Soft Tissue Reconstruction After Sacral Neoplasm Resection: The University of California San Francisco Experience.

PURPOSE: Resection of sacral neoplasms such as chordoma and chondrosarcoma with subsequent reconstruction of large soft tissue defects is a complex multidisciplinary process. Radiotherapy and prior abdominal surgery play a role in reconstructive planning; however, there is no consensus on how to maximize outcomes. In this study, we present our institution's experience with the reconstructive surgical management of this unique patient population. METHODS: We conducted a retrospective review of patients who underwent reconstruction after resection of primary or recurrent pelvic chordoma or chondrosarcoma between 2002 and 2019. Surgical details, hospital stay, and postoperative outcomes were assessed. Patients were divided into 3 groups for comparison based on reconstruction technique: gluteal-based flaps, vertical rectus abdominus myocutaneous (VRAM) flaps, and locoregional fasciocutaneous flaps. RESULTS: Twenty-eight patients (17 males, 11 females), with mean age of 62 years (range, 34-86 years), were reviewed. Twenty-two patients (78.6%) received gluteal-based flaps, 3 patients (10.7%) received VRAM flaps, and 3 patients (10.7%) were reconstructed with locoregional fasciocutaneous flaps. Patients in the VRAM group were significantly more likely to have undergone total sacrectomy (P < 0.01) in a 2-stage operation (P < 0.01) compared with patients in the other 2 groups. Patients in the VRAM group also had a significantly greater average number of reoperations (2 ± 3.5, P = 0.04) and length of stay (29.7 ± 20.4 days, P = 0.01) compared with the 2 other groups. The overall minor and major wound complication rates were 17.9% and 42.9%, respectively, with 17.9% of patients experiencing at least 1 infection or seroma. There was no association between prior abdominal surgery, surgical stages, or radiation therapy and an increased risk of wound complications. CONCLUSIONS: Vertical rectus abdominus myocutaneous flaps are a more suitable option for patients with larger defects after total sacrectomy via 2-staged anteroposterior resections, whereas gluteal myocutaneous flaps are effective options for posterior-only resections. For patients with small- to moderate-sized defects, local fasciocutaneous flaps are a less invasive and effective option. Paraspinous flaps may be used in combination with other techniques to provide additional bulk and coverage for especially long postresection wounds. Furthermore, mesh is a useful adjunct for any reconstruction aimed at protecting against intra-abdominal complications.

Paraspinous Muscle Flaps in Complex Pediatric Spine Surgeries: A 12-Year Single Institution Experience.

PURPOSE: The benefits of paraspinous flaps in adult complex spine surgery patients are established in the literature; however, their use in pediatric patients has not been well described. This study compares clinical outcomes with and without paraspinous muscle flap closure in pediatric patients who have undergone spine surgery. METHODS: We conducted a retrospective review of all pediatric spine surgeries at the University of California, San Francisco from 2011 to 2022. Patients were divided into 2 cohorts based on whether the plastic surgery service closed or did not close the wound with paraspinous muscle flaps. We matched patients by age, American Society of Anesthesiology classification, prior spinal surgical history, and diagnosis. Surgical outcomes were compared between the 2 cohorts. RESULTS: We identified 226 pediatric patients who underwent at least one spinal surgery, 14 of whom received paraspinous flap closure by plastic surgery. They were matched in a 1:4 ratio with controls (n = 56) that did not have plastic surgery closure. The most common indication for plastic surgery involvement was perceived complexity of disease by the spine surgeon with concern for inadequate healthy tissue coverage (78.6%), followed by infection (21.4%). Postoperative complications were similar between the two groups. The plastic surgery cohort had a higher rate of patients who were underweight (57.1% vs 14.3%, P < 0.01) and had positive preoperative wound cultures (28.6% vs 8.9%, P = 0.05), as well as a higher rate of postoperative antibiotic usage (78.6 vs 17.9%, P < 0.01). There was no difference in recorded postoperative outcomes. CONCLUSIONS: Spine surgeons requested paraspinous flap closure for patients with more complex disease, preoperative infections, history of chemotherapy, or if they were underweight. Patients with paraspinous flap coverage did not have increased postoperative complications despite their elevated risk profile. Our findings suggest that paraspinous muscle flaps should be considered in high-risk pediatric patients who undergo spine surgery.

