The Ideal Microsurgery Fellowship: A Survey of Fellows and Fellowship Directors.

BACKGROUND: Although microsurgery fellowships have existed since the 1980s, there is no established curriculum. Microsurgery fellowships vary greatly in clinical caseload, case diversity, and training resources, and there is no consensus on the appropriate composition of a microsurgery fellowship. This study surveys fellowship directors (FD) and recent microsurgery fellows (MFs), graduates, to describe the ideal microsurgery fellowship program. METHODS: A 15-item questionnaire was sent to 38 FDs and 90 recent microsurgery fellowship graduates. This questionnaire addressed program attributes, case volumes and compositions, ideal experiences, and time allocation to different fellowship experiences. Data were analyzed using descriptive statistics, t-tests, and Chi-squared tests. RESULTS: The FD and MF surveys had a response rate of 47 and 49%, respectively. Both MF and FD agreed that exposure to microsurgical breast reconstruction is the most important characteristic of a microsurgery fellowship (p = 0.94). MF ranked replantation and supermicro/lymphatic surgery as the next most important microsurgical cases, while FD ranked the anterolateral thigh (ALT) flap and free fibula flap (p < 0.001). Both agreed that revisional surgery after microsurgical reconstruction is a very valuable fellowship experience (p = 0.679). Both agreed that 1 day of clinic a week is sufficient. CONCLUSION: Microsurgical training programs vary in quality and resources. The ideal microsurgery fellowship prioritized breast reconstruction, head and neck reconstruction, and lower extremity reconstruction. Although microsurgical technical expertise is important, a fellowship should also train in revisional surgeries and clinical decision making.

Detailed analysis of the impact of surgeon and hospital volume in microsurgical breast reconstruction.

BACKGROUND: Prior investigations of microsurgical breast reconstruction have not distinguished the effects of surgeon versus hospital volume and failed to address the effect of patient clustering. Our data-driven analysis aims to determine the impacts of surgeon and hospital volume on outcomes of microsurgical breast reconstruction. METHODS: Nationwide Inpatient Sample (NIS) data from 2008 to 2011 was analyzed for patients who underwent microsurgical breast reconstruction. Volume-outcome relationships were analyzed with restricted cubic spline analysis. A multivariable mixed-effects logistic regression was used to account for patient clustering effect. RESULTS: A total of 5,404 NIS patients met inclusion criteria. High-volume (HV) surgeons had a 59% decrease in the risk of inpatient complications, which became non-significant after clustering correction. For HV hospitals, there was a 47% decrease in the risk of inpatient complications (odds ratio = 0.53; 95% confidence intervals 0.30, 0.91; p = 0.021) that was statistically significant with the clustering adjustment. Neither the volume-cost relationship for surgeons nor hospitals remained statistically significant after accounting for clustering. CONCLUSIONS: Hospital volume plays a significant impact on outcomes in microsurgical breast reconstruction, while surgeon volume has comparatively not shown to be similarly impactful. The complexity of care related to microsurgical breast reconstruction warrants equally complex and engineered health systems.

The use of negative pressure wound therapy in severe open lower extremity fractures: identifying the association between length of therapy and surgical outcomes.

BACKGROUND: Negative pressure wound therapy (NPWT) is a widely accepted method of temporary coverage for complex lower extremity wounds before definitive reconstruction. However, the precise role of NPWT in the perioperative management of patients with complicated lower extremity injuries remains unclear. In this study, we examine the effect of NPWT on flap complications and overall outcomes based on timing of soft-tissue reconstruction relative to initial injury and implementation of NPWT. METHODS: We retrospectively reviewed the medical records of 32 consecutive patients presenting to a single institution receiving lower extremity reconstruction after Gustilo class IIIB or IIIC open tibial fractures over a 5-y period. Length of hospitalization, number of surgical procedures, flap failure, infection, and nonunion were parameters of interest in this study. RESULTS: The incidence of complications in patients treated with NPWT was lower compared with patients who underwent wet-to-dry dressing changes, regardless of when surgery was performed. The highest rate of complications was observed in patients operated on >6 wk after injury and who received wet-to-dry dressing changes wound care. By comparison, those who underwent surgery within 1 wk of injury and who were bridged with NPWT had the lowest rate of complications. CONCLUSIONS: The use of NPWT therapy in the perioperative management of patients with open lower extremity fractures reduces complication rates associated with limb salvage surgery. Our results suggest that NPWT can be used as a temporizing measure to optimize patients before flap surgery, effectively lengthening the window of opportunity for definitive reconstruction.

