Building Complex Autologous Breast Reconstruction Program: A Preliminary Experience.

Autologous breast reconstruction is an increasingly popular method of reconstruction for breast cancer survivors. While deep inferior epigastric perforator (DIEP) flaps are the gold standard, not all patients are ideal candidates for DIEP flaps due to low BMI, body habitus, or previous abdominal surgery. In these patients, complex autologous breast reconstruction can be performed, but there is a limited number of programs around the world due to high technical demand. Given the increased demand and need for complex autologous flaps, it is critical to build programs to increase patient access and teach future microsurgeons. In this paper, we discuss the steps, pearls, and preliminary experience of building a complex autologous breast reconstruction program in a tertiary academic center. We performed a retrospective chart review of patients who underwent starting the year prior to the creation of our program. Since the start of our program, a total of 74 breast mounds have been reconstructed in 46 patients using 87 flaps. Over 23 months, there was a decrease in median surgical time for bilateral reconstruction by 124 min (p = 0.03), an increase in the number of co-surgeon cases by 66% (p < 0.01), and an increase in the number of complex autologous breast reconstruction by 42% (p < 0.01). Our study shows that a complex autologous breast reconstruction program can be successfully established using a multi-phase approach, including the development of a robust co-surgeon model. In addition, we found that a dedicated program leads to increased patient access, decreased operative time, and enhancement of trainee education.

Current Concepts in the Management of Primary Lymphedema.

Primary lymphedema is a heterogeneous group of conditions encompassing all lymphatic anomalies that result in lymphatic swelling. Primary lymphedema can be difficult to diagnose, and diagnosis is often delayed. As opposed to secondary lymphedema, primary lymphedema has an unpredictable disease course, often progressing more slowly. Primary lymphedema can be associated with various genetic syndromes or can be idiopathic. Diagnosis is often clinical, although imaging can be a helpful adjunct. The literature on treating primary lymphedema is limited, and treatment algorithms are largely based on practice patterns for secondary lymphedema. The mainstay of treatment focuses on complete decongestive therapy, including manual lymphatic drainage and compression therapy. For those who fail conservative treatment, surgical treatment can be an option. Microsurgical techniques have shown promise in primary lymphedema, with both lymphovenous bypass and vascularized lymph node transfers demonstrating improved clinical outcomes in a few studies.

Reducing Opioid Overprescribing through Procedure-specific Prescribing Guidelines.

Despite advances in opioid-sparing pain management, postdischarge opioid overprescribing in plastic surgery remains an issue. Procedure-specific prescribing protocols have been implemented successfully in other surgical specialties but not broadly in plastic surgery. This study examined the efficacy of procedure-specific prescribing guidelines for reducing postdischarge opioid overprescribing. Methods: A total of 561 plastic surgery patients were evaluated retrospectively after a prescribing guideline, which recommended postdischarge prescription amounts based on the type of operation, was introduced in July 2020. Prescription and postdischarge opioid consumption amounts before (n = 428) and after (n = 133) guideline implementation were compared. Patient satisfaction and prescription frequency of nonopioid analgesia were also compared. Results: The average number of opioid pills per prescription decreased by 25% from 19.3 (27.4 OME) to 15.0 (22.7 OME; P = 0.001) after guideline implementation, with no corresponding decrease in the average number of postdischarge opioid pills consumed [10.6 (15.1 OME) to 8.2 (12.4 OME); P = 0.147]. Neither patient satisfaction with pain management (9.6-9.6; P > 0.99) nor communication (9.6-9.5; P > 0.99) changed. The rate of opioid-only prescription regimens decreased from 17.9% to 7.6% (P = 0.01), and more patients were prescribed at least two nonopioid analgesics (27.5% to 42.9%; P = 0.003). The rate of scheduled acetaminophen prescription, in particular, increased (54.7% to 71.4%; P = 0.002). Conclusions: A procedure-specific prescribing model is a straight-forward intervention to promote safer opioid-prescribing practices in plastic surgery. Its usage in clinical practice may lead to more appropriate opioid prescribing.

Efficacy of PECS block in addition to multimodal analgesia for postoperative pain management in patients undergoing outpatient elective breast surgery: A retrospective study.

