Complications of Wise-Pattern Compared With Vertical Scar Mastopexy/Breast Reduction in Oncoplastic Breast-Conserving Surgery.

BACKGROUND: Oncoplastic breast-conserving surgery (OBCS) is most commonly performed using established or modified mastopexy/breast reduction techniques. Although the comparative complication profiles of Wise-pattern mastopexy/breast reduction techniques compared with vertical scar techniques are well understood, outcomes in the setting of OBCS are unknown. METHODS: A retrospective study was conducted of all patients that underwent OBCS using mastopexy/breast reduction techniques at a single center over a 6-year period. Patients who underwent Wise-pattern techniques were compared with those who underwent vertical scar techniques. Demographic, treatment, and outcomes data were collected. Descriptive statistics were used, and multivariate analysis was performed to evaluate the relationship between these multiple variables and complications. RESULTS: Of 413 eligible patients, 278 patients (67.3%) received a Wise-pattern technique and 135 (32.7%) underwent a vertical scar technique. The overall complication rate was significantly higher in the Wise-pattern than in the vertical scar group (30.6% vs 18.5%, respectively; P = 0.012), as was the major complication rate (11.9% vs 4.4%; P = 0.011) including need for additional surgery for complications (6.8% vs 1.5%; P = 0.029). Complications resulted in a delay to any adjuvant therapy in 20 patients (4.8%); however, the difference between the groups was not significant (6.1% for Wise pattern vs 2.2% for vertical scar; P = 0.098). In a multivariable logistic model, use of a Wise-pattern technique (odds ratio, 0.37 [95% confidence interval, 0.14-0.99]; P = 0.049) was a significant predictor of major complications. CONCLUSIONS: The Wise-pattern mastopexy/breast reduction OBCS technique was associated with a significantly higher complication and major complication rate than vertical scar techniques. The findings should be considered during choice of surgical technique in oncoplastic breast conservation.

Considering the Optimal Timing of Breast Reconstruction With Abdominal Flaps With Adjuvant Irradiation in 370 Consecutive Pedicled Transverse Rectus Abdominis Myocutaneous Flap and Free Deep Inferior Epigastric Perforator Flap Performed in a Chinese Oncology Center: Is There a Significant Difference Between Immediate and Delayed?

PURPOSE: There is an ongoing debate on the optimal sequence of radiation and breast reconstruction. The purpose of this article was to (a) assess the impact of radiation on autologous breast reconstruction and (b) analyze the best timing for autologous breast reconstruction in the setting of radiation in a Chinese population. METHODS: A retrospective review of patients undergoing breast reconstruction with autologous lower abdominal flaps between 2001 and 2014 in the Tianjin Medical University and Cancer Hospital was performed. Patients were grouped by their irradiation status (irradiated vs nonirradiated). The irradiated group was further stratified into 2 groups by the timing of irradiation (immediate breast reconstruction followed by radiation vs prior radiation and delayed breast reconstruction). The primary outcomes were early and late breast complications, secondary and revision surgeries to the reconstructed breast, whereas the secondary outcomes were aesthetic and psychological evaluations of the patients. Logistic regression was used to assess the potential association between irradiation, patient and treatment variables, and surgical outcomes. RESULTS: Three hundred sixty patients with 370 reconstructed breasts were included in the study. Two hundred seventy-eight cases were nonirradiated, of which 158 were immediate and 120 were delayed. Ninety-two cases were irradiated, of which 61 were immediate, and 31 were delayed. Three hundred thirty-two cases underwent pedicled transverse rectus abdominis myocutaneous flap, 38 had deep inferior epigastric perforator flap. The irradiated group had a significant increase in secondary surgery due to fat necrosis (P < 0.001) and in late complications (P = 0.011). A significant increase in flap contracture (P = 0.043) and an increasing trend in the severity of fat necrosis were observed when radiation was performed after breast reconstruction. However, radiation and its timing did not have an adverse impact on patients' aesthetic and psychological evaluations by the Breast-Q survey. CONCLUSIONS: Radiation administered to the reconstructed breast mound increased the rate of late complications and the need for secondary surgery with increased abdominal flap shrinkage and contracture and the severity of flap fat necrosis. Irradiation on the reconstructed breast did not lead to worse aesthetic outcomes due to the generally different expectation in the Chinese female patients in that they were more focused on the breast shape when clothed. Immediate breast reconstruction followed by irradiated was a generally successful treatment sequence in the Chinese module.

