Incidence, Impact, and Management of Incidentalomas on Preoperative Computed Tomographic Angiograms for Breast Cancer Patients with and without Genetic Mutations.

BACKGROUND: Preoperative abdominal computed tomographic angiograms for free flap breast reconstruction improve operative safety and efficiency, but incidental findings are common and potentially affect management. In addition, the authors hypothesized that patients with genetic mutations might have a higher rate of significant findings. The authors present the largest series of computed tomographic angiogram "incidentalomas" in these two populations and an evidence-based algorithm for managing common findings. METHODS: All patients undergoing free flap breast reconstruction at Northwell Health between 2009 and 2017 were eligible. Medical history, perioperative details, and radiology reports were examined with abnormal findings recorded. Published literature was reviewed with radiologists to develop standardized guidelines for incidentaloma management. RESULTS: Of 805 patients included, 733 patients had abdominal imaging. One hundred ninety-five (27 percent) had a completely negative examination. In the remaining 538 patients, benign hepatic (22 percent) and renal (17 percent) findings were most common. Sixteen patients (2.2 percent) required additional imaging (n = 15) or procedures (n = 5). One finding was concerning for malignancy-renal cell carcinoma-which interventional radiology ablated postoperatively. Seventy-nine patients (10.8 percent) had a genetic mutation but were not found to have a statistically significant higher rate of incidentalomas. CONCLUSIONS: The authors' rate of computed tomographic angiography incidental findings (73 percent) is consistent with previous studies, but the rate requiring further intervention (2.2 percent) is lower. Incidental findings were no more common or pathologic among genetic mutation carriers. The authors also introduce an evidence-based algorithm for the management of common incidentalomas. Using these guidelines, plastic surgeons can reassure patients, regardless of mutation status, that incidentalomas are most commonly benign and have minimal impact on their surgical plan.

Obesity and the Abdominal Wall Vasculature: Correlating BMI with Perforator Anatomy.

BACKGROUND: Given the national trends in obesity, reconstructive surgeons are faced with an increasing number of overweight and obese women interested in postmastectomy breast reconstruction. While the link between obesity and adverse postoperative outcomes is well established, few studies have explored the relationship between body mass index (BMI) and the vasculature of the anterior abdominal wall. METHODS: A radiographic review was conducted on female patients who underwent computed tomographic angiography (CTA) of the anterior abdominal wall. CTA studies were evaluated for perforator caliber and quantity. Patients were stratified by BMI. The relationship between BMI and the diameter and number of deep inferior epigastric artery (DIEA) perforators was analyzed using analysis of variance using Minitab software with α of 0.05. RESULTS: There were a total of 916 hemiabdomens included in this study. There was no statistically significant correlation between BMI and DIEA diameter or mean diameter of major (≥ 1 mm) DIEA perforators. There was a statistically significant negative correlation between BMI and the number of major DIEA perforators (p < 0.01). CONCLUSION: Despite the increased demands of excess abdominal adiposity, DIEA perforator caliber was not correlated with BMI on CTA. The number of major DIEA perforators visualized on CTA decreased with increasing body weight may indicate a limitation of CTA for presurgical planning of abdominal free flaps in obese patients.

Infection prophylaxis in periorbital Mohs surgery and reconstruction: a review and update to recommendations.

Mohs micrographic surgery and reconstruction is considered by many as the gold standard for treatment of cutaneous malignancies arising in the periorbital region. It has a high rate of tumor clearance and a low rate of postsurgical complications. One of the most common complications is surgical site infection. Although surgical site infection occurs in less than 3% of patients, it may result in significant morbidity. Considerable research efforts have been devoted to identifying risk factors associated with the development of a postsurgical infection. We examine the impact of endogenous factors (which determine the efficacy of a patient's immune system), exogenous factors (which influence a patient's exposure to bacterial pathogens), and antimicrobial interventions on the incidence of surgical site infection and propose evidence-based recommendations.

Reducing Length of Stay after Microsurgical Breast Reconstruction with a Standardized Postoperative Protocol.

BACKGROUND: Despite widespread acceptance of enhanced recovery after surgery protocols in other surgical specialties, plastic surgery has been slow to adopt fast-track principles. Recently, however, studies have shown that patients undergoing microsurgical breast reconstruction may benefit from a comprehensive postoperative protocol. METHODS: All microsurgical breast reconstructions with abdominal free flaps performed by the senior author (A.K.) at a single institution from June 2009 to December 2013 were reviewed. Demographic information (e.g., age, body mass index, and comorbidities), operative details (e.g., laterality, type of flap), and postoperative data (e.g., complications, length of stay) were collected from patients' medical records. The authors employed a universal comprehensive protocol that dictated all postoperative care as it relates to diet, ambulation, flap monitoring, anticoagulation, analgesia, venous thromboembolism, antibiotic prophylaxis, and discharge criteria. RESULTS: During the study period, 161 patients underwent 289 free flaps. The average length of stay for all patients was 3.26 ± 1.19 days. The incidence of complications requiring return to the operating room was 4.35% (7 patients). The incidence of flap failure was 0.69% (2 of 289 flaps). Only one flap failure occurred after hospital discharge. Statistical analysis demonstrated that the presence of any complication requiring return to the operating room increased hospital course by an average of 1.37 days (p = 0.0027). CONCLUSION: The standardization of postoperative care for patients undergoing microsurgical breast reconstruction results in a short hospital length of stay without increasing the incidence of flap failure or postoperative complications requiring return to the operating room.

Neoumbilicoplasty With a Pedicled Deep Inferior Epigastric Perforator Island Flap.

Management of the umbilicus is a common dilemma at the time of abdominoplasty and abdominal wall reconstruction. It is not uncommon for underlying pathologies, such as hernias and surgical scars, to result in a disfigured or obliterated native umbilicus or make the blood supply to the umbilical stalk unreliable. In these scenarios, the umbilicus is often sacrificed. Staged neoumbilical reconstruction may be offered and typically utilizes a small skin flap and full-thickness skin graft (Ann Plast Surg 2009;63:358-360). Our technique, in contrast, permits reconstruction of the neoumbilicus in the immediate setting utilizing normally discarded skin with a robust blood supply from a deep inferior epigastric artery perforator. In this series of 13 consecutive neoumbilicoplasties, the pedicled deep inferior epigastric artery perforator island flap provided reliable results and favorable aesthetic outcomes.