Hospital volume is associated with cost and outcomes variation in 2,942 pelvic reconstructions.

BACKGROUND: Complex pelvic reconstruction is challenging for plastic and reconstructive surgeons following surgical resection of the lower gastrointestinal or genitourinary tract. Complication rates and hospital costs are variable and may be linked to the hospital case volume of pelvic reconstructions performed. A comprehensive examination of these factors has yet to be performed. METHODS: Data were retrieved for patients undergoing pedicled flap reconstruction after pelvic resections in the American National Inpatient Sample database between 2010 and 2014. Patients were then separated into three groups based on hospital case volume for pelvic reconstruction. Multivariate logistic regression and gamma regression with log-link function were used to analyze associations between hospital case volume, surgical outcomes, and cost. RESULTS: In total, 2,942 patients underwent pelvic flap reconstruction with surgical complications occurring in 1,466 patients (49.8%). Total median cost was $38,469.40. Pelvic reconstructions performed at high-volume hospitals were significantly associated with fewer surgical complications (low: 51.4%, medium: 52.8%, high: 34.8%; p < 0.001) and increased costs (low: $35,645.14, medium: $38,714.92, high: $44,967.29; p < 0.001). After regression adjustment, high hospital volume was the strongest independently associated factor for decreased surgical complications (Exp[ß], 0.454; 95% Confidence Interval, 0.346-0.596; p < 0.001) and increased hospital cost (Exp[ß], 1.351; 95% Confidence Interval, 1.285-1.421; p < 0.001). CONCLUSIONS: Patients undergoing pelvic flap reconstruction after oncologic resections experience high complication rates. High case volume hospitals were independently associated with significantly fewer surgical complications but increased hospital costs. Reconstructive surgeons may approach these challenging patients with greater awareness of these associations to improve outcomes and address cost drivers.

Single-Stage Adipofascial Turnover Flap as an Alternate Option for Large Nasal Defects Usually Requiring Two-Stage Forehead Flap.

BACKGROUND: Large nasal defects involving the tip, ala, and/or columella with denuded cartilage have traditionally required a two-stage forehead flap. As many Mohs patients are presenting older with increased medical comorbidities, a single-stage adipofascial turnover flap with a full-thickness skin graft was developed by the senior author as an alternative method. The authors hypothesize that the adipofascial turnover flap would have similar success rates and cost less than the forehead flap. METHODS: A retrospective review of all patients in the senior author's practice who underwent either a forehead flap or adipofascial turnover flap between January of 2016 and February of 2019 was conducted. The two groups were compared regarding success, complications, and cost. RESULTS: There were seven forehead flap patients and 11 patients with adipofascial turnover flaps. Overall complications were three of seven (43 percent) for the forehead flap group and one of 11 (9 percent) for the adipofascial turnover flap group. There was one mortality, one revision for asymmetry, and one with airflow obstruction in the forehead group. The adipofascial turnover flap group had one partial skin graft loss that healed with local wound care only. There were no flap failures in either group, and the cost savings averaged over $22,000 in the adipofascial turnover flap group. CONCLUSIONS: The single-stage adipofascial turnover flap with full-thickness skin grafting is a safe, reliable, and less expensive alternate to the forehead flap. The forehead flap will remain a workhorse in nasal reconstruction, but multiple operations increase cost and may contribute to higher complication rates. The adipofascial turnover flap appears to be an efficacious and reasonable option compared with the forehead flap.

Quantitative assessment and risk factors for nipple-areolar complex malposition after nipple-sparing mastectomy.