Comprehensive Evaluation of Risk Factors and Management of Impending Flap Loss in 2138 Breast Free Flaps.

Loss of a breast free flap is a relatively rare but catastrophic occurrence. Our study aims to identify risk factors for flap loss and to assess whether different salvage techniques affect flap salvage. We performed a retrospective review of all breast free flaps performed at a single institution from 2000 to 2010. Overall, 2138 flaps were performed in 1608 patients (unilateral, 1120 and bilateral, 488) with 44 flap losses (2.1%). Age, body mass index, smoking, radiation, chemotherapy, and surgeon experience did not affect flap loss. Abdominal flaps based on a single perforator were at significantly higher risk for flap loss compared with flaps based on multiple perforators (P = 0.0007). Subgroup analysis of the subset of 166 compromised free flaps (flaps requiring a return to the operating room, an intraoperative anastomotic revision, or loss/partial loss of a free flap) demonstrated deep inferior epigastric perforator, and other flaps (superficial inferior epigastric artery and superior gluteal artery perforator) were significantly associated with flap loss [odds ratio (OR) 5.20; P = 0.03 and OR 6.91; P = 0.0004, respectively] compared with transverse rectus abdominis myocutaneous and muscle-sparing transverse rectus abdominis myocutaneous flaps. Although an intraoperative complication was not associated with a flap loss, the need for a reoperation was strongly predictive (P < 0.0001). Flap salvage was the highest within the first 24 hours (83.7%) and significantly less between days 1 and 3 (38.6%; P < 0.0001) and beyond 4 days (29.4%; P < 0.0001). Longer ischemia time was significantly associated with flap loss (P = 0.04). Salvage techniques (aspirin, heparinzation, thrombectomy, and thrombolytic) had no impact on flap salvage rates. Heparinization and thrombolytics were associated with higher loss rates (OR 3.40; P = 0.003 and OR 10.36; P < 0.0001, respectively). Free flap loss following breast reconstruction is multifactorial with higher losses in superficial inferior epigastric artery and gluteal flaps, single-perforator abdominal flaps, and longer ischemia times. Salvage rates are most successful within the first 24 hours, and the use of heparinization, aspirin, and thrombolytics does not improve salvage rates.

Choosing the optimal timing for contralateral symmetry procedures after unilateral free flap breast reconstruction.

Achieving symmetry in unilateral free flap breast reconstruction often requires a contralateral procedure; however, no large studies exist that examine the factors related to revisions performed on the contralateral breast. The present study examines the relationship between revision and complication rate, and the type and timing of the contralateral procedure. Retrospective analysis was performed of all unilateral free flap breast reconstructions from January 2000 to December 2010 at a single academic institution. Overall, 1120 patients underwent unilateral free flap breast reconstruction with 558 (49.8%) patients undergoing a contralateral procedure, 154 (27.6%) immediate and 404 (72.4%) delayed. Contralateral procedures included 106 augmentations, 168 reductions, 240 mastopexies, and 37 augmentation-mastopexies. Revision of the symmetry procedure was performed in 114 (20.8%) patients. Augmentation and mastopexy were associated with significantly higher revision rates when performed immediately. The complication rate was higher in immediate contralateral procedures than delayed [15 (9.7%) vs 16 (4.0%), P = 0.01]. The average number of procedures per patient was significantly higher in delayed contralateral procedures than immediate (2.45 vs 1.84, P < 0.0005). In summary, approximately half of patients undergoing a unilateral free flap for breast reconstruction will also undergo a contralateral balancing procedure. Immediate contralateral augmentation and mastopexy carry a higher revision rate and consideration should be given to performing them in a staged fashion. There were no differences in the rate of revisions for breast reductions, and therefore, performance of simultaneous contralateral reduction is a reasonable option. Although complication rates were higher in the immediate cohort, overall "symmetry" was achieved in significantly fewer operations.

