Lumbar Artery Perforator Flaps: A Systematic Review of Free Tissue Transfers and Anatomical Characteristics.

BACKGROUND: The lumbar artery perforator (LAP) flap has gained popularity as a versatile flap in reconstructive surgery; however, few studies have analyzed salient characteristics of this flap. We set out to provide a comprehensive appraisal of free tissue transfers of LAP flaps with specific attention to anatomic features and clinical outcomes. METHODS: Using preferred reporting items for systematic reviews and meta-analyses guidelines, we identified clinical, radiographic, and cadaveric studies of LAP flaps and assessed outcomes, complications, and anatomic parameters, such as pedicle length, diameter, location, and course. RESULTS: A total of 254 articles were initially reviewed, of which 18 met the final inclusion criteria. Ten studies were primarily concerned with anatomic characteristics, and most clinical studies related to breast reconstruction. The operative durations varied between 4.8 and 9.2 hours. Partial and total flap losses were estimated at 2.6% and 7.6%, respectively. Acute revision rates ranged from 16% to 24% related to hematoma, arterial thrombus, and venous thrombus. Donor-site seromas were frequently encountered in breast reconstruction with an incidence of 17% to 78%. CONCLUSIONS: The LAP flap has demonstrated favorable outcomes in various reconstructive scenarios. The caudal perforators generally offer more pedicle length, greater pedicle diameter, and septocutaneous course and may be better suited for flap design. For breast reconstruction, the LAP flap is a useful alternative to abdominal-based flaps, and special attention should be given to optimizing pedicle length using interposition grafts and methods that minimize seroma formation at the donor site.

Outcomes Analysis of Textured Versus Smooth Tissue Expanders in Breast Reconstruction.

INTRODUCTION: Because of concerns related to the correlation of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and textured implants, the use of smooth devices in breast reconstruction has been increasing. Currently, there is a paucity of literature evaluating the safety of smooth tissue expanders (STEs), which are now being used more frequently in first-stage breast reconstruction. This study sought to compare the safety and outcomes associated with STEs compared with textured tissue expanders in prosthesis-based breast reconstruction. METHODS: A single-institution retrospective review of 394 patients undergoing tissue expander-based breast reconstruction (147 smooth and 247 textured) between 2015 and 2019 was conducted. Patient demographics, comorbidities, treatment characteristics, complications, and surgical outcomes were evaluated. Data analysis was performed using Fisher exact and t tests. RESULTS: No significant difference in demographics or complication rates were identified, including rates of hematoma, seroma, wound dehiscence, delayed wound healing, infection, tissue expander malposition, nipple necrosis, mastectomy flap necrosis, reoperation, readmission, and explantation. Average follow-up was 19 and 22 months for the smooth and textured groups, respectively. No cases of BIA-ALCL were identified in either group. CONCLUSIONS: With equivocal safety profiles and no demonstrated risk in BIA-ALCL associated with STEs, this study supports the safety of using STEs compared with textured tissue expanders in prosthesis-based breast reconstruction with the advantage in preventing BIA-ALCL and concludes that there is no role for textured breast expanders.

Successful Microsurgical Scalp Replantation Utilizing Loupe Magnification.

ABSTRACT: Total scalp avulsion is a rare injury that poses a unique reconstructive challenge. Microsurgical replantation is considered the first-line choice; yet anastomotic efforts may be strained to find suitable recipient and target vessels. Concomitant injuries may also delay or hinder operative intervention. These complex scenarios are difficult to navigate and necessitate multidisciplinary input to optimize outcomes. As such, the authors present an illustrative case report of a total scalp avulsion injury that underwent successful microsurgical replantation. This report highlights the novel use of loupe magnification in scalp replantation and reviews technical and clinical nuances that facilitate a favorable reconstruction.

