Assessment of donor-site morbidity following rectus femoris harvest for infrainguinal reconstruction.

BACKGROUND: Advantages of the pedicled rectus femoris myofascial flap for groin wound coverage include a sufficient arc of rotation to reach the groin and inguinal region, a dependable vascular pedicle, and low donor-site morbidity. The authors aim to demonstrate the functional deficit resulting from use of the rectus femoris flap in groin wound reconstruction. METHODS: One hundred six rectus femoris flaps were performed for groin wound reconstruction over a 10-year period. From this cohort, consent was successfully obtained from 20 patients for testing of thigh function. Testing included both a subjective questionnaire eliciting patient assessment of postoperative thigh strength, and objective muscle strength testing using isometric dynamometer analysis. An age- and sex-matched control group of 20 subjects with no operative history or known discrepancy of thigh strength underwent identical testing. RESULTS: : Subjects were tested an average of 33 months postoperatively. Dynamometer studies demonstrated a mean nonoperative and operative thigh peak torque of 135 ft-lb and 104 ft-lb, respectively, or a 21 percent difference in isometric knee extensor strength favoring the dominant leg (p = 0.02). Similarly, the control group exhibited a 17 percent strength difference between both thighs (p = 0.04). CONCLUSIONS: Operative subjects exhibited a lower peak torque generated by the operative leg relative to the nonoperative leg. However, a similar difference was observed in the matched control cohort. Thus, there is little isolated deficit in quadriceps strength as a result of rectus femoris harvest.

Smoking cessation education increases interventions in a New Zealand hospital: World No Tobacco Day revisited.

AIM: To review the impact of educational and other measures on smoking cessation interventions delivered in a New Zealand hospital setting. METHODS: The usage of nicotine replacement therapy (NRT) for inpatients was assessed by data gathered from the hospital pharmacy for a period before and after these educational measures. RESULTS: Quarterly teaching sessions for house surgeons, monthly Effective Brief Intervention sessions for clinical staff and quarterly respiratory nurse training were delivered based on The New Zealand Guidelines for Smoking Cessation. In addition the Hutt Valley District Health Board (HVDHB) Smokefree Policy was revised from a business model to a treatment model. Over the 18 months after the educational initiatives were commenced the numbers of NRT units used in Hutt Hospital rose from a baseline of 768 to 3712--a fourfold increase. CONCLUSION: The increase in NRT usage could be attributed to educative measures put in place. There is an opportunity for similar smoking cessation interventions to exist New Zealand wide; this could have a significant impact on reducing chronic disease.

1000 consecutive venous anastomoses using the microvascular anastomotic coupler in breast reconstruction.

BACKGROUND: Microvascular anastomosis is one of the more critical aspects of free flap surgery. A safe, effective, and expedient method for venous anastomosis minimizes flap ischemia time, is easier on the surgical team, and saves costly operating room time. The authors report on their experience using the Synovis microvascular anastomotic coupling device in 1000 consecutive venous anastomoses in free flap breast reconstruction. METHODS: The authors retrospectively reviewed 1000 consecutive venous anastomoses that were performed using the microvascular anastomotic coupler between July of 2002 and July of 2008. Data were obtained on flap type, recipient vessel, coupler size, incidence of venous thrombosis, timing of venous thrombosis, and morbidity as a result of venous thrombosis. RESULTS: All anastomoses were performed in an end-to-end fashion. There were 460 unilateral cases and 270 bilateral cases of breast reconstruction. Flap types included muscle-sparing free transverse rectus abdominis myocutaneous, deep inferior epigastric perforator, superficial inferior epigastric artery, superior gluteal artery perforator, and inferior gluteal artery perforator. The vast majority of the recipient vessels were the internal mammary or thoracodorsal vessels. Most of the couplers that were used were either 3 or 2.5 mm in diameter. Overall, there were six instances of venous thrombosis (rate of 0.6 percent). There were no total flap losses due to venous thrombosis in this series, although two patients had partial flap necrosis. CONCLUSIONS: The patency rate for venous anastomoses performed with the microvascular coupler is excellent when compared with standard suture techniques and has the advantage of overall easier application.