Does a Latissimus Dorsi Flap Improve Surgical Outcomes of Implant-based Breast Reconstruction following Infected Device Explantation?

Background: The goal of this study was to assess whether adding a latissimus dorsi (LD) flap to a secondary implant-based reconstruction (IBR) improves outcomes following explantation of the primary device due to infection. Methods: We conducted a retrospective study of patients who underwent a second IBR with or without the addition of an LD flap during 2006-2019, following explantation due to infection. Surgical outcomes were collected and compared between reconstruction types. Results: A total of 6093 IBRs were identified during the study period. Of these, 109 underwent a second attempt at breast reconstruction with IBR alone (n = 86, 79%) or IBR/LD (n = 23, 21%) following explantation of an infected device. Rates of secondary device explantation due to a complication were similar between the two groups (26% in the IBR/LD group and 21% in the IBR group; P = 0.60). Among the patients who underwent prior radiotherapy, the IBR/LD group had lower rates of any complication (38% versus 56%; P = 0.43), infection (25% versus 44%; P = 0.39), and reconstruction failure (25% versus 44%; P = 0.39); however, differences were not statistically significant. Conclusion: Following a failed primary breast reconstruction due to infection, it may be appropriate to offer a secondary reconstruction. For patients with a history of radiotherapy, combining an LD flap with IBR may provide benefits over IBR alone. Although not statistically different, this outcome may have clinical significance, considering the magnitude of the effect, and may result in decreased complication rates and a higher chance of reconstructive success.

Distally based dorsal pedal neurocutaneous flap for forefoot coverage.

The authors describe their experience with the use of the distally based dorsal pedal neurocutaneous flap for distal foot coverage. Ten patients underwent reconstruction with 13 flaps between 2004 and 2008. One patient suffered from a traffic accident and 9 from electrical injury. All of the soft tissue defects resulted in metatarsophalangeal joint and phalanx bone exposure. The size of the flaps ranged from 6 × 2 cm to 11 × 6 cm. The flaps were elevated based on intermediate or medial dorsal pedal nerves. Nine flaps were harvested in first stage to repair the distal foot. Among them, 3 showed partial necrosis in the distal region because of venous insufficiency. Four flaps underwent a surgical delay procedure in the first stage and were then transferred to reconstruct phalanx wounds in the second stage, surviving completely. All patients were satisfied with their reconstruction and donor site contour. The distally based dorsal pedal neurocutaneous flap can be used to repair the distal foot soft tissue defects, providing sufficient skin territory and excellent aesthetic and functional recovery. Surgical delay effectively enhances the distally based dorsal pedal neurocutaneous flap survival, particularly for the large size flaps.

Free flap reconstruction of extensive defects following resection of large neurofibromatosis.

BACKGROUND: Neurofibromatosis type 1 (NF-1) is a locally invasive tumor that can grow extensively with diffuse infiltration into surrounding tissue. Resecting a large neurofibroma can result in an extensive defect that is difficult to reconstruct and can cause both aesthetic and functional deformities. METHODS: From 2000 to 2010, 5 patients with NF-1 underwent radical resection and immediate reconstruction with 6 free flaps at our institution. All patients presented with recurrent tumor, and involved head and neck region in 4 and foot in 1 patient. Ages ranged from 18 to 75 years. The follow-up ranged from 1 to 94 months. RESULTS: Defect sizes ranged from 84 to 252 cm. A single free flap was used in 4 cases and 2 free flaps were used in 1 case. All the flaps survived. Complications included loss of skin graft, necrosis of the distal tip of a flap, and wound dehiscence. All complications were successfully managed with minor surgical procedures. CONCLUSION: Immediate reconstruction using a free flap after resecting a large neurofibroma is a safe and reliable method that facilitates radical resection of the tumors that are difficult to resect and that may result in an extensive defect.