Five-Year Breast Surgeon Experience in LYMPHA at Time of ALND for Treatment of Clinical T1-4N1-3M0 Breast Cancer.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a source of postoperative morbidity for breast cancer survivors. Lymphatic microsurgical preventive healing approach (LYMPHA) is a technique used to prevent BCRL at the time of axillary lymph node dissection (ALND). We report the 5-year experience of a breast surgeon trained in LYMPHA and investigate the outcomes of patients who underwent LYMPHA following ALND for treatment of cT1-4N1-3M0 breast cancer. METHODS: A retrospective review of patients with cT1-4N1-3M0 breast cancer was performed in patients who underwent ALND with and without LYMPHA. Diagnosis of BCRL was made by certified lymphedema therapists. Descriptive statistics and lymphedema surveillance data were analyzed using results of Fisher's exact or Wilcoxon rank-sum tests. Logistic regression and propensity matching were performed to assess the reduction of BCRL occurrence following LYMPHA. RESULTS: In a 5-year period, 132 patients met inclusion criteria with 76 patients undergoing LYMPHA at the time of ALND and 56 patients undergoing ALND alone. Patients who underwent LYMPHA at the time of ALND were significantly less likely to develop BCRL than those who underwent ALND alone (p = 0.045). Risk factors associated with BCRL development were increased patient age (p = 0.007), body mass index (BMI) (p = 0.003), and, in patients undergoing LYMPHA, number of positive nodes (p = 0.026). CONCLUSIONS: LYMPHA may be successfully employed by breast surgeons trained in lymphatic-venous anastomosis at the time of ALND. While research efforts should continue to focus on prevention and surveillance of BCRL, LYMPHA remains an option to reduce BCRL and improve patient quality of life.

Safety of Coupled Arterial Anastomosis in Autologous Breast Reconstruction.

BACKGROUND: This study compares the outcomes of coupled versus hand-sewn arterial anastomosis in microvascular breast reconstruction. METHODS: Retrospective chart review of breast reconstruction free flaps performed between 2013 and 2018 was conducted. Primary end points included flap loss, intraoperative arterial anastomosis revision, and operating room takeback. The decision to couple the arterial anastomosis was based on patient's age, surgeon's preference, history of radiation, and vessel quality. All anastomoses were performed under ×3.5 loupe magnification to internal mammary or thoracodorsal vessels. RESULTS: Authors reviewed 104 free flaps; two were lost in hand-sewn group; no flaps were lost in coupled group. There was no significant difference in anastomotic revision rate between coupled and hand-sewn arterial anastomosis (p = 0.186) or return to operating room (OR) between coupled and hand-sewn flaps (p = 1.000). Reasons for takeback included venous congestion and hematoma. CONCLUSION: This study reflects that coupled arterial anastomosis in breast reconstruction may be safely performed without increased risk in anastomotic revision, takeback, or flap loss. Decision to couple should be based on surgeon skill, patient age and history, and assessment of flap and recipient site vasculature.

Minimally Invasive Corneal Neurotization With Acellular Nerve Allograft: Surgical Technique and Clinical Outcomes.

PURPOSE: To describe a minimally invasive surgical technique and its clinical outcomes with the use of acellular nerve allograft to re-establish corneal sensibility in patients with neurotrophic keratopathy. METHODS: Acellular nerve allograft was coapted to an intact supraorbital, supratrochlear, or infraorbital nerve and transferred to the affected eye. Donor nerve pedicles were isolated through a transpalpebral or transconjunctival approach. Retrospective evaluation of preoperative and postoperative corneal sensibility, ocular surface, and best-corrected visual acuity was performed in all patients. Mean follow-up period was 6 months (range: 3-10 months). RESULTS: Corneal neurotization with acellular nerve allograft was successfully performed in 7 patients with restoration of corneal sensibility and corneal epithelial integrity. In vivo confocal microscopy demonstrated increased nerve density in corneal stroma at 4 months after surgery. CONCLUSIONS: The use of acellular nerve allograft allows for a minimally invasive approach to successful corneal neurotization.

Is Unipedicled Transverse Rectus Abdominis Myocutaneous Flap Obsolete Owing to Superiority of DIEP Flap?