PURPOSE: Nipple sparing mastectomy (NSM) for breast cancer preserves the nipple-areola complex (NAC) and has limited the extent of the scar, giving good cosmetic results. However, NAC malposition may occur. The aim of this study is to evaluate NAC malposition after NSM and to determine factors associated with malposition in two-stage reconstruction. METHODS: The subjects were 46 patients who underwent unilateral NSM, without contralateral mastopexy or reduction surgery, in two-stage reconstruction using an expander with implant or flap replacement. Vertical and horizontal NAC malposition and predictors of malposition were evaluated before and more than 1 year after reconstruction surgery. RESULTS: The total amount of saline injected into the expander and aging were significant predictors of increased superior malposition of NAC before and more than 1 year after reconstruction or implant surgery. In contrast, the amount of saline injected into the expander until 2 weeks after expander insertion was a significant predictor of decreased superior NAC malposition. BMI was also a statistically significant predictor of decreased superior NAC malposition, but this result was likely to have been due to the measurement method. Autologous reconstruction was a significant negative predictor of superior malposition at more than 1 year after surgery. Superior NAC malposition resulting from full expansion of the expander improved by a mean vertical angle of 4.5° after autologous reconstruction, but hardly improved after implant use. In autologous reconstruction, NAC tended to move slightly to the lateral side after autologous reconstruction, compared to implant use. CONCLUSIONS: Until 2 weeks after expander insertion, as much saline as possible should be injected to prevent superior NAC malposition. At full expansion, superior malposition of vertical angle > 4.5° may require repositioning surgery.

Assessment of Mastectomy Skin Flaps for Immediate Implant-Based Breast Reconstruction.

Objectives: The aim of this study is to identify the appropriate preoperative evaluation methods for the quality of the skin flaps and subcutaneous breast layer using different imaging techniques in correlation with the intraoperative findings and also their importance for the outcome in immediate implant-based breast reconstruction. Materials and Methods: Clinical evaluation, mammography, breast ultrasound and breast MRI were used for the assessment of the mastectomy skin flaps which enhanced the selection of the adequate surgical technique for breast reconstruction. The evaluation started with the skin flap measurement of 50 patients with breast cancer, who were candidates for modified radical mastectomy (MRM) in 2014, using the above-mentioned methods, without immediate breast reconstruction. Consequently, 46 nipple-sparing mastectomies (NSM) and 21 skin-sparing mastectomies (SSM) with immediate breast reconstruction with implants were performed between 2014 and 2017 after having such a preoperative subcutaneous tissue thickness evaluation. Results: The intraoperative findings of the MRM group showed a 90% accuracy for the MRI preoperative evaluation, 87% for the ultrasound, 81% for the mammography and 71% for the pinch test. The preoperative measurements for the patients undergoing SSM or NSM were a criterion for choosing the surgical technique for breast reconstruction. The rate of postoperative complications was low. Conclusion: Preoperative clinical measurements, breast ultrasound, breast MRI and mammography can enhance the prediction of the skin flap thickness and thus lead to a low rate of complications and good aesthetic results in implant-based immediate breast reconstruction.

Postmastectomy Reconstruction Outcomes After Intraoperative Evaluation with Indocyanine Green Angiography Versus Clinical Assessment.

BACKGROUND: Mastectomy flap necrosis is a major complication in patients undergoing tissue expander-based reconstruction. This study compared the complication rates following mastectomy and immediate reconstruction with intraoperative indocyanine green (ICG) angiography evaluation to those with clinical assessment only. METHODS: We performed a single-institution retrospective study of mastectomy patients who underwent immediate tissue expander-based reconstruction between September 2009 and December 2013. ICG angiography was adopted in March 2012. The rates of complications in the ICG and clinical assessment only groups were compared. Factors associated with complications were identified with the Fischer exact test and univariate analysis. RESULTS: A total of 114 patients were identified; clinical assessment only, 53 patients; ICG angiography, 61 patients. The overall complication rates were not significantly different between the two groups (ICG angiography, 50.8 %; clinical assessment, 43.4 %; p = 0.46). There was no significant difference in the rates of unexpected return to the operating room, cellulitis, hematomas, and seromas. The overall rates of flap necrosis were not significantly different (ICG angiography, 27.9 %; clinical assessment, 18.9 %; p = 0.28). However, the rates of severe flap necrosis were significantly lower with intraoperative ICG angiography (4.9 %) than with clinical assessment only (18.9 %, p = 0.02). On univariate analysis, breast weight (≥500 g) was significantly associated with increased rates of severe flap necrosis (p = 0.04), whereas body mass index, age, smoking status, prior breast surgery, history of radiation therapy, and receipt of nipple-sparing mastectomy were not. CONCLUSIONS: We observed that the implementation of intraoperative ICG angiography was associated with a significant decrease in the rate of severe flap necrosis.