Immediate Versus Delayed-Immediate Autologous Breast Reconstruction After Nipple-Sparing Mastectomy.

INTRODUCTION: Autologous reconstruction following nipple-sparing mastectomy (NSM) is either performed in a delayed-immediate fashion, with a tissue expander placed initially at the time of mastectomy and autologous reconstruction performed later, or immediately at the time of NSM. It has not been determined which method of reconstruction leads to more favorable patient outcomes and lower complication rates. METHODS: We performed a retrospective chart review of all patients who underwent autologous abdomen-based free flap breast reconstruction after NSM between January 2004 and September 2021. Patients were stratified into 2 groups by timing of reconstruction (immediate and delayed-immediate). All surgical complications were analyzed. RESULTS: One hundred one patients (151 breasts) underwent NSM followed by autologous abdomen-based free flap breast reconstruction during the defined time period. Fifty-nine patients (89 breasts) underwent immediate reconstruction, whereas 42 patients (62 breasts) underwent delayed-immediate reconstruction. Considering only the autologous stage of reconstruction in both groups, the immediate reconstruction group experienced significantly more delayed wound healing, wounds requiring reoperation, mastectomy skin flap necrosis, and nipple-areolar complex necrosis. Analysis of cumulative complications from all reconstructive surgeries revealed that the immediate reconstruction group still experienced significantly greater cumulative rates of mastectomy skin flap necrosis. However, the delayed-immediate reconstruction group experienced significantly greater cumulative rates of readmission, any infection, infection requiring PO antibiotics, and infection requiring IV antibiotics. CONCLUSIONS: Immediate autologous breast reconstruction after NSM alleviates many issues seen with tissue expanders and delayed autologous reconstruction. Although mastectomy skin flap necrosis occurs at a significantly greater rate after immediate autologous reconstruction, it can often be managed conservatively.

Long-Term Outcomes in Prepectoral versus Subpectoral Two-Stage Implant-Based Breast Reconstruction after Nipple-Sparing Mastectomy.

BACKGROUND: Implant-based breast reconstruction remains the most often used method following mastectomy, but data are lacking regarding differences in complications and long-term patient-reported outcomes for two-stage subpectoral versus prepectoral reconstruction. This study sought to better understand the risks and impact of these reconstructive approaches on overall satisfaction. METHODS: Patients who underwent unilateral or bilateral nipple-sparing mastectomy and two-stage implant-based reconstruction from 2014 to 2019 were identified from the electronic medical records and contacted via email to complete the BREAST-Q survey. Overall satisfaction was measured by the question, "How happy are you with the outcome of your breast reconstruction?" using a six-point Likert scale. Patients were grouped into subpectoral or prepectoral cohorts. Complications were evaluated retrospectively. Only patients who were at least 6 months from their final reconstruction were included in the analysis. RESULTS: Of the 582 patients contacted, 206 (35%) responded. The subpectoral ( n = 114) and prepectoral ( n = 38) groups did not differ significantly by demographic or treatment characteristics. BREAST-Q scores were also comparable. Complication rates were similar, but prepectoral patients had a significantly higher rate of capsular contracture (16% versus 4%, P < 0.05). Bivariate ordered logistic regression identified prepectoral implant placement, having any postoperative complication, and capsular contracture as predictors of less overall happiness. CONCLUSIONS: The authors' study suggests that prepectoral patients may have slightly higher complication rates but are as satisfied as subpectoral patients after at least a year of follow-up. Further studies should investigate risk factors for capsular contracture, how the risk changes over time, and how the risk affects patient satisfaction.