BACKGROUND: Pedicled transverse rectus abdominis myocutaneous (TRAM) flap was developed by Hartrampf in 1982 for breast reconstruction. Since deep inferior epigastric perforator (DIEP) flap was popularized, it has become the criterion standard for abdominally based breast reconstruction owing to its low donor site morbidity, excellent cosmetic outcomes, and high success rates. The purpose of this review is to determine if a unilateral pedicle TRAM flap has become obsolete to DIEP flap. METHODS: Literature review was performed with key words DIEP flap, pedicled TRAM flap, and comparison of DIEP flap to unilateral pedicled TRAM flap. Specific journals reviewed were Plastic and Reconstructive Surgery and Annals of Plastic Surgery. Flaps were compared in the studies with respect to donor site morbidity, flap-related complications, operative time, length of hospital stay, patient satisfaction, and cost. RESULTS: Abdominal bulge and/or hernia were found to be statistically higher in pedicled TRAM patients in most of the studies reviewed. Also, uniformly flap fat necrosis rate was lower in DIEP patients. Rate of partial flap necrosis, total flap loss, hematoma, seroma, delayed healing, and infection varied in the studies with respect to both flaps without definitive trend towards specific flap technique. Overall patient satisfaction appeared to be higher in DIEP group in several studies. No significant differences between length of hospital stay, overall complication rates, and operative times between DIEP and unilateral pedicled TRAM patients were noted, and the results varied across different studies. Deep inferior epigastric perforator flap reconstructions were associated with higher overall cost in one study. CONCLUSIONS: In a carefully selected patient and circumstances where microsurgery is suboptimal, unipedicled TRAM flap can be a safe and viable option with satisfactory outcomes. It should continue to remain as part of core plastic surgery training and armamentarium of plastic surgeons in autologous breast reconstruction.

Safety of Microsurgery Under Loupes Versus Microscope: A Head-to-Head Comparison of 2 Surgeons With Similar Experiences.

BACKGROUND: Microsurgery is performed using either the operating microscope or loupe magnification. Use of the operating microscope is considered the "criterion standard"; however, loupes are emerging as a safe and reliable technique to perform microsurgery. The purpose of this study was to analyze the safety of microsurgery under loupe magnification compared with the microscope. Previous studies discussing the safety of loupe magnification during microsurgery have been published; however, this is the first study to compare free flap outcomes from 2 surgeons at the same institution, each using their respective technique. METHODS: The outcomes were compared by retrospective chart review of 116 patients, and 148 microvascular free tissue transfers were performed between January 1, 2013, and July 15, 2016, by 2 surgeons (D.S.) and (M.L.). Patients' demographics, free flap failure rate, and other surgical complications were analyzed. Statistical significance was determined by unpaired t test, and χ analysis was used to determine statistical significance in proportions between groups. RESULTS: Thirty-eight percent of flaps were performed under ×3.5 loupe magnification and 62% under the operating microscope. Most free flaps used were deep inferior epigastric perforator or muscle sparing transverse rectus abdominis flaps (52%) for breast reconstruction, remainder of free flaps included ALT, radial forearm, and latissimus dorsi for a variety of reconstructive applications. There was no significant difference between the loupes and microscope groups in intraoperative anastomotic revision rate (27% vs 17%), postoperative arterial or venous thrombosis (4.4% vs 2.6%, 5.4% vs 2.2%), flap loss (3.6% vs 2.2%), or median length of stay (6 days vs 6.5 days). The loupe magnification group had statistically significant shorter setup time (20 minutes, P < 0.01). CONCLUSIONS: Consistent with previously reported studies, we found no statistical difference in free flap outcomes and safety under loupe magnification compared with the operating microscope. This is the first study to demonstrate these findings with 2 microsurgeons both in their first 3 years in practice, with similar training and experience, operating at the same institution and given the same resources, each using either microscopes or loupes for microsurgery.

Endoscopic Corneal Neurotization: Technique and Initial Experience.

PURPOSE: The authors describe a minimally invasive surgical technique to re-establish corneal sensibility in a patient with neurotrophic keratopathy with the supraorbital nerve harvested endoscopically. METHODS: Pedicled contralateral supraorbital nerve was harvested endoscopically through small eyelid crease and scalp incisions and transferred to the affected eye. RESULTS: Endoscopic corneal neurotization was successfully performed with restoration of corneal sensibility and corneal epithelial integrity. CONCLUSIONS: The use of an endoscope allows for a minimally invasive approach to successful corneal neurotization with the supraorbital nerve.

Endoscopic Corneal Neurotization: Cadaver Feasibility Study.

PURPOSE: The authors describe a cadaver feasibility study investigating a minimally invasive technique for corneal neurotization with the supraorbital nerve harvested endoscopically. METHODS: A cadaver study was performed to investigate the technical feasibility of corneal neurotization via endoscopic supraorbital nerve transfer to the corneoscleral limbus. RESULTS: Endoscopic corneal neurotization was successfully performed on each cadaveric hemiface. CONCLUSION: The use of an endoscope allows for a minimally invasive approach to corneal neurotization with the supraorbital nerve.