Gracilis myocutaneous free flap in autologous breast reconstruction.

BACKGROUND: The gracilis myocutaneous free flap provides an alternative for autologous breast reconstruction. It avoids abdominal donor-site morbidity, allows for a quicker recovery, provides an alternative to the thin patient with a hidden and acceptable donor site, and allows for supine positioning for harvest and inset in a timely fashion. METHODS: A retrospective review was conducted of all autogenous postmastectomy reconstructions performed between January of 2005 and March of 2008. All patients receiving gracilis myocutaneous flap reconstruction for postmastectomy defects were included in this study. Office and hospital charts were reviewed. RESULTS: Twenty-seven gracilis flaps were performed during the study period. Average patient age was 50.4 years (range, 35 to 63.4 years), and average body mass index was 25.6 (range, 19.4 to 35.5). Of the 21 patients, 9.5 percent had hypertension, 19 percent smoked, none were diabetic, 14 percent were obese, and 4.8 percent had documented cardiovascular disease. Outcomes included a flap success rate of 100 percent, average operating time of 4.9 hours for unilateral (15 patients) and 6.7 hours for bilateral (six patients) flaps, intraoperative arterial thrombosis rate of 13.6 percent, average hospital stay of 3.75 days, major complication rate of 7.4 percent, and average follow-up of 7 months. CONCLUSIONS: The gracilis myocutaneous free flap provides an alternative breast reconstruction option for today's breast cancer patient. It allows for a quick harvest in the supine setting, creation of a moderate breast volume, consistent anatomy, and acceptable donor-site morbidity with good contour.

500 Consecutive patients with free TRAM flap breast reconstruction: a single surgeon's experience.

BACKGROUND: This study reports on the longitudinal experience and outcomes of one surgeon performing free transverse rectus abdominis musculocutaneous (TRAM) flaps on 500 consecutive patients between 1992 and 2003. METHODS: A retrospective review of hospital and outpatient records was performed. Specific risk factors for successful reconstruction were reviewed, including American Society of Anesthesiologists class, obesity, smoking, medical comorbidities, and irradiation and chemotherapy history. Outcomes measured included the length of hospital stay and the incidence of complications including both thrombotic and nonthrombotic complications. RESULTS: Five hundred sixty-nine free TRAM breast reconstructions were performed in a total of 500 patients. Preoperative patient risk factors included obesity, smoking, hypertension, diabetes, and cardiac disease, with three-fourths of the patients being American Society of Anesthesiologists class II or III. Intraoperative or postoperative thrombosis occurred in 35 reconstructions (6.2 percent). Only one patient had a total flap loss, for a flap success rate of 99.7 percent. Significant nonthrombotic complications occurred in 67 patients (13.4 percent). The most common nonthrombotic complications included wound infection (3 percent), fat necrosis (3 percent), and delayed healing (3 percent). Revision procedures after free TRAM reconstruction were performed in 14.4 percent of cases. CONCLUSIONS: The free TRAM flap is a highly reliable method of autogenous breast reconstruction in a broad spectrum of patients. This free flap has a very low thrombotic complication rate, and abdominal donor defect problems have been limited. Finally, this method of reconstruction can be reliably offered to a wide group of patients, including those considered at high risk for a pedicled TRAM flap reconstruction.

A head-to-head comparison between the muscle-sparing free TRAM and the SIEA flaps: is the rate of flap loss worth the gain in abdominal wall function?

