Intraoperative Indocyanine Green Angiography for Fat Necrosis Reduction in the Deep Inferior Epigastric Perforator (DIEP) Flap.

BACKGROUND: Fat necrosis is a frequent complication (up to 62.5%) of microsurgical breast reconstruction using the deep inferior epigastric perforator (DIEP) flap. This could have important clinical and psychological repercussions, deteriorating the results and increasing reconstruction costs. OBJECTIVES: The aim of this study was to demonstrate the intraoperative use of indocyanine green angiography (ICGA) to reduce fat necrosis in DIEP flap. METHODS: Sixty-one patients who underwent unilateral DIEP flap procedures for breast reconstruction after oncological mastectomy were included (24 cases with intraoperative use of ICGA during surgery, 37 cases in the control group). The follow-up period was 1 year after surgery. The association between the use of ICGA and the incidence of fat necrosis in the first postoperative year, differences in fat necrosis grade (I-V), differences in fat necrosis requiring reoperation, quality of life, and patient satisfaction were analyzed. RESULTS: The incidence of fat necrosis was reduced from 59.5% (control group) to 29% (ICG-group) (P = 0.021) (relative risk = 0.49 [95% CI, 0.25-0.97]). The major difference was in grade II (27% vs 2.7%, P = 0.038). The number of second surgeries for fat necrosis treatment was also reduced (45.9% vs 20.8%, P = 0.046). The ICG group had higher scores on the BREAST-Q. CONCLUSIONS: Intraoperative ICGA is a useful technique for reconstructive microsurgery that might improve patient satisfaction and reduce the incidence of fat necrosis by half as well as reduce its grade, especially in small fat necrosis cases; consequently, ICGA could reduce the number of secondary surgeries for treatment of fat necrosis.

Anterior intercostal artery perforator flap in immediate breast reconstruction: Anatomical study and clinical application.

BACKGROUND: Although the use of lateral intercostal artery perforator (ICAP) flaps for immediate breast reconstruction has been widely described, data on the use of the anterior ICAP (AICAP) flaps for this indication are limited. In this context, we describe the results of anatomical study and our clinical experience with AICAP flaps for breast reconstruction. METHODS: In this study, the location and characteristics of the AICAPs were dissected in 12 female adult formalin-preserved hemitrunks and two fresh-frozen cadavers. Fourteen patients (mean BMI 23) underwent partial breast resection for a quadrant breast cancer followed by breast reconstruction with an intercostal perforator flap. The mean resection size was 6 × 5 × 5.5 cm (range 3-8 × 3.5-7 × 4-8 cm).The main outcome measures were pre-operative and postradiotherapy health-related quality of life assessed with the BREAST-Q reconstruction survey. RESULTS: According to anatomical study, at least one perforator was found in each third of hemitrunks dissected. The mean of perforator size was in diameter 0.42 ± 0.05 mm and in length 3.1 ± 0.36 cm. In clinical outcomes, the mean of flap size was 16 × 5 × 3 cm (range 14-19 × 3-8 × 2-5 cm). The mean surgical time was 120 min (range 109-125 min). Only one partial flap failure was detected. No postoperative changes in breast size were observed, although soft tissue changes were observed in four patients after radiotherapy. The mean BREAST-Q scores changes were 0 in satisfaction with the breast, 5 in satisfaction with outcome, 0 in psychosocial well-being, 6.15 in sexual well being, and 34.69 in physical well-being. CONCLUSIONS: Based on this anatomical and clinical study, we found AICAP flap has a consistent vascularization with good perforators. And moreover, it is suitable for partial breast reconstruction (quadrantectomy) and does not appear to negatively impact patient satisfaction.

Use of fibula flaps to treat persistent talonavicular nonunion: A report of three cases.

Owing to the limited blood supply in the midfoot, multiple arthrodesis attempts in midfood joints may result in severe osteonecrosis, leading to a difficult scenario for bone reconstruction. This article describes the use of fibula flaps (two free and one pedicled flap) to reconstruct bone defects in three cases of persistent nonunion in midfoot joints. Before admission, all patients (aged 32-56 years old) had undergone multiple arthrodesis attempts (range 3-4) aimed at treating joint diseases associated with flatfoot or Müller-Weiss syndrome. All inserted flaps were stable, and bone fusion was confirmed by X-ray examination at month 4. After the follow-up period (range 1-4 years), all patients showed normal, painless gait. No foot deformities or further complications were observed. Our report suggests that fibula flap transfer may be a good alternative for treating persistent nonunion in midfoot joints involving bone loss, and may prevent the osteonecrosis associated with limited blood supply. © 2016 Wiley Periodicals, Inc. Microsurgery 36:430-434, 2016.

Oropharyngeal free flap reconstruction: Transoral robotic surgery versus open approach.