Bipolar Latissimus Dorsi Transfer for Restoration of Pectoralis Major Function in Poland Syndrome.

BACKGROUND: Poland syndrome typically presents as a unilateral congenital complete or partial absence of the pectoralis major muscle, variably with other associated anomalies. Reconstruction of the defect typically concentrates on aesthetic restoration with functional outcomes being unsuccessful or limited. We present an innovative means of true muscle transfer that provided functional benefit to increase upper extremity strength. CASE REPORT: A 16-year-old adolescent boy with Poland syndrome manifesting as left pectoralis major muscle agenesis wished to undergo functional reconstruction. He wanted to play on his high school football team, but could not meet the minimum weightlifting requirements. An ipsilateral latissimus dorsi muscle bipolar functional transfer was done with bone-anchored inset into the sternum and humerus so that muscle flexion would replace the absent pectoralis major. A progressive weight training program was then instituted postoperatively. At 9 months, a significant increase in left upper extremity strength was confirmed. The patient ultimately was able to surpass the weightlifting requirements for his high school football team, and joined the team. CONCLUSIONS: Our highlighted procedure restored functional outcome using both plastic surgical principles and orthopedic techniques for muscle and tendon repair: bipolar muscle transfer and load-bearing muscle inset. Heretofore, transfer of the latissimus for provision of pectoralis major function has not been reported. Functional reconstruction was possible due to stable, bipolar muscle transfer with load-bearing muscle attachments into cortical bone of the anterior sternum and anteromedial aspect of the humerus. The techniques described should be within the skill set of most plastic surgeons, so that functional restoration for those with Poland syndrome is possible and accessible.

Contributing variables to post mastectomy tissue expander infection.

Tissue expander breast reconstruction is a common post mastectomy breast procedure performed by plastic surgeons. The purpose of this study was to define the incidence of breast reconstruction prosthetic infection, relate patient characteristics with increased rate of infection, and analyze the influence of postoperative complications to expander/implant infection. A retrospective, single-institution chart review of 195 women with post mastectomy tissue expander/implant reconstructions performed from 2006 through 2008 was conducted. Total periprosthetic infection rate was calculated. Patient factors, operative technique, and noninfectious complications were analyzed and related to increased periprosthetic infection rate. A binary logistic regression model was fitted using periprosthetic infection as the dependent variable and 12 patient characteristics as independent variables, followed by a step-wise model for best fit with a limited number of independent variables. The overall periprosthetic infection rate per patient over the 2 year period was 5.1%. The incidence of periprosthetic infection per reconstructed breast was 3.2%. Odds ratio estimates indicated that the presence of cellulitis increased the odds of periprosthetic infection more than 200 times (p = <0.0001), and inpatient procedures increased the odds 16 times (p = 0.02). Other variables (i.e., age > 65, DM, flap necrosis, smoking, dehiscence, AlloDerm, etc) failed to reach statistical significance (p > 0.05). Postoperative breast cellulitis and inpatient status appear to be significant risk factors for increased periprosthetic infection. No significant increase in periprosthetic infection rate was noted with other variables in this model.

Objective Comparison of Donor-Site Morbidity following Full and Thoracodorsal Nerve-Preserving Split Latissimus Dorsi Flaps.