Direct-to-Implant Versus 2-Stage Breast Reconstruction: Which Technique Is Better? An Analysis of 104 Patients at a Single Institution.

BACKGROUND: Two-stage (TS) implant-based reconstruction is the most commonly performed method of reconstruction after mastectomy. A growing number of surgeons are offering patients direct-to-implant (DTI) reconstruction, which has the potential to minimize the number of surgeries needed and time to complete reconstruction, as well as improve health care utilization. However, there are conflicting data regarding the outcomes and complications of DTI, and studies comparing the 2 methods exclusively are lacking. METHODS: Patients undergoing implant-based reconstruction after mastectomy within a large interstate health system between 2015 and 2019 were retrospectively identified and grouped by reconstruction technique (TS and DTI). The primary outcomes were a composite of complications (surgical site occurrences), health care utilization (reoperations, unplanned emergency department visits, and readmissions), and time to reconstruction completion. Risk-adjusted logistic and generalized linear models were used to compare outcomes between TS and DTI. RESULTS: Of 104 patients, 42 underwent DTI (40.4%) and 62 underwent TS (59.6%) reconstruction. Most demographic characteristics, and oncologic and surgical details were comparable between groups ( P > 0.05). However, patients undergoing TS reconstruction were more likely to be publicly insured, have a smoking history, and undergo skin-sparing instead of nipple-sparing mastectomy. The composite outcome of complications, reoperations, and health care utilization was higher for DTI reconstruction within univariate (81.0% vs 59.7%, P = 0.03) and risk-adjusted analyses (odds ratio, 3.78 [95% confidence interval [CI], 1.09-13.9]; P < 0.04). Individual outcome assessment showed increased mastectomy flap necrosis (16.7% vs 1.6%, P < 0.01) and reoperations due to a complication (33.3% vs 16.1%; P = 0.04) in the DTI cohort. Although DTI patients completed their aesthetic revisions sooner than TS patients (median, 256 days vs 479 [ P < 0.01]; predicted mean difference for TS [reference DTI], 298 days [95% CI, 71-525 days]; P < 0.01), the time to complete reconstruction (first to last surgery) did not differ between groups (median days, DTI vs TS, 173 vs 146 [ P = 0.25]; predicted mean difference [reference, DTI], -98 days [95% CI, -222 to 25.14 days]; P = 0.11). CONCLUSIONS: In this cohort of patients, DTI reconstruction was associated with higher complications, reoperations, and health care utilization with no difference in time to complete reconstruction compared with TS reconstruction. Further studies are warranted to investigate patient-reported outcomes and cost analysis between TS and DTI reconstruction.

The Impact of a Single Dual-Trained Surgeon in the Management of Mastectomy and Reconstruction.

BACKGROUND: Oncoplastic breast surgery is typically performed using a two-surgeon, two-team approach. The authors present their experience with patients undergoing mastectomy and immediate reconstruction performed by a single, dual-trained breast surgical oncologist and plastic and reconstructive microsurgeon. METHODS: Patients who underwent mastectomy and/or immediate reconstruction performed by the senior author between 2015 and 2019 were divided into single-surgeon or dual-surgeon cohorts, and matched by age, body mass index, reconstruction type, and cancer stage. RESULTS: The authors included 158 patients in their analysis (single-surgeon, n = 45; dual-surgeon, n = 113). Single-surgeon patients underwent surgery 13.2 days earlier than dual-surgeon patients (p < 0.01), and required significantly fewer preoperative (1.9 versus 3.4; p < 0.01) and postoperative visits (6.8 versus 10.7; p < 0.01). Operative duration was comparable (single-surgeon, 245 minutes; dual-surgeon, 245 minutes; p = 0.99). The authors found no significant difference in surgical-site infection, seroma, hematoma, abdominal donor-site healing, or flap and prosthesis loss between the groups. The authors did find that dual-surgeon patients had a significantly higher rate of mastectomy flap necrosis (20 percent versus 4 percent; p = 0.01), which held true on logistic regression when controlling for other variables. BREAST-Q data demonstrated that single-surgeon patients had significantly higher overall scores (p = 0.04), and were significantly more satisfied with their outcomes, surgeon, and the information provided (p = 0.03, p = 0.03, and p = 0.01, respectively). CONCLUSIONS: The single-surgeon approach has the potential to decrease patient burden by requiring fewer preoperative and postoperative visits without compromising surgical outcomes or oncologic safety. Further investigation is warranted into the financial implications and patient outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Prophylactic Muscle Flaps in Primary Vascular Procedures of the Groin.

