A Comparison of the Short-term Outcomes of Three Flap Reconstruction Techniques Used After Beyond Total Mesorectal Excision Surgery for Anorectal Cancer.

BACKGROUND: Surgery for advanced or recurrent pelvic malignancy can result in perineal defects that cannot be closed by wound edge approximation. Myocutaneous flaps can fill the defect and accelerate healing. No reconstruction has been proven to be superior to the others. OBJECTIVE: This study aimed to compare 3 flap procedures after beyond total mesorectal excision surgery. DESIGN: This is a retrospective analysis of a prospective database, according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. SETTINGS: This study was performed at a tertiary hospital. PATIENTS: Consecutive series of patients who required flap reconstruction after beyond total mesorectal excision surgery between 2007 and 2016 were included. MAIN OUTCOME MEASURES: Short-term outcomes after oblique rectus abdominis flap vs vertical rectus abdominis flap vs inferior gluteal artery perforator flap reconstruction were evaluated. RESULTS: Included are 65 (59%) oblique rectus abdominis flap, 30 (27.3%) vertical rectus abdominis flap, and 15 (13.7%) inferior gluteal artery perforator flap outcomes. Sacrectomy was performed in 12 (18.5%), 10 (33.3%), and 8 (53.3%) patients (p = 0.016). Preoperative radiotherapy was used in 60 (92.3%), 26 (86.7%), and 11 (73.3%) patients (p = 0.11). Flap infection and dehiscence occurred in 7 (10.8%), 1 (3.3%), and 4 (26.7%) patients. There was an increased risk of flap complication with inferior gluteal artery perforator flap vs vertical rectus abdominis flap (p = 0.036). Inferior gluteal artery perforator flap (OR, 6.26; p = 0.02) and obesity (OR, 4.96; p = 0.02) were associated with flap complications. Only complications of the oblique rectus abdominis flap decreased significantly over time (p = 0.03). The length of stay and complete (R0) resection rate were not different between the groups. LIMITATIONS: This study was limited because of its retrospective nature and because it was conducted at a single center. CONCLUSIONS: The techniques appear comparable. The approaches should be considered complementary, and the choice should be individualized. See Video Abstract at http://links.lww.com/DCR/B141. COMPARACIÓN DE RESULTADOS A CORTO PLAZO DE TRES TÉCNICAS DE RECONSTRUCCIÓN CON COLGAJO UTILIZADAS DESPUÉS DE LA CIRUGÍA DE ESCISIÓN MESORRECTAL TOTAL EXTENDIDA PARA EL CÁNCER ANORRECTAL: La cirugía para malignidad pélvica avanzada o recurrente puede provocar defectos perineales, que no pueden cerrarse por aproximación de los bordes de la herida. Los colgajos miocutáneos pueden llenar el defecto y acelerar la curación. Ninguna reconstrucción ha demostrado ser superior a las demás.Comparar tres procedimientos de colgajo después de una cirugía de escisión mesorrectal total extendida.Análisis retrospectivo de una base de datos prospectiva, de acuerdo con la Declaración de Fortalecimiento de los informes de estudios observacionales en epidemiología.Hospital de tercer nivel.Series consecutivas de pacientes que requirieron reconstrucción con colgajo después de una cirugía de escisión mesorrectal total extendida entre 2007 y 2016.Resultados a corto plazo después del colgajo oblicuo recto abdominal versus colgajo vertical recto abdominal versus reconstrucción del colgajo perforador de la arteria glútea inferior.Se incluyen 65 (59%) colgajo oblicuo recto abdominal oblicuo, 30 (27.3%) colgajo vertical recto abdominal y 15 (13.7%) colgajo perforador de la arteria glútea inferior. Sacrectomía se realizó en 12 (18.5%), 10 (33.3%) y 8 (53.3%) pacientes respectivamente (p = 0.016). La radioterapia preoperatoria se utilizó en 60 (92.3%), 26 (86.7%) y 11 (73.3%) (p = 0,11). La infección del colgajo y la dehiscencia ocurrieron en 7 (10.8%), 1 (3.3%) y 4 (26.7%). Hubo un mayor riesgo de complicación con el colgajo perforador de la arteria glútea inferior en comparación al colgajo vertical del recto abdominal (p = 0.036). El colgajo perforador de la arteria glútea inferior (OR 6.26, p = 0.02) y la obesidad (OR 4.96, p = 0.02) se asociaron con complicaciones del colgajo. Solo las complicaciones del colgajo oblicuo recto abdominal disminuyeron significativamente con el tiempo (p = 0.03). La duración de la estancia hospitalaria y la tasa de resección completa (R0) no fue diferente entre los grupos.Estudio retrospectivo en centro único.Las técnicas parecen comparables. Los enfoques deben considerarse complementarios y la elección individualizada. Consulte Video Resumen en http://links.lww.com/DCR/B141.