Anterolateral thigh adipofascial flap for correction of facial contour deformities and micromastia.

The anterolateral thigh (ALT) flap has gained popularity, yet the donor site remains problematic. With increased knowledge of the vascular anatomy, we anticipated that we would be able to contour the ALT adipofascial flap when reconstructing facial deformities and micromastia without sacrificing skin at the donor site. A total of 24 cases of hemifacial atrophy and 1 case of micromastia underwent anterolateral thigh adipofascial flap transplantation with vascular anastomosis. All surgical reconstructions resulted in satisfactory results with minimal donor-site morbidity. The anterolateral thigh adipofascial perforator flap is an ideal choice for autologous tissue reconstruction with primary defatting.

Clinical application of the anterolateral thigh flap for soft tissue reconstruction.

The purpose of this article is to describe the author's experience using the anterolateral thigh (ALT) flap for the reconstruction of a variety of soft tissue defects. The flap utility and donor site morbidity were evaluated in 126 cases from March 1985 to August 2007. The ALT flaps were harvested as either free fasciocutaneous, free adipofascial, fasciocutaneous island, or reversed fasciocutaneous island flaps to repair facial, neck, breast, trunk, and extremity defects. In 40 cases (32%), the skin vessels were found to be septocutaneous perforators, and in 86 cases (68%), they were found as musculocutaneous perforators. Of the 126 flaps, 121 survived completely, providing a success rate of 96.0%. There were four cases undergoing multidetector-row computed tomographic angiography (CTA) for preoperative perforator mapping, and all perforators were confirmed intraoperatively. In conclusion, the ALT flap is a versatile and reliable flap that could well be a priority option for soft tissue reconstruction. CTA can provide more valuable and accurate anatomic information about the pedicle and perforators, making it safer and faster to harvest a targeted ALT perforator flap with less donor site morbidity.

Outcomes of Volume Replacement Oncoplastic Breast-Conserving Surgery Using Chest Wall Perforator Flaps: Comparison with Volume Displacement Oncoplastic Surgery and Total Breast Reconstruction.

BACKGROUND: Volume replacement oncoplastic breast-conserving surgery (VR-OBCS) uses islanded or pedicled chest wall fasciocutaneous perforator flaps from outside of the breast footprint to replace the volume that has been excised during lumpectomy, extending the options for breast conservation to patients who may otherwise require mastectomy. This study compares outcomes for VR-OBCS with both standard volume displacement oncoplastic breast-conserving surgery (VD-OBCS) and mastectomy with immediate total breast reconstruction (TBR). METHODS: A retrospective cohort study was conducted; demographic data, clinicopathologic factors, surgical details, and postoperative events were collected until patients had completed their reconstructions. Variables were compared using the t test and analysis of variance test, or chi-square analysis and Fisher's exact test, as appropriate. RESULTS: Ninety-seven consecutive patients (109 immediate breast reconstruction procedures) were included: 43 percent underwent standard VD-OBCS procedures, 35 percent underwent mastectomy with immediate TBR, and VR-OBCS techniques were used in 22 percent, of which only one patient required a delayed procedure for symmetry. Mean whole tumor size was similar in the VR-OBCS and TBR groups and was significantly higher than for the VD-OBCS group (p < 0.05). Overall rate of complications affecting the breast area (p < 0.001), need for additional surgery to either breast (p < 0.001), and time to reconstruction completion (p < 0.001) were significantly higher in the TBR group. CONCLUSIONS: VR-OBCS extends the options for breast conservation to many patients that would otherwise require mastectomy. The complication rate is lower, fewer procedures are necessary, and less time is required to complete the reconstruction when compared with mastectomy and immediate TBR. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Immediate Contralateral Mastopexy/Breast Reduction for Symmetry Can Be Performed Safely in Oncoplastic Breast-Conserving Surgery.