BACKGROUND: Attempts to limit the impact of autogenous breast reconstruction on the abdominal wall have led to the use of the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM), the deep inferior epigastric artery perforator (DIEP), and the superficial inferior epigastric artery (SIEA) flaps. The purpose of this study was to compare the SIEA flap with the muscle-sparing free TRAM flap to determine whether gains in abdominal wall function are offset by flap-related complications. METHODS: Seventy-two consecutive SIEA flaps were compared with 569 consecutive muscle-sparing free TRAM flaps. Outcomes included arterial and venous thrombosis, reoperation, abdominal hernia/bulge, seroma, hematoma, fat necrosis, delayed wound healing, infection, partial flap loss, and total flap loss. Chi-square and Fisher's exact tests were used to determine significant differences. RESULTS: In the SIEA group, there was a higher percentage of overweight patients (p = 0.0001), bilateral cases (p = 0.0001), and smokers (p = 0.0003). Among SIEA flaps, there were two total flap losses (2.9 percent) and no abdominal morbidity. In the muscle-sparing free TRAM flap group, there was one total flap loss (0.18 percent), and a hernia/bulge rate of 1.9 percent (n = 11). The difference in flap loss rate was significant (p = 0.03). There was a higher incidence of vessel thrombosis requiring anastomotic revision in the SIEA group, 17.4 percent (n = 12), compared with the free TRAM group, 6.0 percent (n = 34) (p = 0.0005). CONCLUSIONS: The SIEA flap has a lower rate of hernia/bulge and a higher rate of thrombotic complications. Because of the emotional and financial cost of these complications, the SIEA flap should be undertaken only if strict criteria are met.

Efficacy of preoperative autologous blood donation in free TRAM flap breast reconstruction.

BACKGROUND: The authors critically evaluated the use of autologous blood donation in patients who had surgical breast reconstruction using the free transverse rectus abdominis musculocutaneous (fTRAM) flap technique following mastectomy. METHODS: A retrospective chart review of 201 patients was performed. Patients were operated on at one community hospital and one university hospital. Cohorts of 101 blood donors and 100 control nondonors were established. Demographic and premorbid factors and primary outcome variables were evaluated. RESULTS: The autologous donor and nondonor groups were not statistically different in any demographic categories, and there were no significant differences in premorbid factors between the two groups. Total surgical complications were more common in the autologous donor group (48 percent versus 28 percent; p < 0.004). The autologous donor group was also more likely to receive a transfusion intraoperatively (13 percent versus 0 percent, p < 0.001) or postoperatively (28 percent versus 5 percent, p < 0.001) compared with the nondonor group. CONCLUSIONS: Few patients in the nondonor group required perioperative transfusion, and fewer than half of the donors received their blood back. There was a statistically significant higher rate of surgical complications associated with autologous blood donation, most likely due to relative preoperative anemia. Autologous donation was associated with a significantly higher rate of transfusion intraoperatively and postoperatively. The authors do not recommend autologous blood donation before free TRAM flap autogenous breast reconstruction.

Age-dependent closure of bony defects after frontal orbital advancement.

BACKGROUND: The ability of the immature skull to spontaneously heal large bony defects created after craniofacial procedures was examined over a 25-year period of craniofacial surgery at the Children's Hospital of Philadelphia. METHODS: Only patients who underwent frontal orbital advancement and reconstruction, had at least 1 year of documented follow-up, and had the presence or absence of a bony defect documented on clinical examination were included. The sex, age at operation, diagnosis, history of a prior craniectomy, and presence or absence of a postoperative infection were determined for each patient. A variety of statistics were applied to the data. RESULTS: Eighty-one patients met the inclusion criteria. A statistically significant association between age at operation and closure of bony defect was demonstrated. Children who closed a bony defect after frontal orbital advancement and reconstruction were significantly younger than those children who had a persistent bony defect. Iterative regression analyses demonstrated that a transition point between closure and the inability to close bony defects occurred between 9 and 11 months of age. Closure of bony defects was not statistically associated with sex, prior craniectomy, an FGFR mutation, or a postoperative infection in the regression analysis. CONCLUSIONS: Healing of bony defects after frontal orbital advancement and reconstruction is significantly related to age at initial operation, with a mean age for closure of less than 12 months. Between 9 and 11 months of age, a change occurs that results in an increasingly lower probability of bony defect closure; thus, all other considerations being equal, initial frontal orbital advancement and reconstruction would ideally take place before this occurs.

Free tissue transfer: comparison of outcomes between university hospitals and community hospitals.