Reconstruction of Large Soft Tissue Defects of the Extremities in Children Using the Kiss Deep Inferior Epigastric Artery Perforator Flap to Achieve Primary Closure of Donor Site.

BACKGROUND: The closure of massive skin defects remains challenging, particularly in children. In this report, we describe a technique to achieve primary donor site closure using the kiss deep inferior epigastric perforator (DIEP) flap for the reconstruction of large soft tissue defects located in the extremities of children. METHODS: From May 2011 to May 2016, a retrospective analysis was conducted on 10 pediatric patients with extensive soft tissue defects and reconstruction with double-skin paddle DIEP flap. After harvesting the flap, the skin paddle was divided into 2 separate paddles with a common vascular supply, and then the 2 paddles were sutured side by side through translating 2 paddles or rotating one of the paddles by 90 or 180 degrees, effectively doubling the width of the flap and rejoining it at the recipient site. Data on patient age, medical history, defect size, flap dimensions, recipient vessels, donor site closure, complications, and follow-up were reviewed retrospectively. RESULTS: Nine children had major soft tissue defects of the lower limb, and the remaining one had an upper limb defect. Only 1 case was complicated by partial necrosis of 1 paddle. Primary donor site closure was accomplished in all cases. The flaps were well matched on texture and contour, except that the 2 flaps were bulky at postoperative follow-up. There was no donor site breakdown, with only a slightly noticeable linear scar. CONCLUSION: The kiss DIEP flap could be an alternative for reconstruction of large soft tissue defects of the extremities in children, with lower morbidity and improved cosmetic of the donor site.

Effects of hPTPß inhibitor on microcirculation of rat cremaster muscle flap following ischemia-reperfusion injury.

INTRODUCTION: Inhibition of protein tyrosine phosphatases (PTP) enhances endothelial receptor tyrosine kinases activation and may have beneficial effects on vessel growth and improve blood flow to ischemic tissue. The purpose of this study is to determine influence of hPTPß inhibitors on ischemia-reperfusion injury in muscle flap. MATERIALS AND METHODS: Following cremaster muscle dissection, 60 rats divided into 10 experimental groups (placebo and treatment groups following 0, 1, 2, 3, and 4 h of ischemia). Following group-specific treatment (placebo/hPTPß inhibitor, 15 mg/kg), 2 h of reperfusion is initiated. Observations are performed at 4 h after completion of reperfusion and microcirculatory hemodynamics and leukocyte-endothelial activation were recorded. RESULTS: Administration of hPTPß inhibitor showed preservation of capillary perfusion in group subjected to 2 h of ischemia when compared with placebo (P < .05). The effect of hPTPß inhibitor on mean venule diameter was found to be altered by duration of ischemia and this effect was statistically significant (P < .05). Treated ischemic groups (1 h, 2 h, and 3 h) showed decreased activation of rolling, sticking, and transmigrating leukocytes compared to respective placebo groups at all time points. The differences were significant for transmigrating leukocytes after 2 h and 3 h of ischemia (P < .05). Endothelial edema index was also significantly reduced in 2 h ischemia group (P < .05). CONCLUSION: Administration of hPTP inhibitors after submission of tissue to subcritical ischemia (1-2 h) improved functional capillary perfusion and decreased leukocyte-endothelial activation after 4 h after reperfusion. These results indicate that hPTP inhibitor has a potential postischemic therapeutic effect applied after tissue ischemia just before the reperfusion injury.