Objective: Transoral robotic surgery (TORS) has evolved since its 2009 US Food and Drug Administration approval for use in local stage T1-T2 oropharyngeal carcinoma. The ability to resect increasingly larger and more complex lesions has led to the need to introduce reconstructive techniques through this route, avoiding the classic transmandibular or pull-through approach. Few studies have compared the safety, efficacy, and advantages of TORS versus classic open approaches in oropharyngeal salvage surgery with reconstruction using microanastomosed flaps. Here we retrospectively compare our center's experience with the open approach and TORS and describe the technical variations used. Methods: Between 2013 and 2021, 30 stage III-IV oropharyngeal cancer patients underwent salvage surgery with reconstruction in our center. From 2013 to 2017, 15 patients underwent surgery with the classic open approach, and from 2018 to 2021, an additional 15 patients underwent TORS. We have compared surgical outcomes, post-surgical results, and survival in the two groups. Results: Patient characteristics were similar in the two groups. TORS was associated with shorter surgical time (p < .001), fewer complications (p = .01), shorter hospital stay (p < .001), and lower feeding tube requirements (p = .003). No significant differences were observed between the two groups in the free margin rate or survival. Conclusion: Oropharyngeal salvage surgery with TORS with free flap reconstruction reduced associated morbidity compared to the open approach in a patient cohort with poor prognosis. Level of Evidence: 4.

[Supercharged ileocoloplasty: an option for complex oesophageal reconstructions]. / Ileocoloplastia supercharged: una opción para reconstrucciones esofágicas complejas.

INTRODUCTION: Oesophageal reconstruction in a second time is a complex surgical operation which, in some cases, requires combining microvascular techniques to increase vascular flow to the conduit. "Supercharged" ileocoloplasty allows creation of a longer conduit that makes it possible to replace the entire oesophagus. We describe our initial experience with this technique for the total reconstruction of the oesophagus. MATERIAL AND METHODS: A retrospective review of the period from October 2007 to December 2009 identified 4 patients on whom a deferred oesophageal reconstruction was performed with a "supercharged" ileocoloplasty. The indications of this technique, morbidity and mortality, as well as functional results during follow up were evaluated. RESULTS: The indications of this technique were: previous failure of a left colon interposition (1), oesophageal disconnection due to a gastro-pleural fistula (1), total oesophagogastrectomy (1) and partial oesophagogastrectomy (1) due to the ingestion of caustic substances, respectively. Gastrointestinal complications were the most frequent. Two cervical fistulas were diagnosed which were resolved with an absolute diet, antibiotic therapy and enteral nutrition. There was no mortality. After a median follow up of 14.7 months, two patients were nourished exclusively by mouth, one by a mixed route (oral-enteral) and another exclusively by the enteral route due to an oesophageal stenosis 11 centimetres from the dental arch; this patient required dilations and is awaiting a jejunal graft. CONCLUSIONS: "Supercharged" ileocoloplasty is a complex treatment option for the total reconstruction of the oesophagus when no other alternatives are available. Postoperative morbidity is significant but the functional results are good.

When to assess the DIEP flap perfusion by intraoperative indocyanine green angiography in breast reconstruction?

BACKGROUND: Although the indocyanine green angiography (ICGA) has been used for years in the assessment of Deep Inferior Epigastric Perforator (DIEP) perfusion, it has not yet been established when it should be performed during the surgery. The aim of this study is to evaluate whether it is better to perform the test on the donor or recipient sites. METHODS: Intraoperative perfusion of 46 DIEP flaps was assessed twice, on the donor and recipient sites. Differences between both ischemic areas of each flap were statistically analyzed. In addition, perforator location and risk factors were evaluated in order to assess whether they are associated with changes in the perfusion of the flap between both sites. RESULTS: Differences between ischemic areas on the donor and recipient sites were statistically significant (p = 0.012). However, in most cases (82.6%) the ischemic area was the same on both sites, and the final flap design only changed in two cases (4.3%) because of the ICGA findings on the recipient site. Besides, performing the ICGA on the donor site facilitated the identification of the best perfused areas, allowed a better planning of its placement into the recipient site, and also can be useful to choose the best perforator. Bilateral DIEP flap, lateral location of the perforator and tobacco use had a statistically significant association with lower probability to increase the perfusion area between both sites. CONCLUSIONS: several advantages have been found in performing the ICGA on the donor site to assess the perfusion of the DIEP flap.

The Anterior Intercostal Artery Flap: Anatomical and Radiologic Study.

BACKGROUND: Reconstruction of the anterior thorax is complex because of the presence of aesthetically important areas such as the breast, sternum, and upper abdomen. For this reason, a wide variety of pedicled perforator flaps have been described. The anterior intercostal perforator flap is one of these perforators flaps and is valuable for use in breast reconstruction surgery. METHODS: The location and characteristics of the anterior intercostal perforators were evaluated both anatomically and radiologically. The anatomical study was conducted in a set of 14 hemitrunk cadavers, and the radiologic study was performed retrospectively from a randomly selected set of images obtained from 30 female patients who underwent thoracic computed tomographic angiography for other health problems at the authors' institution during the year 2015. The findings were then compared. RESULTS: A total of 60 perforators in 14 hemitrunks were identified and mapped. Perforators were found in all hemithoraces. The lateral third donor location was the most reliable zone, containing larger and more numerous perforators compared with the other donor regions. According to the radiologic study, a total of 164 perforators in 30 computed tomographic angiographs were identified and mapped. Perforators were found in all thoraxes. CONCLUSIONS: The authors found that the intercostal perforator flap has a consistent vascularization. Computed tomographic angiography is less reliable than dissection in identifying the number of perforators. The authors' findings suggest that intercostal perforator flaps are reliable and consistent flaps for reconstruction of the upper trunk.