BACKGROUND: In university hospitals, free tissue transfer has become a standard method of reconstruction for a broad spectrum of defects. Because of its complexity, free tissue transfer has not been routinely performed in a community hospital setting. This study reports the outcomes of two equal groups of free tissue transfer performed by the same surgeons, comparing the university versus the community hospital setting. METHODS: A total of 735 free tissue transfers were performed at one university hospital and six community hospitals in our region over a 10-year study period. Outcome parameters used in this study included wound complications such as infection, dehiscence, delayed healing, hematoma, and fat necrosis. RESULTS: A total of 674 operations were performed using 735 free tissue transfers: 386 free tissue transfers were performed at the university hospital (53 percent) and 349 (47 percent) were performed at the community hospital. Categories of free tissue transfer reconstruction included breast, lower extremity, head and neck, and upper extremity reconstructions. Most of the breast reconstructions were performed in the community hospital, whereas most of the lower extremity and head and neck reconstructions were performed at the university hospital. Fifty-one major postoperative complications occurred in the university hospital (14 percent), while 31 (10 percent) occurred in the community hospital. Complication rates did not differ significantly between settings; however, there was a trend toward more wound infections in the university hospital and more cases of fat necrosis in the community hospital, most likely reflected in the differing case mix between hospital settings. CONCLUSION: Free tissue transfer is an effective and practical method of reconstruction that has been safely performed in both university and community hospital settings.

Improving outcomes in bilateral breast reconstruction using autogenous tissue.

Bilateral breast reconstruction utilizing autologous free tissue transfer is a complex procedure with multiple options for donor tissue available. This study set out to compare the outcomes of patients undergoing bilateral breast reconstruction with muscle-sparing free TRAM flaps versus those undergoing bilateral reconstructions utilizing procedures which aim to minimize abdominal donor site morbidity in the form of deep inferior epigastric perforator (DIEP) or superficial inferior epigastric (SIEA) flaps. A retrospective review identified 31 patients and 62 free flaps for bilateral autologous breast reconstruction at our teaching institutions in Rochester, NY. Patients receiving procedures which aimed to minimize donor-site morbidity experienced a shorter length of hospital stay versus those patients undergoing bilateral free TRAM procedures (P = 0.0494 by t test and P = 0.0389 by parametric test). There was no significant difference in complication rates between these 2 groups. Other demographic and premorbid factors showed no difference between groups. Here, we demonstrate that bilateral autologous breast reconstruction with flaps which minimize donor site morbidity are a safe and effective option for bilateral reconstruction. Furthermore, patients who received bilateral breast reconstruction with abdominal wall sparing techniques (DIEP or SIEA flaps) had a significantly shorter length of hospital stay, with no significant difference in complication rates when compared with patients undergoing bilateral free TRAM procedures.

Risk factors and complications in free TRAM flap breast reconstruction.

METHODS: The authors retrospectively reviewed 500 free TRAM flaps performed between 1992 and 2003. This cohort was subdivided based on smoking history, obesity, preoperative chemotherapy, preoperative radiation therapy, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), and hypertension, and compared surgical complication rates. Measured complications included fat necrosis, mastectomy flap necrosis, abdominal flap necrosis, partial TRAM flap loss, wound infection, hematoma, seroma, vessel thrombosis, and abdominal hernia. Chi2 analysis and Fisher exact test were performed to determine differences between groups, and linear regression models were used to predict the risk factors of surgical complications. RESULTS: Smokers were more likely to have a higher incidence of wound infection (P = 0.01), mastectomy flap necrosis (P = 0.015), abdominal flap necrosis (P = 0.033), and fat necrosis (P = 0.01). Obese patients were more likely to have higher rates of mastectomy flap necrosis (P = 0.01) and hematoma (P = 0.01). Patients with peripheral vascular disease were more likely to have a higher incidence of wound infection (P = 0.031), and patients with preoperative radiation therapy were more likely to have a higher incidence of seroma (P = 0.043). Logistic regression showed that smoking was found to be a risk factor for fat necrosis (P = 0.006), wound infection (P = 0.002), mastectomy flap necrosis (P = 0.039), and abdominal flap necrosis (P = 0.042). Obesity was a risk factor for mastectomy flap necrosis (P = 0.002). Peripheral vascular disease was a risk factor for wound infection (P = 0.032). CONCLUSION: Awareness of risk factors and associated complications will lead to modification and individualization of surgical techniques in an attempt to limit these complications and continually improve outcomes.