Immediate simultaneous bilateral breast reconstruction with deep inferior epigastric (DIEP) free flap and transverse rectus abdominis musculocutaneous (TRAM) pedicled flap.

Breast reconstructive surgery has evolved tremendously since its inception. Following tumour clearance surgery, physical restoration with breast reconstruction is an important aspect of physical and emotional rehabilitation. Various methods have been described to suit patients demand for the best aesthetic outcome. Surgeon's preference, experience and practicality of differing procedures must be considered. We describe a simultaneous bilateral breast reconstruction with free deep inferior epigastric (DIEP) flap and pedicled transverse rectus abdominis musculocutaneous (TRAM) flap immediately post mastectomies for bilateral breast cancers. The surgery described has resulted in a reasonable technical ease, acceptable flap and abdominal morbidity and good aesthetic outcome.

Reconstruction of Complex Defects of Lower Extremities Using Thinned Free Muscle Flaps.

BACKGROUND: Bulky appearance is a major shortcoming after surface coverage using free muscle flaps. The one-stage thinning procedure at the time of transfer can improve the appearance and avoid additional debulking surgery. We present our experiences in the reconstruction of complex lower extremity defects using thinned free muscle flaps. METHODS: Latissimus dorsi muscle flaps (LDMs) and rectus abdominis muscle flaps (RAMs), which have vessel pedicles running deep in the muscles, were raised and the superficial tissue layers were removed to thin the flaps. These thinned muscle flaps were then used to resurface the wounds on lower extremities followed by coverage of skin autografts on the muscle surfaces. RESULTS: Fourteen LDMs and four RAMs were thinned used for resurfacing eight, five, and three defects on feet, ankles, and pretibial regions, respectively, with wounds that ranged from 6 × 4 cm(2) to 23 × 9 cm(2). All muscle flaps survived the tangential thinning procedures uneventfully. High take rates were observed for most skin grafts, except that a partial skin loss was found in one case. During the 1-20 months follow-up, the skin surface contours over the thinned muscle flaps matched well with adjacent areas. CONCLUSIONS: Intraoperative immediate thinning of LDMs and RAMs can be safely accomplished during the primary reconstruction procedure and may provide an alternative for coverage of complex lower extremity defects. LEVEL OF EVIDENCE V: 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 .

Mandibular reconstruction using an iliac bone flap with perforator-supported external oblique abdominal muscle island: a pilot study.

The deep circumflex iliac artery (DCIA) flap is one of the bone flaps commonly used for mandibular reconstruction. Observation of the skin paddle and Doppler ultrasound are methods that are usually used to monitor DCIA flaps after mandibular reconstruction surgery. The aim of this study was to introduce a novel DCIA flap with a perforator-supported external oblique abdominal muscle (EOAM) island for postoperative flap monitoring. This study included five patients who underwent mandibular reconstruction using this modified technique. The DCIA flap and the EOAM island supplied by the ascending branch of the DCIA were harvested during the surgery. After mandibular reconstruction, the EOAM island was placed in the submandibular region to monitor the blood supply to the DCIA flap after surgery. The blood supply to the DCIA flap was monitored by observing the colour, texture, and bleeding condition of the EOAM island. After the monitoring period, the EOAM was removed and the ascending branch of the DCIA was ligated. The outcome was successful in all patients. The EOAM island supported by the ascending branch of the DCIA is reliable and safe, thus providing a robust option to monitor the blood supply to the DCIA flap.

Near infrared spectroscopy for monitoring flap viability following breast reconstruction.

