Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps.

The American Society of Plastic Surgeons commissioned a multistakeholder Work Group to develop recommendations for autologous breast reconstruction with abdominal flaps. A systematic literature review was performed and a stringent appraisal process was used to rate the quality of relevant scientific research. The Work Group assigned to draft this guideline was unable to find evidence of superiority of one technique over the other (deep inferior epigastric perforator versus pedicled transverse rectus abdominis musculocutaneous flap) in autologous tissue reconstruction of the breast after mastectomy. Presently, based on the evidence reported here, the Work Group recommends that surgeons contemplating breast reconstruction on their next patient consider the following: the patient's preferences and risk factors, the setting in which the surgeon works (academic versus community practice), resources available, the evidence shown in this guideline, and, equally important, the surgeon's technical expertise. Although theoretical superiority of one technique may exist, this remains to be reported in the literature, and future methodologically robust studies are needed.

An innovative approach for sternal closure.

PURPOSE: Midline sternotomy remains the preferred technique for access in cardiac surgery. Application of steel wires has been the preferred method of closure. Because of associated complications, such as superficial and deep infections, as well as bony nonunion complications, an alternative technique is being proposed. The purpose of this study is to evaluate results of a new device for sternal closure. DESCRIPTION: The Sternal Talon (KLS Martin Group, Jacksonville, FL), a lightweight titanium closure device is designed to encircle the sternum, thus yielding a stable closure by effectively distributing the strength of closure over the entire length of the sternotomy. After multiple strength tests demonstrated its superiority over wires, and cadaver tests confirmed its ease of placement, the Food and Drug Administration recently approved the device for its unrestricted use. Eight institutions were chosen to perform initial placements. Patient selection was limited to patients at high risk for sternotomy complications. EVALUATION: In 42 patients who underwent placement of the Sternal Talon (KLS Martin Group) after sternotomy, no wound infections or dehiscence, nonunions, or returns to the operating room were observed. Three postoperative deaths were reported, none of which were device related. The device is magnetic resonance imaging compatible and there are no reported problems with computed tomographic scatter or chest roentgenogram visualization. CONCLUSIONS: These initial cases prove the safety and efficacy of the Sternal Talon device for sternum closure in high-risk patients and may be regarded as an alternative to conventional wire closure. Future prospective studies are warranted to prove the superiority of the device in terms of long-term stability and sternum union rates, as well as decreased infection rates specifically in the high-risk patient population undergoing sternotomy.