How should we manage women with fat necrosis following autologous breast reconstruction: An algorithmic approach.

Fat necrosis is a common complication of autologous breast reconstruction; however, diagnostic criteria are yet to be standardized, making comparison of autologous breast reconstructive techniques challenging. A systematic review found six of 556 articles met inclusion criteria. These results were used to generate an algorithm for managing fat necrosis after autologous breast reconstruction.

Fat Necrosis After DIEP Flap Breast Reconstruction: A Review of Perfusion-Related Causes.

INTRODUCTION: Fat necrosis is a common complication for the deep inferior epigastric perforator (DIEP) flap. A thorough understanding of the factors associated with fat necrosis will aid operative planning for reconstructive surgeons. METHODS: A systematic review of the literature was performed between January 1989 and April 2019. Studies were included if they reported on fat necrosis in DIEP flap or evaluated the perfusion of the DIEP flap. Twenty-eight out of 312 studies met the inclusion and exclusion criteria. RESULTS: Fat necrosis rates ranged from 12.0 to 45.0% on clinical examination within the literature. The four main perforator-specific factors identified included perforator perfusion zones, perforator location, perforator number and venous congestion. Medial row perforators have a wider perfusion zone, while lateral row perforators have a narrow perfusion zone. Holm zone III has a higher rate of fat necrosis compared to Holm zone II. One to two perforators and more than five perforators and a Type III atypical connection between the superficial and deep venous system had a higher rate of fat necrosis. CONCLUSION: The DIEP flap should incorporate between two and three perforators of a substantial calibre; Holm zone III should be excluded if able and careful review of the pre-operative imaging should be performed to analyse the connections between the deep and superficial venous system. There are multiple perfusion-related factors to consider when planning the DIEP flap and ultimately a patient-specific approach to the vascular anatomy is essential. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Upper airway involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis.

BACKGROUND: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare life-threatening hypersensitivity conditions associated with epidermal detachment and mucositis. The indication for flexible nasoendoscopy (FNE) and overall predictive factors for early intubation are unclear. OBJECTIVES: To describe the incidence of airway involvement and the key indicators for intubation in our SJS or TEN patient cohort. To determine the association between FNE findings and early intubation. METHODS: A retrospective review of 45 patients with biopsy proven SJS or TEN admitted to an Australian tertiary burns centre from 2010 to 2017. RESULTS: Thirty-five patients were diagnosed with TEN (77.8%), followed by overlap syndrome (SJS-TEN) (n = 6, 13.3%) and SJS (n = 4, 8.9%). Twenty (44.4%) patients were intubated; and all 20 had a diagnosis of TEN (100.0%) (p < 0.05). Intubated patients had a higher increase in total body surface area percentage(%) from day 1-3 [10.0% (IQR 0.0-23.8%)] and a longer length of stay [26.0 days (IQR 12.5-34.0)], compared to non-intubated patients [0.0% (IQR 0.0-4.0%)], [10.0 days (IQR 6.0-14.0)] (p < 0.05) respectively. The main indications for intubation were to facilitate operative and dressing management (47.4%) followed by airway involvement (26.3%). FNE was performed on 32 patients (71.1%), however FNE findings did not significantly influence intubation rates. CONCLUSION: More than half (n = 20, 57.1%) of the 35 patients diagnosed with TEN underwent intubation, mainly to facilitate operative and dressing management. FNE was performed on most patients, however there was no clear association between FNE findings and early intubation.

How to assess a CTA of the abdomen to plan an autologous breast reconstruction.

The deep inferior epigastric perforator (DIEP) flap is recognised as the most popular option for autologous breast reconstruction. Planning of the DIEP flap involves pre-operative assessment of abdominal vascular anatomy with imaging, of which computed tomographic angiography (CTA) has become the mainstay. CTA enables detailed planning of a range of surgical steps, leading to reduced operative times and improved surgical outcomes. The value of CTA is only demonstrated when the relevant vascular anatomy is able to be demonstrated and appraised. For optimal analysis, a 64-slice multi-detector row CT scanner and imaging software including OsiriX™, Siemens InSpace™ or Horos™ are required. The seven major steps to consider include: (I) perforator size; (II) perforator angiosome; (III) intramuscular course; (IV) deep inferior epigastric artery (DIEA) pedicle; (V) venous anatomy; (VI) superficial inferior epigastric artery (SIEA) and superficial inferior epigastric vein (SIEV); and (VII) abdominal wall structure. These steps should also be reviewed when marking the patient and planning the flap intra-operatively. While CTA has superior sensitivity and specificity in mapping perforator anatomy it also faces challenges due to ionising radiation exposure, contrast-induced allergy and potential nephrotoxicity. Despite these challenges, the benefits of CTA to the individual patient has maintained its role in pre-operative planning of the DIEP flap.