Free flap monitoring is essential to the early detection of compromise thereby increasing the chance of successful salvage surgery. Many alternatives to classical clinical monitoring have been proposed. This study seeks to investigate a relatively new monitoring technology: near infrared spectroscopy (NIRS). Patients were recruited prospectively to the study from a single center. During the research period, 10 patients underwent reconstruction with a free deep inferior epigastric perforator flap (DIEP). Measurements of flap perfusion were taken using NIRS in the preoperative and intraoperative phases and postoperatively for 72 hours. NIRS showed characteristic changes in all cases which returned to theater for pedicle compromise. In these cases, NIRS identified pedicle compromise prior to clinical identification. There were no false-positives. NIRS accurately identified all compromised flaps in our study. In most cases, there was an evidence of changes in oxygen saturation on NIRS prior to clinical observation. Further research, ideally double blind randomized control trials with large sample groups would be required to definitively establish NIRS as an ideal flap monitoring modality.

Buttock reconstruction using a pedicled deep inferior epigastric perforator flap.

Although deep inferior epigastric perforator (DIEP) flaps are mainly used for breast reconstruction as free flaps, they are also useful as pedicled island flaps. However, DIEP flaps have seldom been used for reconstructions in the lateral hip region. Furthermore, to the best of our knowledge, no report has been issued on the use of this flap for buttock reconstruction. The authors describe the successful use of a pedicled oblique DIEP flap for the reconstruction of a severe scar contracture in the buttock. The pedicled DIEP flap can be a useful option for the reconstruction of large buttock defects, and if a transverse DIEP flap is unavailable, an oblique DIEP flap should be considered an alternative.

A clinical review of 9 years of free perforator flap breast reconstructions: an analysis of 675 flaps and the influence of new techniques on clinical practice.

The aim of this study is to review our 9-year experience with deep inferior epigastric perforator (DIEP) breast reconstructions to help others more easily overcome the pitfalls we experienced. A chart review was conducted for all 543 patients who had 622 DIEP breast reconstructions in our clinic between January 2000 and January 2009. In this time, there were an additional 28 superior gluteal artery perforator and 25 superficial inferior epigastric artery reconstructions, bringing the total free flap reconstructions to 675. In the early years, the success rate was 90.7%, the average operative time was 7 hours and 18 minutes, and the complication rate was 33.3%; these have improved to 98.2%, 4 hours and 8 minutes, and 19.3%, respectively. We describe our selection criteria, preoperative vascular mapping, surgical techniques, and postoperative monitoring as they relate to these improvements in outcome, operative time, and complications. The DIEP flap is a safe and reliable option in breast reconstructions. By acquiring experience with the flap and introducing new and improving existing techniques we have improved the ease of the procedure and the success rate and have shortened the operative time.

Laparoscopy allows the harvest of the DIEP flap with shorter fascial incisions as compared to endoscopic harvest: A single surgeon retrospective cohort study.

BACKGROUND: We present a comparative series to utilize minimally invasive endoscopic, total extraperitoneal laparoscopic (TEP-lap), and transabdominal preperitoneal robotic perforator (TAP-RAP) harvest of the deep inferior epigastric (DIE) vessels for autologous breast reconstruction (ABR) to mitigate donor site morbidity. We hypothesized that TEP-lap and TAP-RAP harvests of abdominal-based free flaps are safe techniques associated with decreased fascial incision when compared with the endoscopic harvest. METHODS: We designed a retrospective cohort series of subjects with newly diagnosed breast cancer who presented for ABR using endoscopic (control), laparoscopic, or robotic assistance between September 2017 and April 2019. The primary outcome variables were flap success (i.e., absence of perioperative flap loss), fascial incision length, and intraoperative complications. Secondary variables included operating time, costs, and postoperative complications within 90 days (arterial thrombosis, venous congestion, bulge/hernia, and operative revision). Exclusion criteria included < 90 days follow-up. RESULTS: In total 94, 38, and 3 subjects underwent endoscopic, TEP-lap, and TAP-RAP flap harvests. Mean lengths of fascial incisions for the endoscopic and laparoscopic cohorts were 4.5 ±â€¯0.5 cm and 2.0 ±â€¯0.6 cm (p < 0.0001), while incision length depended on the concurrent procedure in the robotic cohort. No subjects required conversion to an open harvest. There were no bleeding complications, intra-abdominal injuries, flap losses, or abdominal bulges/hernias noted in the TEP-lap and TAP-RAP cohorts. CONCLUSION: Minimally invasive DIEP flap harvest may decrease fascial injury when compared with conventional open harvest. There are significant trade-offs among harvest methods. TEP-lap harvest may better balance the trade-off related to abdominal wall morbidity.

