Evaluation of the methodological quality of articles on autologous breast reconstruction.

BACKGROUND: Breast cancer remains the most common cancer among women worldwide. Autologous breast reconstruction may contribute toward restoring body image and improving quality of life after mastectomy. This systematic literature review describes differences in the quality and type of studies investigating autologous breast reconstruction techniques over time. METHODS: MEDLINE was searched for articles related to the surgical techniques, namely, TRAM, LADO, DIEP, and SGAP/IGAP, for the periods 1970 to 2007 and 2008 to 2010. The quality and type of studies were compared across the two time periods. Full-texts were evaluated according to prespecified quality criteria. RESULTS: The MEDLINE searches yielded 1,057 articles for review; of them, 517 articles were excluded, and 314 had a completed quality criteria checklist and hence were included; of these 314 articles, 206 articles investigated TRAM flaps, 85 investigated LADO flaps, 74 investigated DIEP flaps, and 6 investigated SGAP/IGAP flaps. A total of 218 articles were published between 1970 and 2007 compared to 96 articles published between 2008 and 2010. The comparison of quality scores between the two time periods showed a shift toward higher scores in the period 2008 to 2010. The DIEP technique was investigated more frequently between 2008 and 2010 than between 1970 and 2007, whereas the percentage of articles focusing on the TRAM flap decreased. The percentage of articles investigating the LADO and SGAP/IGAP techniques remained constant across the time periods. CONCLUSIONS: Results relating to the methodological quality of articles on breast reconstruction with autologous tissue show that the quality of publications has improved with time, whereas research interests concerning the type of surgical technique investigated have changed in focus.

The free fasciocutaneous infragluteal (FCI) flap: Outcome and patient satisfaction after 142 breast reconstructions.

BACKGROUND: The free fasciocutaneous infragluteal flap (FCI) is relatively rarely used for autologous breast reconstruction; however, it is a good option for thin patients. The outcome of 142 FCI flaps for breast reconstruction is presented here. MATERIALS AND METHODS: Between January 2008 and December 2013, 142 patients underwent unilateral breast reconstruction with the FCI flap. Outcome analysis, scar quality, postoperative pain, and patient satisfaction were evaluated by questionnaires and established scores. The tactile sensitivity of the breast was measured by the Semmes-Weinstein monofilament test. RESULTS: The mean age was 45.4 ± 9.17 (23-69) years, the mean follow-up was 40.2 (12-58) months, and the rate of flap loss was 0.7% (n = 1). Postoperative pain was stated with 4.2 ± 2.5 points on the visual analog scale (VAS). The quality of breast reconstruction was rated "very good" (n = 43) or "good" (n = 33) by 71% of patients, and 89% (n = 96) of patients would recommend this procedure to others. As expected, postoperative mobility was achieved in 80% (n = 86) of patients and some obtained this even earlier. Forty-seven patients presented for follow-up examination (44%). Scars on the reconstructed breasts were rated with 1 (n = 16) or 2 (n = 22) points in 81% and scars at the infragluteal donor site with 2 (n = 17) or 3 (n = 25) points on the Vancouver scar scale (VSS) in 89%. Patients subjectively stated having better sensitivity of the reconstructed breast than measured objectively by monofilaments. CONCLUSION: The FCI flap is a safe method for breast reconstruction due to a low percentage of flap loss and complications. Good patient satisfaction along with fast postoperative mobilization can be achieved. The FCI flap should be considered a suitable alternative for autologous breast reconstruction.

The sGAP flap: rare exception or second choice in autologous breast reconstruction?