BACKGROUND: Oncoplastic breast-conserving surgery expands the indications for breast conservation. When performed using modified mastopexy/breast reduction techniques, the optimal timing of the contralateral symmetrizing mastopexy/breast reduction remains unclear. This study examined the effect of the timing of symmetrizing mastopexy/breast reduction on oncoplastic breast-conserving surgery outcomes. METHODS: A retrospective study was conducted of all patients who underwent oncoplastic breast-conserving surgery using mastopexy/breast reduction techniques at a single center from 2010 to 2016. Patients who received synchronous (immediate) contralateral breast symmetrizing mastopexy were compared with those who underwent a delayed symmetrizing mastopexy procedure. Demographic, treatment, and outcome data were collected. Descriptive statistics were used and multivariate analysis was performed to evaluate the various relationships. RESULTS: There were 429 patients (713 breasts) included in the study; of these, 284 patients (568 breasts) underwent oncoplastic breast-conserving surgery involving mastopexy/breast reduction techniques and immediate symmetrizing mastopexy, and 145 patients underwent delayed contralateral symmetrizing mastopexy. The overall complication rate was similar between the immediate and delayed groups (25.4 percent versus 26.9 percent, respectively; p = 0.82), as was the major complication rate (10.6 percent versus 6.2 percent; p = 0.16). Complications resulted in a delay in adjuvant therapy in 18 patients (4.2 percent); in two patients (0.7 percent), this delay resulted from a complication in the contralateral symmetrizing mastopexy breast. Immediate contralateral symmetrizing mastopexy was not associated with increased risk of complications per breast (p = 0.82) or delay to adjuvant therapy (p = 0.6). CONCLUSION: Contralateral mastopexy/breast reduction for symmetry can be performed at the time of oncoplastic breast-conserving surgery in carefully selected patients without significantly increasing the risk of complications or delay to adjuvant radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Fewer Revisions in Abdominal-based Free Flaps than Latissimus Dorsi Breast Reconstruction after Radiation.

The most commonly chosen flaps for delayed breast reconstruction after postmastectomy radiation therapy (PMRT) are abdominal-based free flaps (ABFFs) and pedicled latissimus dorsi (LD) musculocutaneous flaps. The short-and long-term advantages and disadvantages of delayed ABFFs versus LD flaps after PMRT remain unclear. We hypothesized that after PMRT, ABFFs would result in fewer postoperative complications and a lower incidence of revision surgery than LD flaps. METHODS: We retrospectively reviewed a prospectively maintained database of consecutive patients who underwent unilateral, delayed breast reconstruction after PMRT using ABFFs or pedicled LD flaps with implants at the MD Anderson Cancer Center between January 1, 2001, and December 31, 2011. We compared outcomes and additional surgeries required between the 2 groups. Univariate and multivariate logistic regression modeling analyzed the relationships between patient and reconstruction characteristics and postoperative outcomes. RESULTS: A total of 139 consecutive patients' breast reconstructions were evaluated: 101 ABFFs (72.7%) versus 38 LDs (27.3%). Average follow-up was similar for ABFF and LD reconstructions. Although ABFF and LD reconstructions experienced similar rates of overall (30.7% vs 23.7%, respectively; P = 0.53), donor-site (8.91% vs 5.13%, respectively; P = 0.48), and flap (20.7% vs 17.9%, respectively; P = 0.37) complications, the LD reconstructions required more additional surgeries (92.1% vs 67.3%; P < 0.001). Furthermore, LDs required more revision surgeries more than 1 year after reconstruction (37.1% vs 14.7%; P = 0.02). CONCLUSION: Although early complication rates were similar for both types of reconstructions, ABFFs seem to have the advantage of providing a more durable result that required fewer revision surgeries in the long term.

Decellularized skin/adipose tissue flap matrix for engineering vascularized composite soft tissue flaps.