Iliac crest free flap for maxillary reconstruction.

PURPOSE: Reconstructing defects after maxillary resections presents a challenge for the reconstructive surgeon because of the critical role played by the maxillary skeleton in facial function and esthetics. Obturation, local or locoregional flaps, and soft tissue free flaps are good options for maxillary reconstruction; however, the lack of bone reconstruction often leads to ptosis of the facial tissues, particularly of the nasal base and columella, under the effects of gravity and makes it impossible to place osseous implants for dental rehabilitation. We present our experience with the iliac crest free flap for maxillary reconstruction, focusing on the advantages of this technique and particularly on flap positioning, which is dependent on defect site and size. Finally, 2 representative cases will be presented. PATIENTS AND METHODS: Between January 1, 1996, and January 1, 2008, 14 patients were treated for maxillary reconstruction with an iliac crest free flap. In 6 patients, the floor of the orbit was included in the resection. In 5 patients, we performed reconstructions using bone grafts harvested from the iliac crest, whereas in the remaining patient a titanium mesh was used. RESULTS: All flaps were harvested and transposed. Minor complications included wound dehiscence in 2 cases, ectropion in 2, and nasal airway obstruction in 1. No major complications or donor site morbidity occurred. No oronasal communication or swallowing impairments developed in any patient. Seven patients completed oral rehabilitation with dental implant placement; the remaining 7 refused the treatment because of financial problems, and 4 patients were rehabilitated with a mobile prosthesis. CONCLUSIONS: The iliac crest free flap is an optimal method for maxillary defect reconstruction. The main advantages of the flap are the large amount of bone provided, its height, and the possibility of including the internal oblique muscle. Flap insetting is the key part of the procedure, and whether to use vertical or horizontal placement of the flap is the main consideration. Finally, the low rate of donor site morbidity reported in our patients, as in the recent literature, makes this flap even more safe and reliable.

Outcomes after Split Abdominal Wall Muscle Flap Repair for Large Congenital Diaphragmatic Hernias.

INTRODUCTION: Repair of large congenital diaphragmatic hernias (CDHs) is challenging. As primary repair is not always feasible, patches are commonly used. An alternative treatment is split abdominal wall muscle flap repair, which uses vascularized autologous tissue. The aim of this study was to analyze the long-term outcome of large CDH defects undergoing split abdominal wall muscle repair. MATERIALS AND METHODS: This is a retrospective review (2003-2016) of large CDH treated by split abdominal wall muscle flap repair. RESULTS: In a total of 107 CDH patients, the abdominal muscle flap technique was used in 10 (9.3%); 7 had been prenatally treated with tracheal occlusion. Two patients experienced recurrence at 2 months and 6 years, respectively. Only one patient required abdominoplasty due to abdominal wall muscle weakness. Two patients developed progressive scoliosis; one of them required orthopaedic treatment. Minor chest wall deformities were detected in seven, but only one required orthopaedic treatment. The lung-to-head ratio was 0.79 in patients developing musculoskeletal deformities, and 1.5 in those without this complication (p < 0.05). Median follow-up was 11.2 years (3.5-14.2), and all patients were alive at the time of writing this article. CONCLUSION: The split abdominal wall muscle flap technique is a valid option for repair of large CDH. Associated musculoskeletal deformities seem to be influenced not only by the repair technique used but also by the degree of pulmonary hypoplasia and inherent pathophysiological changes.