Same-Day Discharge for Immediate Breast Reconstruction: A National Surgical Quality Improvement Program Study.

BACKGROUND: Patients undergoing immediate breast reconstruction with tissue expanders are frequently admitted after surgery for monitoring and pain control, which introduces additional costs and risks of nosocomial infection. Same-day discharge could conserve resources, mitigate risk, and return patients home for faster recovery. The authors used large data sets to investigate the safety of same-day discharge after mastectomy with immediate postoperative expander placement. METHODS: A retrospective review was performed of patients in the National Surgical Quality Improvement Program database who underwent breast reconstruction using tissue expanders between 2005 and 2019. Patients were grouped based on date of discharge. Demographic information, medical comorbidities, and outcomes were recorded. Statistical analysis was performed to determine efficacy of same-day discharge and identify factors that predict safety. RESULTS: Of the 14,387 included patients, 10% were discharged the same day, 70% on postoperative day 1, and 20% later than postoperative day 1. The most common complications were infection, reoperation, and readmission, which trended upward with length of stay (6.4% versus 9.3% versus 16.8%), but were statistically equivalent between same-day and next-day discharge. The complication rate for later-day discharge was statistically higher. Patients discharged later had significantly more comorbidities than same or next-day discharge counterparts. Predictors of complications included hypertension, smoking, diabetes, and obesity. CONCLUSIONS: Patients undergoing mastectomy with immediate tissue expander reconstruction are usually admitted overnight. However, same-day discharge was demonstrated to have an equivalent risk of perioperative complications as next-day discharge. For the otherwise healthy patient, going home the day of surgery is a safe and cost-effective option, although the decision should be made based on the individual patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Impact of mastectomy flap necrosis on prepectoral reconstructive outcomes.

INTRODUCTION: As reconstructive surgeons have increasingly transitioned to the prepectoral plane for prosthetic breast reconstruction, the implications of mastectomy skin flap necrosis have become more concerning. Our goal was to evaluate the effect of skin flap necrosis on reconstructive outcomes in patients undergoing immediate prepectoral breast reconstruction. METHODS: A retrospective review was conducted of patients undergoing immediate two-stage prepectoral reconstruction at a single center with at least 3 months follow-up. Postoperative complications, reconstructive outcome, and time to final implant were compared between patients with and without mastectomy skin necrosis. RESULTS: A total of 301 patients underwent 509 prepectoral breast reconstructions. Forty-four patients (14.6%) experienced postoperative mastectomy skin flap necrosis. Demographic and reconstructive characteristics were similar between the necrosis and no necrosis cohorts. Patients with skin necrosis were more likely to undergo reoperation after tissue expander (64% vs 19%, p < 0.01) and undergo expander replacement (13.6% vs 3.5%, p = 0.02). However, rates of reconstructive failure (6.8% vs 6.2%), major infection (9.1% vs 9.0%), and minor infection (13.6% vs 17.5%) after expander placement were statistically similar. Patients with skin necrosis trended toward longer time before final implant placement, although the difference was not statistically significant (6.5 vs 5.0 months, p = 0.08). There was no difference in complication rates between the necrosis and no necrosis cohort after final implant placement. There was a higher rate of revision surgery after implant placement in the necrosis cohort (12.5% vs 4.1%, p = 0.047). CONCLUSIONS: Mastectomy skin flap necrosis is a concerning postoperative event, particularly in patients with prepectoral prostheses. We observed that patients with skin necrosis experience higher reoperation rates in the expander period, yet have similar infection rates and achieve similar final reconstructive outcomes compared to patients without necrosis.

Salvage rates of compromised free flap breast reconstruction after recurrent thrombosis.