BACKGROUND: Complications following vascular procedures involving the groin can lead to significant morbidity. Achieving stable soft tissue coverage over sites of revascularization can help mitigate complications. Prior evidence supports the use of muscle flaps in reoperative groins and in high risk patient populations to reduce postoperative complications. Data regarding the use of prophylactic muscle flap coverage of the groin is lacking. Therefore, the purpose of this study is to evaluate the effect of immediate prophylactic muscle flap coverage of vascular wounds involving the groin. METHODS: A retrospective cohort study was performed on all patients undergoing primary open vascular procedures involving the groin for occlusive, aneurysmal, or oncologic disease between 2014 and 2020 at a single institution where plastic surgery was involved in closure. Patient demographics, comorbidities, surgical details, and postoperative complications were compared between patients who had sartorius muscle flap coverage of the vascular repair versus layered closure alone. RESULTS: A total of 133 consecutive groins were included in our analysis. A sartorius flap was used in 115 groins (86.5%) and a layered closure was used in 18 (13.5%). Wound breakdown was similar between groups (25.2% sartorius vs. 38.9% layered closure, P = 0.26). However, the rate of reoperation was significantly higher in the layered closure group (50.0% vs. 12.2%, P < 0.01). Among patients who experienced wound breakdown (N = 36), a larger proportion of layered closure patients required operative intervention (71.4% vs. 20.7%, P = 0.02). Other rates of complications were not statistically different between groups. CONCLUSIONS: In patients undergoing primary open vascular procedures involving the groin, patients who underwent prophylactic sartorius muscle flap closure had lower rates of reoperation. Although incisional breakdown was similar between the groups overall, the presence of a vascularized muscle flap overlying the vascular repair was associated with reduced need for reoperation and allowed more wounds to be managed with local wound care alone. Consideration should be given to this low morbidity local muscle flap in patients undergoing vascular procedures involving the groin.

Diagnosis and Treatment of Lymphatic Complications of the Groin Following Open Lower Extremity Revascularization with Plastic Surgery Closure.

INTRODUCTION: Lymphatic complications following vascular procedures involving the groin require prompt treatment to limit morbidity. Several treatments have been described, including conservative management, aspiration, sclerotherapy, and direct lymphatic ligation with or without a muscle flap have been described. To date, there is no data indicating which treatment results in the shortest time to recovery. We sought to address this gap by conducting a retrospective cohort study. METHODS: We reviewed all patients who developed a lymphatic complication after undergoing an open revascularization procedure in the groin between 2014 and 2020 in which plastic surgery was involved in the closure. A control group consisted of patients from the same timespan who did not develop a lymphatic complication. Demographics, comorbidities, operative details, and outcomes were compared between these groups. For cases identified with a lymphatic complication, the method of diagnosis, culture data, and treatment details were collected, and outcomes were compared for surgical management versus sclerotherapy. RESULTS: There were 27 lymphatic complications and 60 control patients. The complication group had a higher incidence of aortofemoral bypass (25.8% vs. 8.3%, P = 0.04), and a lower incidence of femoral-to-distal bypass (11.1% vs. 45.0%, P < 0.01). Daily drain output volume from postoperative days 1-5, and days 6-10, was significantly higher in the complication group than in the controls (194.0 vs. 44.0, P < 0.01; and 429.5 vs. 35.0, P < 0.01, respectively). In the lymphatic leak group, 16 patients (59.3%) had surgical treatment and six (22.2%) had sclerotherapy. Of those who had surgery, 71.4% had successful outcomes without the need for an additional intervention, whereas all of the patients analyzed who were treated with sclerotherapy had successful outcomes without further intervention. The average time to resolution was significantly shorter for surgery than for sclerotherapy (38.7 vs. 86.0 days, P = 0.03). CONCLUSIONS: Daily postoperative drain volume can assist with early diagnosis of a lymphatic leak in the groin following an open revascularization procedure. Sclerotherapy and surgery were each successful, but surgery resulted in significantly shorter times to resolution. In the appropriate candidates, surgery should be considered first line management of a lymphatic leak.