Rectus Fascia Versus Fascia Lata for Autologous Fascial Pubovaginal Sling: A Single-Center Comparison of Perioperative and Functional Outcomes.

OBJECTIVE: To compare perioperative and functional outcomes of autologous fascia lata versus rectus fascia pubovaginal sling in female patients with stress urinary incontinence (SUI). METHODS: The charts of all patients undergoing pubovaginal sling for SUI from 2012 to 2017 at a single center were retrospectively reviewed. Patients were divided into 2 groups: those with the sling harvested from the fascia lata (FL group) and those with the sling harvested from the rectus fascia (RF group). RESULTS: Between 2012 and 2017, 105 women underwent pubovaginal slings: 21 using FL and 84 using RF. Operative time did not differ significantly between the FL and RF groups (84 vs 81.9 minutes; P=0.68). Estimated blood loss was lower in the FL group (91.7 vs 141.6 mL; P=0.04). There were more wound complications in the RF group, although this was not statistically significant (0% vs 14.3%; P=0.12). Overall complications were comparable between FL and RF groups (52.4% vs 48.9%; P=0.81), but the proportion of Clavien grade 2 or greater were higher in the RF group (4.8% vs 20.2%; P=0.11). Overall, wound complications accounted for 29.3% of postoperative complications in the RF group (12/41). Functional outcomes were comparable between FL and RF groups, with similar rates of patients without SUI symptoms after 1 month (82.4% vs 76.4%; P=0.74), 1 year (55.6% vs 63.8%; P=0.76), and at the latest follow-up (66.7% vs 65.8%; P=0.87). CONCLUSIONS: When compared with rectus fascia for pubovaginal sling, fascia lata may decrease perioperative morbidity, especially wound complications, without compromising functional outcomes.

Enhanced Recovery after Surgery Protocols Decrease Outpatient Opioid Use in Patients Undergoing Abdominally Based Microsurgical Breast Reconstruction.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have known benefits in the inpatient setting, but little is known about their impact in the subsequent outpatient setting. On discharge, multimodal analgesia has been discontinued, nerve blocks and pain pumps have worn off, and patients enter a substantially different physical environment, potentially resulting in a rebound effect. The objective of this study was to investigate the effect of ERAS protocol implementation on outpatient opioid use and recovery. METHODS: Patients who underwent abdominally based microsurgical breast reconstruction before and after ERAS implementation were reviewed retrospectively. Ohio state law mandates that no more than 7 days of opioids may be prescribed at a time, with the details of all prescriptions recorded in a statewide reporting system, from which opioid use was determined. RESULTS: A total of 105 patients met inclusion criteria, of which 46 (44 percent) were in the pre-ERAS group and 59 (56 percent) were in the ERAS group. Total outpatient morphine milligram equivalents used in the ERAS group were less than in the pre-ERAS group (337.5 morphine milligram equivalents versus 668.8 morphine milligram equivalents, respectively; p =0.016). This difference was specifically significant at postoperative week 1 (p =0.044), with gradual convergence over subsequent weeks. Although opioid use was significantly less in the ERAS group, pain scores in the ERAS group were comparable to those in the pre-ERAS group. CONCLUSIONS: The benefits of ERAS protocols appear to extend into the outpatient setting, further supporting their use to facilitate recovery, and highlighting their potential role in helping to address the prescription opioid abuse problem. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Abdominal fascial flaps for providing total implant coverage in one-stage breast reconstruction: an autologous solution.