Various flaps are available for autologous breast reconstruction. However, there is no accepted standard. The superior gluteal artery perforator (sGAP) flap is one possible option for autologous breast reconstruction. Eighty-one sGAP flaps were performed for breast reconstruction. Patient data regarding age, body mass index, medical history, timing of reconstruction, operating time, success of the operation, and complications were retrospectively analyzed. The success rate was 93% ( N = 75). Thrombosis occurred in nine flaps, and three revisions were successful. There was no partial necrosis. All but one bilateral breast reconstruction was performed in two stages. The average time between the reconstructions was 3 and 5 months (2 to 6). The average operating time was 7 hours 36 minutes (5'45 to 9'33). For autologous breast reconstruction, there is no universally accepted standard and no flap meets all the requirements. The deep inferior epigastric perforator flap is our first choice. We favor the sGAP as a second choice particularly for larger breast sizes. For a staged bilateral reconstruction, the sGAP flap advances to be our first choice. The sGAP flap is a safe and reliable perforator flap providing a good breast projection, cosmetically pleasing outcome on the breast, and an acceptable outcome on the buttock with the disadvantage of a demanding dissection.

Superior gluteal artery perforator flap in bilateral breast reconstruction.

The incidence of bilateral breast reconstruction is increasing particularly due to genetic counseling and the option for bilateral prophylactic mastectomies. The decision to undergo a prophylactic mastectomy depends on the achievable outcomes of breast reconstruction. The free superior gluteal artery perforator flap (sGAP) flap is one option for autologous bilateral reconstruction which has rarely been reported.All bilateral sGAP flaps performed in the department of plastic surgery at the Behandlungszentrum Vogtareuth over a period of 4.5 years were retrospectively analyzed for indication, success rate, and complications.Thirty sGAP flaps were performed for bilateral breast reconstruction. The average age of the 15 women was 42 years and the average body mass index was 20.8. Indications for breast reconstruction were predominantly prophylactic mastectomies (60%). Indication for a sGAP flap was either a thin patient with insufficient abdominal tissue or a 2-staged bilateral reconstruction. 83% of the breast reconstructions were performed secondarily and 93% in 2 stages. The average operating time was 7 hours 12 minutes. Twenty-nine flaps (97%) were successful. Complications were fat necrosis (n = 3), hematoma (n = 3), and breast seroma (n = 1). Donor site complications were seroma (n = 8), infection (n = 1), and wound dehiscence (n = 1).Our results with bilateral breast reconstruction with the sGAP flap show cosmetically appealing results with high success and low complication rates on the breast. However, seromas on the donor site occurred in 27%. In addition, the sGAP flap is a technically demanding and time consuming operation. We recommend the sGAP flap when the abdomen has not enough tissue bulk to perform a deep inferior epigastric perforator flap or for a 2-staged bilateral reconstruction. This is often the case in women with a hereditary high risk of breast cancer who often present as young and slim patients.

Free latissimus dorsi flap with long venous grafts for closure of a soft tissue defect of the spine in a patient with Noonan's syndrome: a case report.

A 23-year-old male patient was operated for a soft tissue defect of the spine using a free musculocutaneous latissimus dorsi flap with two 21-cm long venous grafts connecting the flap to its vascular supply at the thoracodorsal vessels. This young patient suffered from Noonan's Syndrome that is a complex hereditary malformation syndrome with clinical features often leading to spinal deformities and gibbus development. The defect originated from a former internal vertebral fixation that was necessary for erective correction of such a spinal deformity. After perforation of the introduced material and debridement the defect was 4 x 8 cm in size, which was successfully closed by the free latissimus dorsi transfer. However, two venous grafts were necessary because the extension of the pedicled muscle was not sufficient to reach the defect. This is the first case in literature where a free flap was used with two venous grafts to close a soft tissue defect of the spine in the special case of a vertebral deformity based on a Noonan's Syndrome.

The free gracilis perforator flap: anatomical study and clinical refinements of a new perforator flap.