Incidence of Surgical Site Infection Following Mastectomy With and Without Immediate Reconstruction Using Private Insurer Claims Data.

OBJECTIVE: The National Healthcare Safety Network classifies breast operations as clean procedures with an expected 1%-2% surgical site infection (SSI) incidence. We assessed differences in SSI incidence following mastectomy with and without immediate reconstruction in a large, geographically diverse population. DESIGN: Retrospective cohort study. PATIENTS: Commercially insured women aged 18-64 years with ICD-9-CM procedure or CPT-4 codes for mastectomy from January 1, 2004 through December 31, 2011 METHODS: Incident SSIs within 180 days after surgery were identified by ICD-9-CM diagnosis codes. The incidences of SSI after mastectomy with and without immediate reconstruction were compared using the χ2 test. RESULTS: From 2004 to 2011, 18,696 mastectomy procedures among 18,085 women were identified, with immediate reconstruction in 10,836 procedures (58%). The incidence of SSI within 180 days following mastectomy with or without reconstruction was 8.1% (1,520 of 18,696). In total, 49% of SSIs were identified within 30 days post-mastectomy, 24.5% were identified 31-60 days post-mastectomy, 10.5% were identified 61-90 days post-mastectomy, and 15.7% were identified 91-180 days post-mastectomy. The incidences of SSI were 5.0% (395 of 7,860) after mastectomy only, 10.3% (848 of 8,217) after mastectomy plus implant, 10.7% (207 of 1,942) after mastectomy plus flap, and 10.3% (70 of 677) after mastectomy plus flap and implant (P<.001). The SSI risk was higher after bilateral compared with unilateral mastectomy with immediate reconstruction (11.4% vs 9.4%, P=.001) than without (6.1% vs 4.7%, P=.021) immediate reconstruction. CONCLUSIONS: SSI incidence was twice that after mastectomy with immediate reconstruction than after mastectomy alone. Only 49% of SSIs were coded within 30 days after operation. Our results suggest that stratification by procedure type facilitates comparison of SSI rates after breast operations between facilities.

A Cost-Utility Analysis Comparing the Sartorius versus the Rectus Femoris Flap in the Treatment of the Infected Vascular Groin Graft Wound.

BACKGROUND: The purpose of this study was to examine the sartorius and rectus femoris flaps as reasonable coverage options for the infected vascular groin graft wound. The authors' goal was to perform a cost-utility analysis of the sartorius flap versus the rectus femoris flap in the treatment of an infected vascular groin graft. METHODS: Cost-utility methodology involved a literature review compiling outcomes for specific flap interventions, obtaining utility scores for complications to estimate quality-adjusted life-years, accruing costs using Diagnosis-Related Group and Current Procedural Terminology codes for each intervention, and developing a decision tree that could portray the more cost-effective strategy. The authors also performed sensitivity analysis to check the robustness of their data. Szilyagi III and Samson III and IV grades of infected groin grafts were included in the study. RESULTS: Twenty-six studies were used pooling 296 patients (234 sartorius flaps and 62 rectus flaps). Decision tree analysis noted that the rectus femoris flap was the more cost-effective option. It was the dominant treatment option given that it was more clinically effective by an additional 0.30 quality- adjusted life-years, with the sartorius flap option costing an additional $2241.88. The sartorius flap had a 13.68 percent major complication rate versus an 8.6 percent major complication rate for the rectus femoris flap. One-way sensitivity analysis showed that the sartorius flap became a cost-effective option if its major complication rate was less than or equal to 8.89 percent. CONCLUSION: The rectus femoris flap in the treatment of the infected vascular groin graft is a cost-effective option compared with the sartorius flap.

Use of a patient and observer scar assessment scale to evaluate the V-Y advancement flap for reconstruction of medial cheek defects.

