive breast surgery, future research to rigorously develop and validate new cosmetic and reconstructive breast surgery-specific instruments is needed.

Microvascular reconstruction of the skull base: a clinical approach to surgical defect classification and flap selection.

Skull-base tumor resection and reconstruction produce a major physiologic and anatomic impact on the patient. At our institution, the use of vascularized, free-tissue transfer has replaced pedicled flaps as the preferred modality for reconstructing complex cranial base defects involving resection of dura, brain, or multiple major structures adjacent to skull base, including the orbit, palate, mandible, skin, and other structures. The goals of reconstruction are to: (1) support the brain and orbit; (2) separate the CNS from the aerodigestive tract; (3) provide lining for the nasal cavity; (4) re-establish the nasal and oropharyngeal cavities; (5) provide volume to decrease dead space; and (6) restore the three-dimensional appearance of the face and head with bone and soft tissues. Surgical management requires a multidisciplinary effort with collaborating neurosurgical, head and neck, and plastic surgical teams. Successful reconstruction of skull base defects is predicated upon a careful appreciation of the specific region. Defects may be classified based on their anatomic location and loss of volume, support, and skin cover. Free flaps provide reliable, well-vascularized soft tissue to seal the dura, obliterate dead space, cover exposed cranial bone, and provide cutaneous coverage for skin or mucosa.