BACKGROUND: The latissimus dorsi flap is a workhorse for reconstruction. However, flap harvest has been variably reported to result in donor-site morbidity. The aim of this study was to compare donor-site morbidity following harvest of a split latissimus dorsi flap, preserving the anterior branch of the thoracodorsal nerve, and a traditional nerve-sacrificing full latissimus dorsi flap. METHODS: Patients who underwent split or full latissimus dorsi flaps between July of 2017 and August of 2020 at a single center were recalled for assessment. Donor-site morbidity in the shoulder was evaluated through the Disabilities of the Arm, Shoulder and Hand questionnaire; the Shoulder Pain and Disability Index; and the American Shoulder and Elbow Surgeons questionnaire. Medical Research Council strength grading was also performed. RESULTS: A total of 22 patients in the split latissimus dorsi cohort and 22 patients in the full latissimus dorsi cohort were recalled. Patient-reported outcomes as assessed through the Disabilities of the Arm, Shoulder and Hand questionnaire; Shoulder Pain and Disability Index; and American Shoulder and Elbow Surgeons questionnaire scores revealed statistically greater (p < 0.05) donor-site morbidity associated with the traditional compared to split latissimus dorsi flap. Seven patients in the full latissimus dorsi cohort had less than Medical Research Council grade 5 power at the shoulder, whereas all patients in the split latissimus dorsi cohort demonstrated full power at the shoulder. CONCLUSIONS: Traditional full latissimus dorsi flaps were found to result in greater donor-site morbidity compared to thoracodorsal nerve-preserving split latissimus dorsi flaps. Split latissimus dorsi flaps may be beneficial in preserving donor-site function and strength. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Hyperfractionated-Accelerated Reirradiation with Proton Therapy for Radiation-Associated Breast Angiosarcoma.

Purpose: Radiation-associated angiosarcoma (RAAS) is a rare complication among patients treated with radiation therapy for breast cancer. Hyperfractionated-accelerated reirradiation (HART) improves local control after surgery. Proton therapy may further improve the therapeutic ratio by mitigating potential toxicity. Materials and Methods: Six patients enrolled in a prospective registry with localized RAAS received HART with proton therapy between 2015 and 2021. HART was delivered twice or thrice daily in fraction sizes of 1.5 or 1.0 Gy, respectively. All patients received 45 Gy to a large elective volume followed by boosts to a median dose of 65 (range, 60-75) Gy. Toxicity was recorded prospectively by using the Common Terminology Criteria for Adverse Events, version 4.0. Results: The median follow-up duration was 1.5 (range, 0.25-2.9) years. The median age at RAAS diagnosis was 73 (range, 60-83) years with a median latency of 8.9 (range, 5-14) years between radiation therapy completion and RAAS diagnosis. The median mean heart dose was 2.2 (range, 0.1-4.96) Gy. HART was delivered postoperatively (n = 1), preoperatively (n = 3), preoperatively for local recurrence after initial management with mastectomy (n = 1), and as definitive treatment (n = 1). All patients had local control of disease throughout follow-up. Three of 4 patients treated preoperatively had a pathologic complete response. The patient treated definitively had a complete metabolic response on her posttreatment PET/CT (positron emission tomography-computed tomography) scan. Two patients developed distant metastatic disease despite local control and died of their disease. Acute grade 3 toxicity occurred in 3 patients: 2 patients undergoing preoperative HART experienced wound dehiscence and 1 postoperatively developed grade 3 wound infection, which resolved. Conclusion: HART with proton therapy appears effective for local control of RAAS with a high rate of pathologic complete response and no local recurrences to date. However, vigilant surveillance for distant metastasis should occur. Toxicity is comparable to that in photon/electron series. Proton therapy for RAAS may maximize normal tissue sparing in this large-volume reirradiation setting.

Basal cell carcinoma and rhinophyma.

Rhinophyma, the end stage in the development of acne rosacea, is characterized by sebaceous hyperplasia, fibrosis, follicular plugging, and telangiectasia. Although it is commonly considered a cosmetic problem, it can result in gross distortion of soft tissue and airway obstruction. Basal cell carcinoma (BCC) is a rare finding in patients with rhinophyma. The objective of this study is to review the literature of BCC in rhinophyma and report on a case. A 70-year-old male presented with long-standing rosacea that resulted in a gross nasal deformity. The patient suffered from chronic drainage and recurrent infections that failed conservative treatment with oral and topical antibiotics. The patient decided to proceed with surgical intervention and underwent tangential excision and dermabrasion in the operating room. Since 1955 there have been 11 cases reported in the literature. In our case, the pathology report noted that the specimen had an incidental finding of a completely resected BCC. The patient did well postoperatively and at follow-up remains tumor-free. Despite the uncommon occurrence of BCC in resection specimens for rhinophyma, we recommend that all specimens be reviewed by a pathologist. If BCC is detected, re-excision may be necessary and careful follow-up is mandatory. Larger studies would be needed to determine the correlation between the 2 conditions.

Assessment of Free Flap Breast Reconstructions.

Free flap breast reconstruction may be offered as a treatment option at federal facilities with appropriate patient selection and planning.