BACKGROUND: Silicone implants are often used in immediate breast reconstruction. Complications associated with silicone-based implant reconstruction, such as capsular contracture, implant palpability, and visibility, are best avoided by placing the implant under a reliable soft-tissue cover such as the pectoralis major muscle. This muscle, however, is not always sufficient for complete coverage of the silicone implant. This is especially true for large implants. By including the fascia of the upper abdominal muscles in the reconstruction, this problem can be overcome. We describe our experience with one-stage breast reconstruction utilizing the fascia of the upper abdominal muscles to provide adequate soft-tissue coverage of the implant. METHODS: This technique was used in the reconstructions of ten patients over 4 years (2005-2009). This method was selected by the operating surgeon at the time of surgery if the pectoralis major muscle was felt to be of inadequate size to provide adequate implant coverage. The pectoralis major muscle was released from its sternal and caudal attachments to the chest wall. The rectus abdominis fascia and external oblique fascia were elevated as a combined cephalic-based flap. This fascial flap was advanced cranially and sutured to the released pectoralis major muscle after insertion of the implant. RESULTS: The mean size of the silicone implant was 448.2 cc and mean follow-up was 19.7 months. All implants were adequately covered with soft tissue at the end of each case. Complications included one patient with a hematoma, one patient with skin necrosis at the suture line, and one patient with an implant infection necessitating removal. CONCLUSION: There are many ways to provide soft-tissue coverage of silicone breast implants in breast reconstruction. These include acellular dermis slings, polyglycolic mesh, deepithelialized skin, and muscle. The ideal soft-tissue cover would be supple, easily harvested, of minimal morbidity, of minimal cost, and preferably autologous. We feel that the technique described here has these qualities and allows for complete coverage of silicone implants. An additional benefit of this technique is that it helps to increase the definition of the inframammary sulcus. This method is a good alternative in providing implant coverage during breast reconstruction, especially when there is a large implant or small pectoralis major muscle.

Should free deep inferior epigastric artery perforator flaps be considered a quality indicator in breast reconstruction?

Over the past several decades, technical advances in breast reconstruction have resulted in the development of flaps that are aimed at progressively decreasing abdominal wall morbidity. There is, however, ongoing controversy related to the superiority of deep inferior epigastric perforator (DIEP) flaps over muscle-sparing TRAM (MS-TRAM) flaps. Hence, the question remains unanswered as to which approach should be considered the standard of care, and more importantly, whether the rate of DIEP flap utilization should be considered a quality metric in breast reconstruction. In this review article, we examine the literature pertaining to abdominal free tissue transfer in breast reconstruction from both donor site and flap characteristics as well as the resultant complications and morbidity. The impact on the donor site remains a prevailing principle for autologous breast reconstruction; thus, must be adequately respected when classifying what is left behind following flap harvest. The most commonly used nomenclature is too simplistic. This, in turn, leads to inadequate incorporation of critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. Currently, there is insufficient evidence to support DIEP flap harvest as a quality indicator in breast reconstruction, as DIEP flap outcomes are not clearly superior when compared with MS-TRAM flaps.

MDCT in the preoperative planning of abdominal perforator surgery for postmastectomy breast reconstruction.

OBJECTIVE: This study aimed to evaluate the utility of MDCT in planning abdominal perforator surgery for breast reconstruction in patients who have undergone mastectomy. SUBJECTS AND METHODS: One hundred twenty-six consecutive patients scheduled for postmastectomy breast reconstruction using deep inferior epigastric perforator flaps underwent MDCT. The images were evaluated to identify, characterize, and map the dominant musculocutaneous perforator vessels of the deep inferior epigastric artery. In the first 36 patients, we compared the intraoperative findings with the preoperative MDCT findings. In the latter 90 patients, the dominant perforator vessels were directly selected on the basis of MDCT findings. RESULTS: We found an exact correlation between the intraoperative and radiologic findings in the first 36 cases. In the following 90 cases, the average operating time saved per patient was 1 hour 40 minutes and there was a significant reduction in postsurgical complications. The preoperative evaluation by MDCT confirmed the wide range of variability in the vascular anatomy of the abdominal wall previously described in anatomic studies. CONCLUSION: MDCT provides valuable information before surgery about the arterial anatomy of the inferior abdominal wall. It enables accurate identification of the most suitable dominant perforator vessel and makes surgical perforator flap procedures for breast reconstruction faster and safer.