A Systematic Review of the Utility of Indocyanine Angiography in Autologous Breast Reconstruction.

BACKGROUND: In the last decade, a number of studies have demonstrated the utility of indocyanine green (ICG) angiography in predicting mastectomy skin flap necrosis for immediate breast reconstruction. However, data are limited to investigate this technique for autologous breast reconstruction. Although it may have the potential to improve free flap outcomes, there has not been a large multicenter study to date that specifically addresses this application. METHODS: A thorough literature review based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was conducted. All studies that examined the use of intraoperative ICG angiography or SPY to assess perfusion of abdominally based free flaps for breast reconstruction from January 1, 2000, to January 1, 2020, were included. Free flap postoperative complications including total flap loss, partial flap loss, and fat necrosis were extracted from selected studies. RESULTS: Nine relevant articles were identified, which included 355 patients and 824 free flaps. A total of 472 free flaps underwent clinical assessment of perfusion intraoperatively, whereas 352 free flaps were assessed with ICG angiography. Follow-up was from 3 months to 1 year. The use of ICG angiography was associated with a statistically significant decrease in flap fat necrosis in the follow-up period (odds ratio = 0.31, P = 0.02). There was no statistically significant difference for total or partial flap loss. CONCLUSIONS: From this systematic review, it can be concluded that ICG angiography may be an effective and efficient way to reduce fat necrosis in free flap breast reconstruction and may be a more sensitive predictor of flap perfusion than clinical assessment alone. Future prospective studies are required to further determine whether ICG angiography may be superior to clinical assessment in predicting free flap outcomes.

Developing Human Skin Contains Lymphocytes Demonstrating a Memory Signature.

Lymphocytes in barrier tissues play critical roles in host defense and homeostasis. These cells take up residence in tissues during defined developmental windows, when they may demonstrate distinct phenotypes and functions. Here, we utilized mass and flow cytometry to elucidate early features of human skin immunity. Although most conventional αß T (Tconv) cells in fetal skin have a naive, proliferative phenotype, a subset of CD4+ Tconv and CD8+ cells demonstrate memory-like features and a propensity for interferon (IFN)γ production. Skin regulatory T cells dynamically accumulate over the second trimester in temporal and regional association with hair follicle development. These fetal skin regulatory T cells (Tregs) demonstrate an effector memory phenotype while differing from their adult counterparts in expression of key effector molecules. Thus, we identify features of prenatal skin lymphocytes that may have key implications for understanding antigen and allergen encounters in utero and in infancy.

A Bipedicled Flap for Closure of the Anterolateral Thigh Flap Donor Site.