BACKGROUND: Microvascular complications after free flap breast reconstruction are devastating problems that increase patient morbidity and potentially lead to flap loss. Yet, there is a dearth of literature about rates of free flap salvage after recurrent vascular thromboses. METHODS: A retrospective review of all patients undergoing microvascular breast reconstruction at UCLA Medical Center from January 1991 to June 2010 was conducted. The incidence of microvascular thrombosis was evaluated and rates of flap salvage and complications were specifically analyzed after a single microvascular revision (Single Event), 2 or more revisions (Multiple Event), and delayed presentation (>2 days) with attempted salvage (Delayed Event). RESULTS: During the study period, 2094 free flap breast reconstructions were evaluated. Of these, 75 (3.6%) flaps suffered a microvascular complication and 16 (0.76%) flaps were lost. The overall salvage rate was 78.7% (59/75) with the highest salvage rate of 95.9% (47/49) for Single Events. Multiple Events had a salvage rate of 53.3% (8/15), whereas Delayed Events had a salvage rate of 27.3% (3/11). The salvage rate decreased with repeated microvascular events (P < 0.01). In the Multiple Event group, vascular conversion (alternate recipient vessel) correlated with improved flap salvage (87.5%), whereas the lack thereof was associated with flap loss (P < 0.001). CONCLUSIONS: The salvage rate of free flap breast reconstruction diminishes dramatically with recurrent microvascular complications, but can be improved with vascular conversion. The salvage rate in cases of delayed presentation is even worse confirming the need for vigilant postoperative monitoring and aggressive intervention in the setting of flap compromise.

Factors influencing patient interest in plastic surgery and the process of selecting a surgeon.

BACKGROUND: Understanding patient interest in cosmetic surgery is an important tool in delineating the current market for aesthetic surgeons. Similarly, defining those factors that most influence surgeon selection is vital for optimizing marketing strategies. OBJECTIVE: The authors evaluate a general population sample's interest in cosmetic surgery and investigate which factors patients value when selecting their surgeon. METHODS: An anonymous questionnaire was distributed to 96 individuals in waiting rooms in nonsurgical clinics. Respondents were questioned on their ability to differentiate between a "plastic" surgeon and a "cosmetic" surgeon, their interest in having plastic surgery, and factors affecting surgeon and practice selection. Univariate and multivariate analyses were conducted to define any significant correlative relationships. RESULTS: Respondents consisted of 15 men and 81 women. Median age was 34.5 (range, 18-67) years. Overall, 20% were currently considering plastic surgery and 78% stated they would consider it in the future. The most common area of interest was a procedure for the face. The most important factors in selecting a surgeon were surgeon reputation and board certification. The least important were quality of advertising and surgeon age. The most cited factor preventing individuals from pursuing plastic surgery was fear of a poor result. Most (60%) patients would choose a private surgicenter-based practice. CONCLUSIONS: The level of importance for each studied attribute can help plastic surgeons understand the market for cosmetic surgery as well as what patients look for when selecting their surgeon. This study helps to define those attributes in a sample population.

The challenging patient in autologous breast reconstruction: obesity, breast ptosis and beyond.

Autologous breast reconstruction has consistently demonstrated excellent patient satisfaction, ideal aesthetic results, and a low risk of complications. With the increasing incidence of breast cancer diagnoses and higher reconstruction rates, surgeons encounter a broader spectrum of patients. Obese patients undergoing breast reconstruction are more likely to experience a surgical complication. While free tissue transfer carries a higher donor site complication rate, implant-based reconstruction carries a higher loss of reconstruction in this population. Additionally, autologous reconstruction consistently demonstrates better patient-reported outcomes. Oncoplastic reconstruction is an oncologically safe alternative to free tissue transfer and implant reconstruction which reduces the risk of complications and the risk of delaying adjuvant therapy. Particularly in obese patients for whom radiation is indicated based on tumor size or nodal involvement, oncoplastic reconstruction is maximally beneficial. The Goldilocks mastectomy is yet another alternative to free tissue transfer or implant reconstruction which carries an acceptable risk profile, especially when augmentation with tissue expander or implant is delayed and performed at a second stage. In patients with breast ptosis undergoing skin-sparing mastectomy, vertical skin reduction allows an acceptable aesthetic result while minimizing the risk for mastectomy flap necrosis (MFN), especially in comparison to Wise pattern skin reduction. If a nipple-sparing mastectomy (NSM) is to be performed in the setting of breast ptosis, a nipple delay or a pre-mastectomy reduction/mastopexy is the safest and most conservative approach, but can alter the timeline for primary cancer resection and therefore is predominantly performed in patients with a genetic predisposition or those undergoing a prophylactic mastectomy. Patients with obesity, breast ptosis, advanced age, active smoking history, prior radiation therapy, or abdominal procedures can carry an increased risk of complications and present a challenge to plastic surgeons. We review the most recent literature published regarding reconstruction in these patient groups and seek to provide practical information to help inform clinical decision-making and operative execution.