Using a perfusion decellularization protocol, we developed a decellularized skin/adipose tissue flap (DSAF) comprising extracellular matrix (ECM) and intact vasculature. Our DSAF had a dominant vascular pedicle, microcirculatory vascularity, and a sensory nerve network and retained three-dimensional (3D) nanofibrous structures well. DSAF, which was composed of collagen and laminin with well-preserved growth factors (e.g., vascular endothelial growth factor, basic fibroblast growth factor), was successfully repopulated with human adipose-derived stem cells (hASCs) and human umbilical vein endothelial cells (HUVECs), which integrated with DSAF and formed 3D aggregates and vessel-like structures in vitro. We used microsurgery techniques to re-anastomose the recellularized DSAF into nude rats. In vivo, the engineered flap construct underwent neovascularization and constructive remodeling, which was characterized by the predominant infiltration of M2 macrophages and significant adipose tissue formation at 3months postoperatively. Our results indicate that DSAF co-cultured with hASCs and HUVECs is a promising platform for vascularized soft tissue flap engineering. This platform is not limited by the flap size, as the entire construct can be immediately perfused by the recellularized vascular network following simple re-integration into the host using conventional microsurgical techniques. STATEMENT OF SIGNIFICANCE: Significant soft tissue loss resulting from traumatic injury or tumor resection often requires surgical reconstruction using autologous soft tissue flaps. However, the limited availability of qualitative autologous flaps as well as the donor site morbidity significantly limits this approach. Engineered soft tissue flap grafts may offer a clinically relevant alternative to the autologous flap tissue. In this study, we engineered vascularized soft tissue free flap by using skin/adipose flap extracellular matrix scaffold (DSAF) in combination with multiple types of human cells. Following vascular reanastomosis in the recipient site, the engineered products successful regenerated large-scale fat tissue in vivo. This approach may provide a translatable platform for composite soft tissue free flap engineering for microsurgical reconstruction.

Obese Women Experience Fewer Complications after Oncoplastic Breast Repair following Partial Mastectomy Than after Immediate Total Breast Reconstruction.

BACKGROUND: The authors hypothesized that obese patients would experience fewer complications after oncoplastic breast reconstruction following partial mastectomy than after immediate breast reconstruction following total mastectomy. METHODS: Complication rates were compared for oncoplastic breast reconstruction versus immediate breast reconstruction (with either implants or autologous tissue) in consecutive obese patients (body mass index ≥ 30 kg/m(2)) treated at a single center between January of 2005 and April of 2013. Logistic regression was used to analyze the associations between patient and surgical characteristics and postoperative outcomes. RESULTS: The study included 408 patients: 131 oncoplastic breast reconstruction and 277 immediate breast reconstruction patients. Presenting breast cancer stage was similar between the two groups. Oncoplastic breast reconstruction patients were older (55 years versus 53 years; p = 0.029), more obese (average body mass index, 37 kg/m(2) versus 35 kg/m(2); p < 0.001), and had more comorbidities. Nevertheless, the oncoplastic breast reconstruction group experienced fewer major complications requiring operative management (3.8 percent versus 28.5 percent; p < 0.001), fewer complications delaying adjuvant therapy (0.8 percent versus 14.4 percent; p < 0.001), and fewer incidences of hematoma/seroma formation (3.1 percent versus 11.6 percent; p < 0.004) than the immediate total breast reconstruction group. Univariate analysis found oncoplastic breast reconstruction to be an independent protector against major complications (OR, 0.1; p < 0.001) and complications that delayed adjuvant therapy (OR, 0.05; p = 0.002). CONCLUSION: Oncoplastic breast reconstruction likely represents a safer option than immediate total breast reconstruction following mastectomy for obese patients, particularly for patients who are superobese or present with preexisting medical comorbidities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Development and Feasibility of a Specialty-Specific National Surgical Quality Improvement Program (NSQIP): The Head and Neck-Reconstructive Surgery NSQIP.