Anterolateral thigh (ALT) free flaps have become reliable options for head-to-toe reconstruction. Although perforator anatomy is fairly predictable, in cases of eccentric perforator location, we proposed shifting the entire flap laterally and preserving a medial bipedicled flap between the original incision and the new medial flap margin. This facilitates primary donor site closure instead of harvesting a flap larger than anticipated. We conducted a retrospective chart review of ALT flaps performed between 2007 and 2019 and identified patients who underwent bipedicled closure of the donor site. Demographics, flap characteristics, and surgical technique were evaluated. Six patients had bipedicled donor site closure related to primary perforators located lateral to the original flap design. The mean defect size was 91 cm2, and bipedicled flap width ranged from 4 to 6 cm. All donor sites were closed primarily. Five of the donor thigh sites healed without complications, and 1 patient had superficial delayed healing of the medial bipedicled incision, which healed with local wound care. The ALT has become an invaluable flap in microsurgical reconstruction, yet it is not without limitations. Primary donor site closure is generally not feasible for larger flaps, thus necessitating skin grafting of the donor site and/or prolonged wound care. Our technique facilitates primary closure of the donor site in patients who otherwise would have required harvest of a larger than necessary flap based on eccentric perforator anatomy. The medial bipedicled flap is straightforward, reproducible, and allows for modifications of the original flap design to better fit the defect.

A Critical Analysis of Prosthetic Augmentation of Autologous Microvascular Breast Reconstruction.

INTRODUCTION: The combined approach using both an implant and autologous tissue for breast reconstruction has become more common over the last 10 years. We sought to provide a systematic review and outcomes analysis of this technique. METHODS: We searched PubMed and the Cochrane Library database to identify studies that described implant augmentation of autologous flaps for breast reconstruction. The references of selected articles were also reviewed to identify any additional pertinent articles. RESULTS: We identified 11 articles, which included 230 patients and 378 flaps. Implants used ranged in size from 90 to 510 cc, with an average size of 198 cc. Implants were more frequently placed at the time of autologous reconstruction and in the subpectoral plane. There were no total flap losses, and partial flap loss occurred in 3 patients (1%). There were no cases of venous or arterial thrombosis and no early return to the operating room for flap compromise. Eight implants (2%) were lost because of infection or extrusion, and capsular contracture occurred in 9 breasts (3%). When stratified by the timing of implant placement (immediate vs delayed), there were no significant differences in any postoperative outcomes except the immediate group had a higher infection rate. CONCLUSIONS: The criteria for women to be candidates for autologous tissue breast reconstruction can be expanded by adding an implant underneath the flap. We found the overall flap loss rate is comparable with standard autologous flap reconstruction, and the implant loss rate is lower than that in patients who undergo prosthetic reconstruction alone.

Success rates of re-excision after positive margins for invasive lobular carcinoma of the breast.

Rates of positive margins after surgical resection of invasive lobular carcinoma (ILC) are high (ranging from 18 to 60%), yet the efficacy of re-excision lumpReceptor subtypeectomy for clearing positive margins is unknown. Concerns about the diffuse nature of ILC may drive increased rates of completion mastectomy to treat positive margins, thus lowering breast conservation rates. We therefore determined the success rate of re-excision lumpectomy in women with ILC and positive margins after surgical resection. We identified 314 cases of stage I-III ILC treated with breast conserving surgery (BCS) at the University of California, San Francisco. Surgical procedures, pathology reports, and outcomes were analyzed using univariate and multivariate statistics and Cox-proportional hazards models. We evaluated outcomes before and after the year 2014, when new margin management consensus guidelines were published. Positive initial margins occurred in 118 (37.6%) cases. Of these, 62 (52.5%) underwent re-excision lumpectomy, which cleared the margin in 74.2%. On multivariate analysis, node negativity was significantly associated with successful re-excision (odds ratio [OR] 3.99, 95% CI 1.15-13.81, p = 0.029). After 2014, we saw fewer initial positive margins (42.7% versus 25.5%, p = 0.009), second surgeries (54.6% versus 20.2%, p < 0.001), and completion mastectomies (27.7% versus 4.5%, p < 0.001). In this large cohort of women with ILC, re-excision lumpectomy was highly successful at clearing positive margins. Additionally, positive margins and completion mastectomy rates significantly decreased over time. These findings highlight improvements in management of ILC, and suggest that completion mastectomy may not be required for those with positive margins after initial BCS.

Development and Validation of a Nipple-Specific Scale for the BREAST-Q to Assess Patient-Reported Outcomes following Nipple-Sparing Mastectomy.