Sarcopenia Best Predicts Complications in Free Flap Breast Reconstruction.

Breast reconstruction remains a major component of the plastic surgeon's repertoire, especially free-flap breast reconstruction (FFBR), though this is a high-risk surgery in which patient selection is paramount. Preoperative predictors of complication remain mixed in their utility. We sought to determine whether the sarcopenia score, a validated measure of physiologic health, outperforms the body mass index (BMI) and modified frailty index (mFI) in terms of predicting outcomes. Methods: All patients with at least 6-months follow-up and imaging of the abdomen who underwent FFBR from 2013 to 2022 were included in this study. Appropriate preoperative and postoperative data were included, and sarcopenia scores were extracted from imaging. Complications were defined as any unexpected outcome that required a return to the operating room or readmission. Statistical analysis and regression were performed. Results: In total, 299 patients were included. Patients were split into groups, based on sarcopenia scores. Patients with lower sarcopenia had significantly more complications than those with higher scores. BMI and mFI both did not correlate with complication rates. Sarcopenia was the only independent predictor of complication severity when other factors were controlled for in a multivariate regression model. Conclusions: Sarcopenia correlates with the presence of severe complications in patients who undergo FFBR in a stronger fashion to BMI and the mFI. Thus, sarcopenia should be considered in the preoperative evaluation in patients undergoing FFBR.

Current options in breast reconstruction with or without radiotherapy.

PURPOSE OF REVIEW: A brief overview of the current options in breast reconstruction with special consideration given to the effect of radiotherapy is presented. RECENT FINDINGS: Breast reconstruction is an important part of the overall care of mastectomy patients. Studies have demonstrated improved psychological well being, better quality of life, and most recently increased survival in women who have undergone breast reconstruction. Advancements such as nipple and skin sparing mastectomies, acellular dermal matrix, and improved implant technology have improved the results of implant-based breast reconstruction. The development of perforator flaps has further minimized donor-site morbidity with autologous tissue breast reconstruction. Despite much progress, difficulties remain in the management of patients with locally advanced breast cancer who will require radiation. SUMMARY: Informed physician counseling of current breast reconstruction options is an integral part of the overall care of patients undergoing mastectomy. Special consideration needs to be made for patients with locally advanced breast cancer who require radiotherapy.

Assessment of advanced age as a risk factor in microvascular breast reconstruction.

BACKGROUND: The population of elderly people is the fastest growing population in the United States. Because breast cancer typically affects the elderly population, surgeons will be performing more mastectomies in older patients. In this study, we evaluate the risks of microvascular breast reconstruction as a function of increasing age. METHODS: Between July 2002 and September 2009, a retrospective analysis of 818 free-flap breast reconstructions was used to assess the risk of age on surgical outcomes. Patient comorbidities, the American Society of Anesthesiologists (ASA) classification, and length of hospital stay were used to assess the rates of complications among our age cohorts. RESULTS: Advanced age was not associated with increased complications (P > 0.69). ASA class was a significant predictor of overall complications (P < 0.03) as well as the rate of fat necrosis (P < 0.01) and hematoma (P < 0.001). Flap loss occurred in 1.5% of operations, but there was no difference among the various age groups. Previous surgery was associated with an increased risk of flap loss (P < 0.001), and hypertension also increased the risk of thrombosis (P < 0.04). There was no difference in mean length of hospital stay (4.27 days). CONCLUSIONS: Advanced age should not be considered a risk factor for microvascular breast reconstruction. Because ASA status did predict overall surgical complications, surgeons should consider the patients' overall health status in deciding whether to operate.

Vascular complications and microvascular free flap salvage: the role of thrombolytic agents.