BACKGROUND: The V-Y advancement flap (VYF) is not commonly used to reconstruct defects located on the medial cheek. The quantitative assessment of VYF for this indication has not been reported. In evaluation of surgical scarring, the Patient and Observer Scar Assessment Scale (POSAS) has been validated for use in burn and breast surgery scars, but its usefulness in dermatologic surgery has not been determined. OBJECTIVE: To present our experience with the use of the POSAS to assess the success of VYF reconstruction for surgical defects on the medial cheek. METHODS AND MATERIALS: Fourteen patients with medium to large (>5 cm(2) ) medial cheek Mohs defects reconstructed using VYF were assessed. Final cosmetic and functional results were analyzed after a follow-up of 6 months to 2 years (mean follow-up 21 months) using the POSAS. RESULTS: Observers using the POSAS gave a mean score for VYF reconstructions of 9.1 ± 2.3 (5 represents normal skin, 50 represents worst imaginable scar). Patients using the POSAS gave a mean score for VYF reconstructions of 10 ± 4 (6 representing normal skin, 60 representing worst imaginable scar). CONCLUSION: VYF reconstruction of medium to large defects of the medial cheek is a useful option. The POSAS may be a helpful tool for evaluating reconstructive results in dermatologic surgery.

Modified acrylic cranioplasty for large cranial defects.

OBJECTIVE: To describe a novel technique for constructing polymethylmethacrylate (acrylic) cranioplasty to repair large cranial defects. METHODS: A rim of bone is cut from the edge of the skull defect using a craniotome. This bony rim provides a scaffold to fashion the acrylic cement away from the patient thus avoiding thermal injury to the brain. The inner edge of the bony rim is drilled circumferencially to form a groove. Acrylic is then used to fill the defect in the bony rim with continuous manipulation of the paste from both sides to form a dome in the shape of the skull. The groove allows the edge of the acrylic dome to fit snugly with the bony rim thus avoiding sinking. The final cranioplasty, comprised of the hardened acrylic dome with the surrounding bone rim, is firmly attached to the skull with bioplates. RESULTS: We used the modified acrylic cranioplasty technique in three patients. Modified acrylic cranioplasty is cheaper and immediately available, compared with ten cases of titanium cranioplasty, with similar cosmetic outcome, intraoperative blood loss and operating theatre time. CONCLUSION: Our technique is quick and easy to perform, avoids thermal injury to the brain and produces a strong implant with excellent cosmesis even with large bony defects.

Assessment of vertical scar migration after classical abdominoplasty followed by lower abdominal flap fixation / Avaliação da migração vertical da cicatriz pós-abdominoplastia clássica com fixação do retalho abdominal inferior

BACKGROUND: In plastic surgery, the postoperative scar is a frequent concern. It is very important for the surgeon to understand the natural evolution of the scar. The abdominoplasty scar has a natural tendency to move upwards over time. In this study, the extent of natural vertical scar migration after abdominoplasty was calculated and the effect of fixing the lower abdominal flap to prevent this rise was assessed. METHODS: This prospective and randomized study was conducted at the 38th Nursing service of Santa Casa de Misericórdia do Rio de Janeiro, during 2010, and included 20 female patients with an indication for abdominoplasty. The patients were randomly divided into two groups, A and B. Classical abdominoplasty was performed in group A patients, according to the technique recommended by Prof. Ivo Pitanguy. Patients in group B also underwent lower abdominal flap fixation by suturing of Scarpa's fascia and the rectus abdominis muscle aponeurosis. At both two weeks and six months after surgery, the distance of vertical scar movement was measured in 16 patients after application of exclusion criteria. The average vertical migration and the mean difference between the groups were calculated. RESULTS: The average difference between the groups in vertical migration throughout the scar was 0.4 cm, with a mean overall migration of 1.06 cm and 0.68 cm in groups A (control group) and B (cases with fixation), respectively. CONCLUSIONS: The scar formed after abdominoplasty undergoes vertical migration over time; this migration is decreased when the lower abdominal flap is fixed. The surgeon should be aware of scar migration for better planning of the incision location.