BACKGROUND: Nipple-sparing mastectomy and immediate reconstruction has become increasingly popular for prophylactic and therapeutic indications. Patient-reported outcomes instruments such as the BREAST-Q provide important information regarding patient satisfaction and aesthetic and functional outcomes. However, a validated patient-reported outcomes scale specifically addressing nipple-related outcomes following nipple-sparing mastectomy is not currently available. METHODS: The authors developed a new scale measuring nipple outcomes by adapting nipple reconstruction questions from the BREAST-Q breast reconstruction module. Patients completed the questions using the think-aloud method and underwent semistructured cognitive interviews to discuss their nipple-sparing mastectomy experience to elicit new concepts. Interviews were coded and additional questions were added based on this analysis after receiving additional input from a multidisciplinary group of breast cancer providers. The final scale was distributed electronically to a larger group with solicitation for any issues that were not addressed in the question set. RESULTS: Ten patients completed the initial questionnaire. Analysis of the cognitive interviews identified nipple sensation, position, projection, scarring, symmetry, and surgical expectations as key content areas. After revising the questionnaire, an additional 35 patients completed it electronically. All respondents felt the questions were clear and no additional issues needed to be addressed. Feedback was used to clarify the instructions for how to respond to the questions if bilateral nipple-sparing mastectomy had been performed. CONCLUSIONS: Through qualitative patient interviews and adaptation of existing BREAST-Q questions, appropriate nipple-focused questions were developed to assess outcomes following nipple-sparing mastectomy. Incorporating these questions into patient-reported outcomes assessment of patients undergoing nipple-sparing mastectomy can help improve future techniques and optimize outcomes.

Medial Femoral Condyle Free Flap Reconstruction of Complex Foot and Ankle Pathology.

BACKGROUND: Complex hindfoot pathology may benefit from vascularized bone flap reconstruction rather than traditional bone grafting techniques. Medial femoral condyle (MFC) flaps provide vascularized periosteum, skin, and corticocancellous bone. METHODS: A retrospective, single-institution cohort study of consecutive MFC flaps performed for complicated hindfoot reconstruction between 2013 and 2019 was reviewed. Radiologic follow-up assessed osseous union and clinical outcomes were evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score. Thirty MFC flaps were performed in 28 patients for complex hindfoot pathology. Twenty-seven flaps had adequate clinical and radiographic follow-up (mean 15.8 months). RESULTS: The majority presented with avascular necrosis (83%) and failed prior operations (67%, mean 3.1). Most hindfoot procedures involved arthrodesis (n = 24, 80%); tibiotalocalcaneal (n = 11) and talonavicular (n = 7) most frequently. Mean osseous flap volume was 10.3 cm3 (range 1.7-18.4 cm3); one flap required takeback for venous congestion but no total flap losses occurred. Primary osseous union was initially achieved in 20 patients (74%, mean 217 days). Six flaps developed interface nonunion; 5 underwent revision arthrodesis and ultimately achieved union in 24/27 flaps (89%, mean 271 days). Risk factors for nonunion were body mass index (BMI) >30 (P = .017) and prior arthrodesis (P = .042). Mean AOFAS hindfoot scores increased significantly from 52.3 preoperatively to 70.7 postoperatively (P < .001). Subscore analysis demonstrated significant improvement in postoperative pain scores from 14.2 to 27.3 out of 40 (P < .001). CONCLUSION: The MFC free flap provided vascularized bone for complicated foot and ankle reconstruction with relatively low donor site morbidity, promising osseous union results, and improved functional outcomes. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Characterizing infections in prosthetic breast reconstruction: A validity assessment of national health databases.