BACKGROUND: The free gracilis perforator flap is a fascioadipocutaneous flap on the medial thigh, based on perforators of the main pedicle of the gracilis myocutaneous flap. METHODS: An anatomical study was performed using 43 cadaver dissections. The vascular anatomy of the gracilis perforator flap with regard to myocutaneous and septocutaneous perforators was assessed. Clinical application was demonstrated in 14 cases. RESULTS: Musculocutaneous perforators of the gracilis muscle pedicle were present in all dissections and were 0.5 mm or more in 93 percent. Septocutaneous perforators were found in 84 percent of the dissections, and perforators of 0.5 mm or more were found in 63 percent. Most musculocutaneous perforators were found in the anterior quarter of the muscle where the pedicle enters the gracilis muscle. A constant intramuscular anastomosis between the main and second vascular pedicles of the gracilis was demonstrated that allowed design of an extended gracilis perforator flap. CONCLUSIONS: Successful clinical application in 14 cases confirmed vascular reliability. The gracilis perforator flap is a pliable, thin flap from the medial thigh that can be as large as 18 x 15 cm. The donor site is inconspicuous, and a functional gracilis muscle is preserved. By including a constant intramuscular anastomosis, it is possible to extend the territory of the free flap distally up to a length of 27 cm. Indications include reconstruction of cutaneous defects such as unstable scars or contractures. The medial thigh adipose tissue correlates well with the body mass index and thus can be used for breast reconstruction as a second choice if an abdominal perforator flap is not available.

Management of postneurosurgical bone flap loss caused by infection.

LEARNING OBJECTIVES: After studying this article, the participant should: 1. Be able to define indications and timing for secondary cranioplasty. 2. Understand the surgical options for reconstructing the cranium and overlying soft-tissue defect including their advantages and disadvantages. 3. Be able to apply this knowledge to the clinical setting of an infectious bone flap loss. BACKGROUND: Infection after craniotomy occurs in approximately 1.1 to 8.1 percent of cases and often necessitates bone flap removal. For a secondary cranioplasty, there is an increased risk of recurrent infection, which influences the reconstructive plan. The soft tissue/scalp is frequently compromised by infection, sequelae of prior surgery, and/or adjuvant radiation therapy. METHODS: A literature review was conducted to compile and summarize the indications for secondary cranioplasty after infectious bone flap loss, the timing of the procedure, and the surgical options for bone and soft-tissue reconstruction. In coordination with soft-tissue coverage, cranioplasty options include alloplastic reconstruction, allogeneic or autogenous bone grafts, and free tissue transfer. RESULTS: The literature review identified the following factors that must be considered in the treatment plan for secondary cranioplasty after postneurosurgical bone flap loss: indications, timing of reconstruction, soft-tissue status and the need for soft-tissue reconstruction, and method of cranioplasty. CONCLUSIONS: Treatment recommendations for cranioplasty in the clinical setting of infectious postneurosurgical bone flap loss are presented. These guidelines consider the risk factors for a recurrent infection, the condition of the soft-tissue coverage, and the concavity of the preoperative cranial deformity.

Functional total and subtotal heel reconstruction with free composite osteofasciocutaneous groin flaps of the deep circumflex iliac vessels.

Functional and esthetic reconstruction of the bony and tendinous structures with a stable, sensate soft tissue integument after complex posttraumatic defects of the heel is demanding. Cases are rare in the literature and hardly comparable due to their heterogeneity. The reconstructive approach has to consider both patient profile and the reconstructive tree, with free microvascular flaps playing a primary role. The goals are the reconstruction of both osteotendinous structures and slender soft tissue lining for proper shoe fitting for ambulation and mechanical and thermal protection. The flap should be sensate in weightbearing areas to optimize gait and to prevent long-term complications by ulcers. The osteofasciocutaneous deep inferior circumflex artery (DCIA) flap is especially suitable for complex heel defects with subtotal or total loss of the calcaneal bone as all components (iliac bone, groin skin, and fascia lata) can have a wide range of size and shape. We operated on 2 cases with this variable composite flap. One patient had a complete heel defect by war shrapnel. The complete calcaneus, soft heel, and Achilles tendon were reconstructed. The second patient had an empty os calcis after a comminuted fracture and a lateral crush-induced soft tissue defect. In both patients, a stable wound closure, osseous integration, and weightbearing ambulation could be achieved.