IMPORTANCE: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) serves the need for continual quality assessment in general surgery. Previously, no parallel mechanism specific to head and neck oncologic surgery existed. OBJECTIVE: To address the need for continual quality assessment in subspecialty surgery by adapting the ACS NSQIP platform for complex head and neck oncologic surgical procedures. DESIGN, SETTING, AND PARTICIPANTS: With an institutional ACS NSQIP team's guidance, surgeons from the departments of head and neck surgery and plastic and reconstructive surgery developed disease- and procedure-specific preoperative, intraoperative, and postoperative variables specific to head and neck surgery requiring reconstruction. Collection occurred with 100% sampling and standard ACS NSQIP 30-day follow-up. After a pilot period, long-term functional outcomes were added to this platform. A total of 312 patients underwent head and neck surgery requiring reconstruction at an academic medical center between August 1, 2012, and June 30, 2013. EXPOSURES: Development of a specialty-specific head and neck surgery ACS NSQIP platform. MAIN OUTCOMES AND MEASURES: The feasibility of adapting the ACS NSQIP platform to capture complex head and neck surgery metrics in all patients. RESULTS: Head and neck surgery-specific preoperative, intraoperative, and postoperative variables were added to the ACS NSQIP platform and evaluated in 312 patients (201 [64.4%] male). Only 42 patients (13.5%) had no preoperative risk factors, and 136 (43.6%) had 3 or more risk factors. The mean (SD) duration of operation was 9.4 (3.0) hours (range, 1.7-19.3 hours). The mean (SD) postoperative length of stay was 7.9 (4.7) days (range, 1-40 days), 58 patients (18.6%) had an unplanned return to the operating room, 23 patients (7.4%) were readmitted within 30 days, and 3 patients (1.0%) died within 30 days. More than half of the patients (160 [51.3%]) did not experience a postoperative occurrence. CONCLUSIONS AND RELEVANCE: To our knowledge, this is the first comprehensive complex oncologic surgery outcomes platform derived from ACS NSQIP methods. The initial pilot demonstrates the ability to systematically capture head and neck surgery-specific variables with complete sampling. With multi-institutional expansion, increased accrual, and long-term patient-reported outcomes, we hope to set risk-adjusted benchmarks that may underpin quality improvement efforts in complex head and neck surgery.

Reconstruction for total and near-total glossectomy defects.

Reconstruction of total or near-total glossectomy defects has been challenging and the functional outcomes are often disappointing. In this article, the 10-year experience of total or near-total tongue reconstruction at the University of Texas M.D. Anderson Cancer Center is reviewed. The trends of surgical and functional outcomes, length of hospital stay, and choices of flaps and recipient vessels are identified. In addition, the investigators' experience, as well as a literature review, of sensory and motor reinnervation for tongue reconstruction is presented.

Lip and perioral reconstruction.

For defects up to approximately 80% of either upper or lower lip, reconstructions that use remaining lip and cheek can function and look reasonably well. Free tissue transfers, such as the free radial forearm flap, are useful for larger defects as they import additional tissue in one step and reduce microstomia, which is more likely to result from local tissue repairs. At best, free flaps provide a static dam or curtain that functions as a lip; at worst, they deliver a large amount of composite tissue to allow for primary healing. Satisfactory outcomes after free flap reconstructions for lip are best achieved when the transferred tissue is integrated with the native tissues by suspending free flaps appropriately, resurfacing with the flaps with vermilion substitutes, and judicious interposition of remaining lip segments.

Breast reconstruction with postmastectomy radiation therapy: current issues.