INTRODUÇÃO: Na cirurgia plástica, uma constante preocupação é a cicatriz pós-operatória. É muito importante para o cirurgião conhecer a evolução natural da cicatriz. A cicatriz de abdominoplastia tem a tendência natural de subir com o passar do tempo. Neste estudo, calculou-se a migração vertical natural da cicatriz pós-abdominoplastia, avaliando o efeito da fixação do retalho abdominal inferior na prevenção dessa ascensão. MÉTODO: Estudo prospectivo e randomizado, realizado na 38ª Enfermaria da Santa Casa de Misericórdia do Rio de Janeiro durante o ano de 2010, incluindo 20 pacientes do sexo feminino com indicação de abdominoplastia, divididas em dois grupos, A e B, aleatoriamente. Nas pacientes do grupo A, foi realizada abdominoplastia clássica, segundo técnica preconizada pelo Prof. Ivo Pitanguy, e no grupo B foi incluída a fixação do retalho abdominal inferior por meio de sutura interessando a fáscia de Scarpa e a aponeurose do músculo reto abdominal. Duas semanas e seis meses após a cirurgia, foi medida a distância vertical em 16 pacientes, após aplicação dos critérios de exclusão, calculando-se a média de migração vertical e a diferença média entre os dois grupos. RESULTADOS: A diferença média de migração vertical ao longo de toda a cicatriz foi de 0,4 cm, sendo a média geral de migração nos grupo A (controle) e B (casos com fixação) de 1,06 cm e 0,68 cm, respectivamente. CONCLUSÕES: A cicatriz pós-abdominoplastia sofre migração vertical ao longo do tempo, sendo menor quando o retalho inferior é fixado. O cirurgião deve estar ciente da migração sofrida pela cicatriz para melhor planejamento da posição de sua incisão.

When is surgical tracheostomy indicated? Surgical "U-shaped" versus percutaneous tracheostomy.

OBJECTIVE: Tracheostomy is one of the most frequent interventions for ICU patients. The current trend in performing a tracheostomy is a percutaneous approach because of its popularity and significant advantages. In this study, certain indications of surgical tracheostomy (ST) are suggested and furthermore, ST is compared with percutaneous tracheostomy (PT). PATIENT AND METHODS: We performed a U-shaped ST in 121 patients and PT in 85 patients between March 2003 and December 2006. All of the STs were opened U-shaped in the operating room. In this technique; instead of removing the tracheal ring, it was used to create a flap. The tracheal flap was hung with a suture from middle of the 2nd or the 3rd cartilage rings, as a guide. Also, the PT procedure "Griggs dilatation technique" was performed in the ICU. RESULTS: PT and ST had similar complication rates: 4.1% for ST [bleeding in 2 patients, stenosis in 2, and stomal infection in 1] versus 3.6% for PT [bleeding in 2 patients, and pneomothorax in 1] (p = 0.08). No significant difference was found regarding mean operation time between ST [12 min (9-18)] and PT [8 min (6-16)] (p = 0.09) CONCLUSIONS: Staff utilization and cost seem like the major advantages of PT. However, our surgical technique has similar complication rates with PT and moreover, using ST still remains favorable for select patients with thyroid hyperplasia, short neck, tracheaomalacia, obesity, neck operation history and for children.

Delayed primary versus late secondary wound closure in the treatment of postsurgical sternum osteomyelitis.

Sternal osteomyelitis and poststernotomy mediastinitis is a severe and life-threatening complication after the cardiac surgery. The incidence ranges up to 3% with a mortality rate up to 29%. In addition, postoperative infections after sternotomy are associated with prolonged hospital stay, increased healthcare costs and impaired quality of patient life, representing an economic and social burden. The emergence of increasing antimicrobial resistant bacteria augments the importance of postsurgical infections since the antimicrobial choices are becoming limited. Furthermore, the incidence of infection is an indicator for the quality of patient care in the international benchmark studies. Although several therapy strategies are nowadays present in clinical practice, there is a lack of evidence-based surgical consensus for treatment of this surgical complication. In most cases the poststernotomy mediastinitis involves surgical revision with debridement, open dressing and/or vacuum-assisted therapy. After the granulation tissue on open chest wound is achieved, secondary closure and/or reconstruction with vascularized soft tissue flaps, such as omentum or pectoral muscle is performed. It seems there is a need for more effective surgical treatment of poststernotomy wound infections, which may address the prolonged hospitalization and reduce the number of surgical interventions and with this also the perioperative morbidity. In light of this we propose a randomized study comparing new delayed primary closure of the sternum to the secondary vacuum-assisted closure.