BACKGROUND: Vascular thrombosis with flap loss is the most dreaded complication of microvascular free tissue transfer. Thrombolytic agents such as tissue plasminogen activator have been used clinically for free flap salvage in cases of pedicle thrombosis. Yet, there is a paucity of data in the literature validating the benefit of their use. METHODS: A retrospective review of the breast reconstruction free flap database was performed at a single institution between the years of 1991-2010. The incidence of vascular complications (arterial and/or venous thrombosis) was examined to determine the role of adjuvant thrombolytic therapy in flap salvage. Pathologic examination was used to determine the incidence of fat necrosis after secondary revision procedures. RESULTS: Seventy-four cases were identified during the study period. In 41 cases, revision of the anastamoses was performed alone without thrombolytics with 38 cases of successful flap salvage (92.7%). In 33 cases, anastamotic revision was performed with adjuvant thrombolytic therapy, and successful flap salvage occurred in 28 of these cases (84.8%). Thrombolysis did not appear to significantly affect flap salvage. Interestingly, only two of the salvaged flaps that had received thrombolysis developed fat necrosis, whereas 11 of the nonthrombolysed flaps developed some amount fat necrosis (7.1% vs. 28.9%, P < 0.05). CONCLUSIONS: The decreased incidence of fat necrosis may be attributable to dissolution of thrombi in the microvasculature with the administration of thrombolytics. Although the use of adjuvant thrombolytic therapy does not appear to impact the rate of flap salvage, their use may have secondary benefits on overall flap outcomes.

Survival in breast cancer patients undergoing immediate breast reconstruction.

Immediate and early-delayed breast reconstruction are the preferred methods of reconstruction in breast cancer patients treated with mastectomy. These options for reconstruction allow for superior outcomes through peri-operative planning between the oncologic surgeon and reconstructive team. We used the Surveillance, Epidemiology, and End Results (SEER) database to study the overall survival of patients treated with immediate or early-delayed breast reconstruction after mastectomy. Population level de-identified data was abstracted from the National Cancer Institute's SEER cancer database. We obtained data for all female patients with breast cancer treated with mastectomy from 2000 to 2002. Patients with missing or incomplete data were excluded. Univariate and multivariate statistics were performed using Intercooled Stata 7.0 (College Station, TX). A total of 51,702 patients were included in the study. The mean age was 60.8 (range 20-104) years old. Reconstruction was performed in 16.7% of patients. Multivariate analysis showed that patients treated with mastectomy and reconstruction had a significantly lower hazard ratio of death (HR=0.62, p<0.001) compared with patients treated with mastectomy only, when controlling for demographic and oncologic covariates. Black patients comprised 7.5% of the total population, and multivariate analysis showed that black patients had a significantly increased hazard ratio of death (HR=1.43, p<0.001) when compared with white patients, when controlling for all other covariates including reconstruction status. We show that women with breast cancer who undergo breast reconstruction after mastectomy do not have a worse overall survival than those not undergoing breast reconstruction. This is true when patient age, race, income, and marital status; and tumor stage, histology, grade, use of radiotherapy, and mastectomy site (bilateral or unilateral) are controlled for.

Late free-flap salvage with catheter-directed thrombolysis.

INTRODUCTION: Despite high success rates with free-tissue transfer, flap loss continues to be a devastating event. Flap salvage is often successful if vascular complications are recognized and treated early. However, delayed presentation of flap compromise is an ominous predictor of flap loss. Late free-flap salvage has been described with poor long-term results. Catheter-directed thrombolysis (CDT) has only been described in context with free-tissue transfer in a case of distal bypass salvage. OBJECTIVES: The authors examined the efficacy of highly selective CDT in late salvage of free-flaps with vascular compromise. METHODS: Two patients underwent highly selective CDT after delayed presentation (>5 days) of flap compromise. Patient 1 is a 59-year-old woman who underwent delayed breast reconstruction with a free TRAM flap and presented with arterial thrombosis 12 days postoperatively. Patient 2 is a 53-year-old man who underwent fibular osteocutaneous free-flap reconstruction of a floor of mouth defect who developed venous thrombosis 6 days postoperatively. Patient 2 underwent two attempted operative anastamotic revisions with thrombectomies and local thrombolysis prior to CDT. RESULTS: The average time of presentation was 9 days, with the average time to CDT being 9.5 days. Patient 1 had an arterial thrombosis, whereas Patient 2 had a venous thrombosis. Both patients underwent successful thrombolysis after super-selective angiograms. Continuous infusions of thrombolytic agents were used in both patients for approximately 24 h. Average length of stay postCDT was 7 days with no perioperative complications. Long-term follow-up demonstrated complete flap salvage with no soft tissue loss. CONCLUSION: Despite extremely delayed presentation, aggressive CDT was successful in both breast, and head and neck reconstructions with excellent long-term flap results. CDT appears to be a useful modality in managing difficult cases of free-flap salvage.