Fabrication of a neotrachea using engineered cartilage.

OBJECTIVES: Surgical management of long-segment tracheal stenosis is an ongoing problem. Many types of tracheal prostheses have been tried but with limited success because of immune rejection, graft ischemia, or restenosis. Tissue engineered cartilage may offer a solution to this problem, although scaffolds, which are currently often used for support, can lead to biocompatibility problems. This study investigated the feasibility of scaffold-free cartilage to tissue engineer a vascularized neotrachea in rabbits. STUDY DESIGN: Animal study. METHODS: Autologous neotracheal constructs were implanted in the abdomen of six New Zealand white rabbits. Auricular chondrocytes were used to engineer scaffold-free cartilage sheets. A muscle flap raised from the external abdominal oblique muscle and the engineered cartilage were wrapped around a silicone stent to fabricate a vascularized neotrachea in vivo. In two of the six rabbits, a full thickness skin graft was used to create an epithelial lining. The constructs were harvested after either 6 or 10 weeks. RESULTS: All neotracheal constructs were healthy with well-vascularized and integrated layers. The implanted engineered cartilage underwent a remodeling process, forming a solid tracheal framework. Constructs harvested after 10 weeks proved to have significantly better mechanical properties than after 6 weeks and were comparable with the rabbit's native trachea. CONCLUSION: Scaffold-free engineered cartilage can successfully fabricate a well-vascularized, autologous neotrachea with excellent mechanical properties. The results suggest that this approach can be used to reconstruct tracheal defects in rabbits.

Epicardial deposition of endothelial progenitor and mesenchymal stem cells in a coated muscle patch after myocardial infarction in a murine model.

OBJECTIVES: To assess, using an in vivo engraftment strategy combining bone marrow cell (BMC) transplantation and tissue cardiomyoplasty, the functional outcome of distinct vascular progenitor cell therapy (endothelial progenitor (EPC) and mesenchymal stem (MSC) cells) at distance of myocardium infarction (MI). The study was also designed to test whether scaffold mixing progenitors with unfractionated BMC could improve progenitor recruitment in the damaged myocardium. METHODS: To track engrafted progenitor cells in vivo, cultured murine MSC and EPC were transduced with eGFP lentiviruses. Thirty days after cryogenical induction of MI, C57BL/6J mice were randomized to receive muscle patch placement coated or not (control group), labeled EPC or MSC mixed to the ration of 1:10, or not with unfractionated BMC. Two weeks after transplantation, cardiac function was recorded and heart sections were examined to detect GFP-labeled progenitor cells and analyze cell differentiation. RESULTS: This study showed that either type of mono cell therapy improved angiogenesis and cell survival in the scar but only MSC exhibited the capacity to invade the scar. We found no evidence of myocardial or vascular regeneration from progenitor cells. Engraftment of the progenitors/unfractionated BMC mix increased repopulation and thickness of the scar. CONCLUSION: Combined therapy with unfractionated BMC and expanded MSC appeared thus promising for scar repopulation.

Use of latissimus dorsi and abdominal external oblique muscle for reconstruction of a thoracic wall defect in a cat with feline osteochondromatosis.

A 4-year-old, male castrated European shorthair cat was presented with a firm mass palpable on the right caudal rib cage. Lateral and ventrodorsal radiographs of the thorax revealed a 4x3x2cm large, expansile and radiodense mass originating from the distal part of the 13th rib. After removal of the tumour, which was histopathologically confirmed as feline osteochondromatosis, the diaphragm, omentum, external abdominal oblique and latissimus dorsi muscles were used to reconstruct the defect. Feline osteochondromatosis is induced by retroviruses, eg, feline leukaemia virus, for which the cat tested positive. The tumour was removed for palliative reasons, because such tumours have the tendency to transform into osteosarcomas. Six months after the surgical excision the cat showed no clinical signs of reoccurrence.