Avoiding denervation of rectus abdominis in DIEP flap harvest II: an intraoperative assessment of the nerves to rectus.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap aims to reduce donor-site morbidity by minimizing rectus muscle damage; however, damage to motor nerves during perforator dissection may denervate rectus muscle. Although cadaveric research has demonstrated that individual nerves do not arise from single spinal cord segments and are not distributed segmentally, the functional distribution of individual nerves remains unknown. Using intraoperative nerve stimulation, the current study describes the motor distribution of individual nerves supplying the rectus abdominis, providing a guide to nerve dissection during DIEP flap harvest. METHODS: Twenty rectus abdominis muscles in 17 patients undergoing reconstructive surgery involving rectus abdominis (DIEP, transverse rectus abdominis musculocutaneous, or vertical rectus abdominis musculocutaneous flaps) underwent intraoperative stimulation of nerves innervating the infraumbilical segment of the rectus. Nerve course and extent of rectus muscle contraction were recorded. RESULTS: In each case, three to seven nerves entered the infraumbilical segment of the rectus abdominis. Small nerves (type 1) innervated small longitudinal strips of rectus muscle, rather than transverse strips as previously described. There was significant overlap between adjacent type 1 nerves. In 18 of 20 cases, a single large nerve (type 2) at the level of the arcuate line supplied the entire width and length of rectus muscle. CONCLUSIONS: Nerves innervating the rectus abdominis are at risk during DIEP flap harvest. Small, type 1 nerves have overlapping innervation from adjacent nerves and may be sacrificed without functional detriment. However, large type 2 nerves at the level of the arcuate line innervate the entire width of rectus muscle without adjacent overlap and may contribute to donor-site morbidity if sacrificed.

Upper cervicothoracic sympathetic block increases blood supply of unipedicled TRAM flap.

A prospective clinical study was conducted to evaluate the impact of upper cervicothoracic sympathetic block (CTGB) on blood supply of the unipedicled transverse rectus abdominis musculocutaneous (TRAM) flap. The use of the technique is first reported herein, as a manipulation improving arterial blood flow within the flap in high-risk patients, thus reducing postoperative morbidity. From March 2003 to September 2006, 28 heavy smokers, who underwent delayed breast reconstruction with unipedicled TRAM flap, were included in the study. Intraoperative upper cervicothoracic block (ganglia C5,6,7 and T1,2) was performed in 16 patients (group A), while 12 patients, who did not consent to have the blockade (group B), were the control. Clinical evaluation and thermographic monitoring of skin temperature, using the Thermacam A40 (FLIR systems, Wilsonville, OR), was used in all patients and determined the blood flow within the flap. All patients were monitored for early and late complications. In all group A patients, CTGB resulted in TRAM flap temperature increase within 9.5 to 16 min. Flap temperature elevation was found to be significantly higher (P < 0.001) and hospital stay was significantly shorter (P = 0.004) in group A patients. No CTGB or TRAM flap complications were recorded in group A patients. However, in group B, major fat necrosis occurred in 2 patients and partial (1/3) flap necrosis in 1 patient. Upper cervicothoracic sympathetic block is a reliable, safe, and useful technique for increasing blood flow within TRAM flaps in high-risk patients, like heavy smokers, and it minimizes postoperative morbidity.

Satisfaction with outcome and attitudes towards scarring among women undergoing breast reconstructive surgery.

OBJECTIVE: Surgical breast reconstruction following mastectomy often results in scarring not only to the breast but often to the donor-site area. However, few studies have been devoted to the potential effects of scarring among women who underwent breast reconstruction. The aim of the study was to explore these women's attitudes towards scarring. METHOD: Fifteen women who had undergone Transversus Abdominis Myocutaneous (TRAM) flap breast reconstruction surgery (mean age 50 years) took part in a semi-structured qualitative interview. The interview examined their experiences of breast reconstruction surgery, post-surgical adjustment and the impact of scarring. RESULTS: Scarring, particularly donor-site scarring, emerged as the main area of dissatisfaction with the breast reconstruction process. Expectations of the surgery and information provided prior to surgery were also found to relate to women' reports of overall satisfaction. CONCLUSION: This study highlighted that satisfaction with breast reconstruction surgery included relief at not needing to wear prostheses and increased body confidence. However, some women reported unrealistic expectations regarding the outcomes of breast reconstruction surgery including extended recovery time and donor-site scarring. PRACTICE IMPLICATIONS: Future patients may therefore benefit from a patient-centred evaluation of their information needs incorporating both their preferences for type and amount of information at each stage of treatment and recovery as well as their understanding and interpretation of the information given to them.