Impact of Prior Tissue Expander/Implant on Postmastectomy Free Flap Breast Reconstruction.

BACKGROUND: Implant-based breast reconstructions can result in unsatisfactory results requiring surgical revision or salvage reconstructive surgery with autologous tissue. This study compares the outcomes and complications of salvage (tertiary) flap reconstruction after failed prosthesis placement to those of primary/secondary flap reconstruction. METHODS: All patients undergoing free flap breast reconstruction after failed prosthesis between July 1, 2005, and June 30, 2014, were identified. A matched number of patients who underwent a de novo free flap breast reconstruction were selected randomly for review. The indication for prosthesis removal, demographic and operative data, flap type and inset, and complication rates were evaluated. RESULTS: Eighty-nine women with a history of failed implant-based reconstruction required free flap reconstruction for salvage in 121 breasts. Capsular contracture was the most common indication for prosthesis removal (62.0 percent). Recipient vessel scarring was 5.23 times more likely to occur in the prior prosthesis group (p < 0.001). Alternate flap types other than deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flaps were more frequently used in this cohort. Major complications requiring operative management were more common in the experimental group (17.4 percent versus 8.1 percent; p = 0.035). No difference was noted in flap loss rates, operative take back, or operative time. CONCLUSIONS: Salvage breast reconstruction with autologous tissue after failed prosthesis can be safely performed, with success rates similar to those of primary free flap breast reconstruction. However, these procedures may have increased complexity because of recipient vessel scarring, higher rates of prior radiation therapy, and major complications, which may warrant appropriate preoperative planning and patient counseling. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Implant-based immediate breast reconstruction in the previously augmented patient.

BACKGROUND: Millions of women have undergone augmentation mammaplasty with implants and breast cancer continuing to be the most common non-cutaneous malignancy in female patients. Reconstructive surgeons will inevitably encounter breast cancer patients with prior augmentation. Implant-based techniques represent the most common form of breast reconstruction overall and remains a common option among those who were previously augmented. OBJECTIVE: The purpose of this study is to evaluate outcomes of implant-based reconstruction in previously augmented women. METHODS: A retrospective review from September 2004 to December 2009 was performed. 38 women (63 breasts) with a history of prior augmentation (PA) who underwent implant-based reconstruction were identified and compared to a non-prior augmented (NPA) control group (77 patients; 138 breasts). Normative data, augmentation details, reconstruction method, complication rates, and revision rates were evaluated. RESULTS: The total complication rate was significantly different between the two groups with 18 complications (28.6%) occurring in 9 PA breasts and 20 complications (14.5%) in 19 NPA breasts (p-value 0.037). When analyzed by specific complication subtypes, capsular contracture was the only complication that bordered significance between the two cohorts (p-value 0.057). Complication rates were otherwise similar regardless of augmentation or reconstruction type. CONCLUSION: Implant-based reconstruction is a safe option for previously augmented patients that is able to provide outcomes similar to non-augmented patients. Results are not affected by the location of previous implants or the implant-based reconstruction method. There may be a higher incidence of capsular contracture in the previously augmented patient that warrants further investigation and preoperative discussion.

Rescue of an in vitro palate nonfusion model using interposed embryonic mesenchyme.