INTRODUCTION: Current guidelines in the United States require reporting only the 30-day postoperative outcomes to standardized databases, including the National Surgical Quality Improvement Program (NSQIP). Thus, many breast implant-related complications go unreported in standard databases. We sought to characterize late periprosthetic infections following implant-based breast reconstruction. METHODS: We conducted a retrospective analysis of all women who underwent expander/implant reconstruction from 2005 to 2014 at two institutions. All periprosthetic infections were identified and divided into early and late cohorts (≤30 days or >30 days). Infection was defined as any episode where antibiotics were initiated or a prosthetic device was explanted because of clinical evidence of the infection. RESULTS: In the 1820 patients (2980 breasts) identified, 421 periprosthetic infections occurred (14%). Of these, 173 (41%) were early and 248 (59%) were late (mean time to infection = 66.4 ± 101.9 days). Patients with late infections were more likely to be current smokers or have diabetes than patients with early infections (p < 0.034 for both). Infections caused by gram-negative bacteria and antimicrobial-resistant strains of Staphylococcus were more common in the early infection group (p < 0.001 for both). Implant loss due to infection was more common in the late infection group (p = 0.037). DISCUSSION: Late periprosthetic infections following implant-based breast reconstruction are underestimated in national outcome databases and have unique risk factors and microbiology compared to early infections. A system-level change in reevaluating and redefining a timeline for tracking and treating implant infections is necessary, given the substantial morbidity associated with, and frequency of, late periprosthetic infections.

An Innovative Risk-Reducing Approach to Postmastectomy Radiation Delivery after Autologous Breast Reconstruction.

INTRODUCTION: Postmastectomy radiation therapy (PMRT) has known deleterious side effects in immediate autologous breast reconstruction. However, plastic surgeons are rarely involved in PMRT planning. Our institution has adopted a custom bolus approach for all patients receiving PMRT. This offers uniform distribution of standard radiation doses, thereby minimizing radiation-induced changes while maintaining oncologic safety. We present our 8-year experience with the custom bolus approach for PMRT delivery in immediate autologous breast reconstruction. METHODS: All immediate autologous breast reconstruction patients requiring PMRT after 2006 were treated with the custom bolus approach. Retrospective chart review was performed to compare the postirradiation complications, reconstruction outcomes, and oncologic outcomes of these patients with those of previous patients at our institution who underwent standard bolus, and to historical controls from peer-reviewed literature. RESULTS: Over the past 10 years, of the 29 patients who received PMRT, 10 were treated with custom bolus. Custom bolus resulted in fewer radiation-induced skin changes and less skin tethering/fibrosis than standard bolus (0% vs 10% and 20% vs 35%, respectively), and less volume loss and contour deformities compared with historical controls (10% vs 22.8% and 10% vs 30.7%, respectively). CONCLUSIONS: Custom bolus PMRT minimizes radiation delivery to the internal mammary vessels, anastomoses, and skin; uniformly doses the surgical incision; and provides the necessary radiation dose to prevent recurrence. Because custom bolus PMRT may reduce the deleterious effects of radiation on reconstructive outcomes while maintaining safe oncologic results, we encourage all plastic surgeons to collaborate with radiation oncologists to consider this technique.

Distraction Osteogenesis of Multiple Ribs for the Treatment of Acquired Thoracic Dystrophy.

Acquired thoracic dystrophy is a complication associated with early open repair of pectus excavatum resulting from extensive cartilage resection. The condition can cause serious functional and physiologic impairments, including cardiac compression and restrictive pulmonary function. We describe a 17-year-old boy with acquired thoracic dystrophy after Ravitch repair of pectus excavatum during infancy, whom we treated with distraction osteogenesis. The patient had a marked deformity of the chest wall and general hypoplasia of the central portion of the ribcage, with resultant symptomatic dyspnea on exertion and reduced pulmonary function. After osteotomies and distraction osteogenesis of bilateral ribs 4-8 using customized distraction devices, he had improved thoracic contour, resolution of dyspnea, and decreased restrictive pulmonary symptoms. This case suggests that distraction osteogenesis, already used extensively in craniomaxillofacial and orthopedic surgery, may be a novel method for management of this condition.