Two recent trials have demonstrated superior locoregional control, disease-free survival, and overall survival in node-positive breast cancer patients with the addition of postmastectomy radiation therapy to mastectomy and chemotherapy. Based on these results, there has been an increased use of postmastectomy in patients with early-stage breast cancer. The inability to determine which patients will require postmastectomy radiation therapy has increased the complexity of planning for immediate breast reconstruction. There are two potential problems with performing an immediate breast reconstruction in a patient who will require postmastectomy radiation therapy. One problem is that postmastectomy radiation therapy can adversely affect the aesthetic outcome of an immediate breast reconstruction. Several studies have evaluated the outcomes of breast reconstructions that were performed before radiation therapy and have revealed a high incidence of complications and poor aesthetic outcomes. Furthermore, these studies have found that often an additional flap is required to restore breast shape and symmetry. The other potential problem is that an immediate breast reconstruction can interfere with the delivery of postmastectomy radiation therapy. During planning for immediate breast reconstruction, it is imperative to carefully review the stage of disease and the likelihood the patient will require postmastectomy radiation therapy. Unfortunately, the ability to detect and predict the presence or extent of axillary lymph node involvement is limited, and the need for postmastectomy radiation therapy is usually not known until after mastectomy. In all cases of decision making regarding possible postoperative radiation therapy and whether or not to perform immediate breast reconstruction, the situation should be discussed at a multidisciplinary conference or addressed among the various medical, surgical, and radiation teams, with active participation by the patient. Immediate breast reconstruction probably should be avoided in patients known to require postmastectomy radiation therapy and delayed until it is certain the therapy will be needed in patients who may require the therapy.

Upper extremity limb salvage with microvascular reconstruction in patients with advanced sarcoma.

Limb salvage is a viable alternative to amputation in many cases of advanced sarcoma. The authors examined their experience with microvascular reconstruction of upper extremity defects after sarcoma resection, focusing on oncologic and functional outcomes. A retrospective analysis yielded 17 patients who underwent 18 free flap procedures and met the inclusion criteria. Most patients (71 percent, n = 12) had recurrent sarcoma at presentation to the authors' institution. Malignant fibrous histiocytoma was the most common pathologic subtype (n = 6). High-grade tumors were present in 94 percent of patients (n = 16). The free flap survival rate was 100 percent. The rectus abdominis flap was the most common free flap used (39 percent; n = 7). Local recurrence occurred in nine flaps (50 percent), and five patients ultimately required amputations. Six patients (35 percent) had distant recurrence. The mean Enneking score for limb function was 73 percent of the maximum (21.9 of 30). The 5-year disease-specific survival rate was 61.3 percent. In select patients with advanced upper extremity sarcoma undergoing limb salvage, microvascular flap reconstruction can provide reliable, safe coverage with reasonable preservation of function.

Breast reconstruction in older women: advantages of autogenous tissue.

As the population ages, the treatment of breast cancer among elderly women is becoming increasingly common. Decisions with regard to breast reconstruction require not only consideration of patient age and comorbidities but also a need to balance life expectancy with quality of life. Although it is often assumed that implant-based breast reconstruction is the least disruptive method, especially among patients who may be facing limited survival times, it was hypothesized that autogenous tissue breast reconstruction is a well-tolerated and perhaps preferable means of reconstruction for older women who choose to undergo reconstruction following mastectomy. No large series of autogenous tissue reconstructions in this age group has been presented. A retrospective study of 84 postmastectomy reconstructions (66 unilateral and 18 bilateral; 78.6 percent immediate) performed at the authors' institution for 81 women 65 years of age or older, between April of 1987 and December of 2000, was undertaken. Reconstructions were implant-based ( = 26), latissimus dorsi flap-based ( = 24), or transverse rectus abdominis myocutaneous (TRAM) flap-based ( = 34). Of the 34 TRAM flaps, 21 were free or supercharged. Breast complications were more frequent ( < 0.05) among recipients of implant-based reconstructions (76.9 percent) than among recipients of latissimus dorsi flap (41.7 percent) or TRAM flap (35.3 percent) reconstructions. In multivariate logistic regression analyses, comorbidities, smoking, radiotherapy, and body mass index had no effect. Medical complications without long-term sequelae were observed for two patients who underwent latissimus dorsi flap reconstructions and two patients who underwent free TRAM flap reconstructions; the difference in the rates of medical complications was not significant. At the mean follow-up time of 4.2 years, 92.8 percent of all study patients exhibited no evidence of disease. Notably, despite being free of disease, seven of the 26 patients (27 percent) who underwent implant-based reconstructions abandoned further reconstructive efforts after complications necessitated implant removal. It was concluded that age alone should not determine the type of breast reconstruction and that autogenous tissue breast reconstruction can be a safe successful alternative for women 65 years of age or older.