RESUMO
Frenchay Hospital has long since been established as the center for plastic surgery in Bristol, providing care to the city and its surrounding catchment area. From humble origins in the Second World War when the site took on the role of a large military hospital providing reconstructive surgery for the victims of war to a busy modern-day National Health Service establishment, the plastic surgery unit at Frenchay Hospital has grown and developed through in parallel with the genesis and development of the specialty. Recent centralization of care in Bristol has seen a massive reorganization of services, and with it the closure of Frenchay Hospital. Because the plastic surgery unit establishes a new home at Southmead Hospital, this review documents the foundations of reconstructive surgery in Bristol and the South West United Kingdom.
Assuntos
Centro Cirúrgico Hospitalar/história , Cirurgia Plástica/história , História do Século XX , Hospitais/história , Humanos , Medicina Estatal/história , Reino UnidoRESUMO
BACKGROUND: Venous congestion is the principle cause of flap failure after microsurgical breast reconstruction. We aim to correlate preoperative computed tomography angiography (CTA) findings with postoperative venous congestion to predict patients at risk of congestion. METHODS: All patients undergoing deep inferior epigastric perforator (DIEP) breast reconstruction between August 2009 and August 2013 underwent preoperative CTA and prospectively entered the study. Patients with postoperative venous congestion were matched with a similar cohort of complication-free patients. Preoperative CTAs were randomized and re-interpreted by a radiologist, blinded to the subsequent clinical outcome. Inter-group comparisons were performed. RESULTS: Two hundred and forty DIEP flaps were performed in 202 patients over the 4-year study. Venous congestion affected 15 flaps (6.3%). Preoperative CTA showed significantly more atypical venous connections between deep and superficial systems in congested flaps compared to controls (66.7% vs. 8%; P < .0001), with a positive predictive value of 83%. Atypical connections were narrow, tortuous, or incomplete. Patients with congestion-free flaps had more normal connections (80% vs. 26.7%; P < .001) and more cranial perforators (P = .02). Similar CTA findings between groups included perforator size and lateral position, superficial inferior epigastric vein size, crossing of midline, and absent connections (P > .05). CONCLUSIONS: Preoperative CTA identifies atypical venous connections between deep and superficial systems that increase the risk of postoperative DIEP congestion five-fold. Identifying atypical venous connections maximizes the chances of flap survival and minimizes complications for patients considering DIEP breast reconstruction.
Assuntos
Neoplasias da Mama/diagnóstico por imagem , Angiografia por Tomografia Computadorizada , Hiperemia/etiologia , Mamoplastia/efeitos adversos , Retalho Perfurante , Complicações Pós-Operatórias/etiologia , Adulto , Neoplasias da Mama/cirurgia , Estudos de Coortes , Artérias Epigástricas , Feminino , Humanos , Mastectomia , Pessoa de Meia-Idade , Valor Preditivo dos TestesRESUMO
Total IntraVenous Anaesthesia is frequently the anaesthetic of choice for enhanced recovery after surgery pathways during breast reconstruction free flap surgery. This relies upon the continuous intravenous infusion of propofol. We describe our experience of two patients where augmentation of a venously congested DIEP flap with a cephalic vein transposition procedure, risked interruption of the intravenous delivery of anaesthesia to the patient. We also share our steps taken to mitigate this risk going forward.
Assuntos
Anestesia Intravenosa , Retalhos de Tecido Biológico/irrigação sanguínea , Mamoplastia/métodos , Artérias Epigástricas , HumanosRESUMO
BACKGROUND: The longevity and durability of implant-based reconstruction is limited and many patients who develop complications seek alternative reconstruction. Recent studies have shown tertiary reconstruction with autologous tissue to be safe in the short term. But no study has looked in-depth at the motivation for seeking referral and its long-term outcome. METHODS: This was a retrospective study using patient case-notes and a prospectively-collated database. One hundred and fifteen patients underwent tertiary breast reconstruction with a Deep Inferior Epigastric Perforator (DIEP) flap between 1998 and 2016. RESULTS: Mean age was 49 (23-67). The predominant initial reconstruction was expander (71%). Twenty nine percent received a definitive reconstruction (implant with acellular dermal matrix or pedicled latissimus dorsi). The proportion of patients who received post-mastectomy radiotherapy (PMRT) to their implant was 72%. Thirty four percent underwent surgical salvage prior to referral for autologous tissue and this was significantly higher in the group that did not receive PMRT (29% vs 40, pâ¯=â¯0.04). Predominant motivation for autologous reconstruction was poor cosmesis (62%) and/or grade III/IV capsular contracture (27%). Mean time from implant to DIEP was 4 years 5 months. Ten percent had complications requiring re-operation. Flap loss was 0.7%. Fifty five percent required an additional ipsilateral procedure and 47% required symmetrization. Median follow-up was 20-months (6-months to 7-years). CONCLUSIONS: We present the largest UK series of tertiary breast reconstruction. Tertiary reconstruction is safe with a surgical outcome comparable to delayed autologous reconstruction. Patients with implant complications often had multiple failed attempts at salvage prior to referral. We advocate careful consideration of implants in the setting of PMRT and early referral for autologous tissue once complications become apparent.
Assuntos
Implante Mamário/métodos , Neoplasias da Mama/cirurgia , Carcinoma Ductal de Mama/cirurgia , Carcinoma Intraductal não Infiltrante/cirurgia , Carcinoma Lobular/cirurgia , Retalho Perfurante , Terapia de Salvação/métodos , Derme Acelular , Adulto , Idoso , Implante Mamário/instrumentação , Implantes de Mama , Artérias Epigástricas , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Retalho Perfurante/irrigação sanguínea , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/cirurgia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Músculos Superficiais do Dorso/transplante , Centros de Atenção Terciária , Expansão de Tecido/instrumentação , Expansão de Tecido/métodos , Dispositivos para Expansão de Tecidos , Falha de TratamentoRESUMO
A common cause for loss of a deep inferior epigastric perforator (DIEP) flap is venous congestion secondary to inadequate outflow via the deep perforating vessels. Further anastomosis of the superficial venous system provides effective outflow and salvage of the congested DIEP. Multiple methods have been described requiring dissection of additional recipient venous systems or around the perforating vessels in order to provide a vein onto which the superficial system may be anastomosed. These are potentially associated with increased morbidity and risk of damage to the pedicle. We describe an alternative technique of harvesting an additional length of deep inferior epigastric pedicle cranial to the perforator onto which an anastomosis may be performed. This avoids the need for additional dissection of recipient vessels or further handling of the perforator, its venae comitantes and the main pedicle of the flap thus reducing the risk of damage.