Patency assessment of the internal jugular vein after neck dissection.

Twenty-seven patients with oral malignant tumours, who underwent neck dissection with preservation of the internal jugular vein (IJV), were studied retrospectively to evaluate patency of the IJV. Twenty-three patients underwent ablative surgery of the primary lesion with neck dissection and 4 underwent neck dissection alone. Three patients received simple closure and skin grafting of the primary lesion, and 20 received reconstruction surgery (4 platysma flaps, 3 radial forearm flaps, 3 lateral upper arm flaps, 2 pectoralis major myocutaneous flaps and 8 rectus abdominis myocutaneous flaps). The maximum and minimum diameters of the IJV as measured on computed tomographic (CT) scans were used to assess patency. The cross-sectional area of the IJV and the ratio of its long axis to short axis (L/S ratio) were calculated. The relation between the change in IJV status and the type of flap used for reconstruction was also examined. Occlusion of the IJV was present in 3.7% of the patients, and 'narrowing' was present in 63.6%. The size of the flap significantly correlated with 'narrowing' of the IJV, suggesting that 'narrowing' was caused mainly by compression due to the flap.

Devascularizing complications of free fibula harvest: peronea arteria magna.

The authors present a case report of devascularizing complications following free fibula harvest. A retrospective review of 93 consecutively imaged limbs demonstrated a peronea arteria magna (PAM) prevalence of 5.3 percent in an urban population, which was used to perform a cost-effectiveness analysis for preoperative vascular imaging of the donor limb using magnetic resonance angiography (MRA) and traditional angiography (TA). Donor-site complications of fibula harvest range from 15 to 30 percent, but are rarely limb-threatening. Limb loss is a dreaded complication of congenital PAM, which can be present with a normal vascular exam. Some microsurgery groups advocate using no preoperative imaging of the donor limb; they rely on intraoperative assessment of the vascular anatomy. An aborted harvest due to aberrant anatomy leads to both direct and indirect added costs. The authors believe that MRA imaging of the donor limb, being minimally invasive, is cost-effective and indicated for free fibula transfers. For equivocal results, conversion to more invasive and costly TA may be necessary.

Skin-sparing mastectomy flap complications after breast reconstruction: review of incidence, management, and outcome.

This study assesses the incidence and outcome of skin-sparing mastectomy (SSM) flap complications after breast reconstruction. The authors performed a retrospective review of 37 consecutive patients undergoing SSM and immediate breast reconstruction, focusing on preoperative demographics, management of complications, and early outcome. Univariate analysis comparing patients with and without complications was performed using Student's t-test and chi-square analysis. From July 2000 to December 2001, 37 patients (mean age 48.1, range 24-71 y) underwent SSM and breast reconstruction (unilateral 20, bilateral 17) via TRAM flaps (n = 18), latissimus flaps (n = 13), and expander/implants (n = 6). SSM flap complications occurred in nine patients (24.3%) and included mild (n = 2), moderate (n = 5), and severe (n = 2) skin loss, resulting in four cases of dehiscence, five reoperations, and no delay in postoperative adjuvant therapy (required in six patients). Previous irradiation (n = 5, p = 0.045) and diabetes (n = 3, p = 0.001) were associated with SSM flap complications, but age, smoking, previous breast cancer, and type of reconstruction were not. Patients with SSM flap loss had a higher body mass index (BMI) than those without complications (30.0 vs. 24.3; p = 0.025). Skin flap complications after SSM and breast reconstruction are not uncommon but did not delay the initiation of adjuvant chemotherapy or radiotherapy, despite the need for reoperation. Patients with elevated BMI, diabetes, and previous irradiation may be at increased risk for SSM flap complications.