The authors previously established an in vitro palate nonfusion model on the basis of a spatial separation between prefusion embryonic day 13.5 mouse palates (term gestation, 19.5 days). They found that an interpalatal separation distance of 0.48 mm or greater would consistently result in nonfusion after 4 days in organ culture. In the present study, they interposed embryonic palatal mesenchymal tissue between embryonic day 13.5 mouse palatal shelves with interpalatal separation distances greater than 0.48 mm in an attempt to "rescue" this in vitro palate nonfusion phenotype. Because no medial epithelial bilayer (i.e., medial epithelial seam) could potentially form, palatal fusion in vitro was defined as intershelf mesenchymal continuity with resolution of the medial edge epithelia bilaterally. Forty-two (n = 42) palatal shelf pairs from embryonic day 13.5 CD-1 mouse embryos were isolated and placed on cell culture inserts at precisely graded distances (0, 0.67, and 0.95 mm). Positive controls consisted of shelves placed in contact (n = 6). Negative controls consisted of shelves placed at interpalatal separation distances of 0.67 mm (n = 6) and 0.95 mm (n = 7) with no interposed mesenchyme. Experimental groups consisted of embryonic day 13.5 palatal shelves separated by 0.67 mm (n = 11) and 0.95 mm (n = 12) with interposed lateral palatal mesenchyme isolated at the time of palatal shelf harvest. Specimens were cultured for 4 days (n = 19) or 10 days (n = 23), harvested, and evaluated histologically. All positive controls at 4 and 10 days in culture showed complete histologic palatal fusion. All negative controls at 4 days and 10 days in culture remained unfused. Five of six palatal shelves separated at 0.67 mm interpalatal separation distance with interposed mesenchyme were fused at 4 days, and all five were fused at 10 days. At an interpalatal separation distance of 0.95 mm with interposed mesenchyme (n = 12), no palates (zero of four) were fused at 4 days, but seven of eight were fused at 10 days. These data suggest that nonfused palatal shelves can be "rescued" with an interposed graft of endogenous embryonic mesenchyme to induce fusion in vitro.

Microvascular lifeboats: a stepwise approach to intraoperative venous congestion in DIEP flap breast reconstruction.

The deep inferior epigastric perforator (DIEP) flap is becoming a widely practiced method of autologous breast reconstruction. Although it has been shown to be a safe and reliable technique with acceptable morbidity, disadvantages include a comparatively higher incidence of venous congestion and total flap loss compared with autologous reconstruction with a pedicled or free transverse rectus abdominis myocutaneous flap. Venous congestion is reported in up to one-third of cases of breast reconstruction with a DIEP flap. If venous congestion is detected and addressed intraoperatively compared with postoperatively, outcomes are significantly improved. A wide variety of techniques have been introduced to augment venous drainage to treat congestion and prevent flap failure. Here, the authors offer a comprehensive review of techniques available to address intraoperative venous congestion in DIEP flaps for breast reconstruction. From this review, the authors propose a stepwise, algorithmic approach to diagnosing and treating this potentially devastating complication.

The effect of prior abdominal surgery on abdominally based free flaps in breast reconstruction.

BACKGROUND: The abdomen has long remained the preferred donor site in breast reconstruction. Over time, the flap has evolved to limit morbidity with reduced muscular harvest. Previous abdominal operations, however, may limit the ability to perform a muscle- or fascia-sparing flap. The purpose of this study was to evaluate outcomes in women who had prior abdominal operations and underwent abdominally based autologous breast reconstruction. METHODS: All patients who underwent abdominally based breast free flap reconstruction between 2004 and 2009 were reviewed. A study group of patients with previous open abdominal surgery were compared to patients with no prior abdominal surgery. Patient demographics, operative details, and flap and donor-site complications were analyzed. RESULTS: A total of 539 patients underwent abdominally based breast free flap reconstruction. The study group consisted of 268 patients (341 flaps) and the control group consisted of 271 patients (351 flaps). Prior abdominal surgery led to greater muscular harvest, as 19.9 percent in the study group versus 12.0 percent required muscle-sparing 1-type harvest (p < 0.01). Both groups presented similar overall complications, with the exception of lower partial flap loss and increased wound healing complications in the study group (p < 0.05). Abdominal wall laxity became less frequent with increasing number of prior abdominal operations. CONCLUSIONS: Abdominally based flaps for breast reconstruction, including muscle-sparing 3 (deep inferior epigastric perforator) flaps, can be performed safely in patients with prior abdominal surgery. These patients should be informed, however, of an increased chance of muscular harvest and wound healing complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.