Background: Pectoralis nerve blocks (PECS) have been shown in numerous studies to be a safe and effective method to treat postoperative pain and reduce postoperative opioid consumption after breast surgery. However, there are few publications evaluating the PECS block effectiveness in conjunction with multimodal analgesia (MMA) in outpatient breast surgery. This retrospective study aims to evaluate the efficacy of PECS's blocks on perioperative pain management and opioid consumption. Methods: We conducted a retrospective study to assess the efficacy of preoperative PECS block in addition to preoperative MMA (oral acetaminophen and/or gabapentin) in reducing opioid consumption in adult female subjects undergoing outpatient elective breast surgery between 2015 and 2020. A total of 228 subjects were included in the study and divided in two groups: PECS block group (received PECS block + MMA) and control Group (received only MMA). The primary outcome was to compare postoperative opioid consumption between both groups. The secondary outcome was intergroup comparisons of the following: postoperative nausea and vomiting (PONV), incidence of rescue antiemetic medication, PACU non-opioid analgesic medication required, length of PACU stay and the incidence of 30-day postoperative complications between both groups. Results: Two hundred and twenty-eight subjects (n = 228) were included in the study. A total of 174 subjects were allocated in the control group and 54 subjects were allocated in the PECS block group. Breast reduction and mastectomy/lumpectomy surgeries were the most commonly performed procedures (48% and 28%, respectively). The total amount of perioperative (intraoperative and PACU) MME was 27 [19, 38] in the control group and 28.5 [22, 38] in the PECS groups (p = 0.21). PACU opioid consumption was 14.3 [7, 24.5] MME for the control group and 17 [8, 23] MME (p = 0.732) for the PECS group. Lastly, the mean overall incidence of postsurgical complications at 30 days was 3% (N = 5), being wound infection, the only complication observed in the PECS groups (N = 2), and hematoma (N = 2) and wound dehiscence (N = 1) in the control group. Conclusion: PECS block combined with MMA may not reduce intraoperative and/or PACU opioid consumption in patients undergoing outpatient elective breast surgery.

Evaluating the Efficacy of Two Regional Pain Management Modalities in Autologous Breast Reconstruction.

At our institution, multimodal opiate-sparing pain management is the cornerstone of our enhanced recovery program for autologous breast reconstruction. The purpose of this study was to compare postoperative outcomes and pain control metrics following implementation of an enhanced recovery program with two different regional analgesia approaches. METHODS: This retrospective cohort study identified 145 women who underwent autologous breast reconstruction from 2015 to 2017. Three groups were included: historical control patients (n = 46) and enhanced recovery patients that received multimodal pain management including a postoperative transversalis abdominis plane block with either a continuous local anesthetic catheter (n = 60) or a single-shot of liposomal bupivacaine (n = 39). The primary outcome was pain scores in the first three postoperative days. Secondary outcomes were opioid consumption in oral morphine equivalents and length of stay. RESULTS: Postoperative pain scores were similar across all three groups until postoperative day 3. Length of stay was significantly shorter in both of the enhanced recovery cohorts (3.0 [3.0, 4.0]) compared with control patients (4.0 [4.0, 5.0], P < 0.001). Likewise, average total oral morphine equivalents consumption was significantly reduced in enhanced recovery patients (continuous catheter 215.9 (95% CI, 165.4-266.3); liposomal bupivacaine 211.0 (95% CI, 154.8-267.2); control 518.4 (95% CI 454.2-582.7), P < 0.001). Neither length of stay (P = 0.953), nor oral morphine equivalents consumption (P = 0.883) differed by type of regional analgesia. CONCLUSION: Compared with control patients, both approaches to regional transversalis abdominis plane block analgesia as part of an opiate-sparing enhanced recovery pain management strategy were successful, but neither superior to the other.

Prospective pilot study protocol evaluating the safety and feasibility of robot-assisted nipple-sparing mastectomy (RNSM).

INTRODUCTION: Nipple-sparing mastectomy (NSM) can be performed for the treatment of breast cancer and risk reduction, but total mammary glandular excision in NSM can be technically challenging. Minimally invasive robot-assisted NSM (RNSM) has the potential to improve the ergonomic challenges of open NSM. Recent studies in RNSM demonstrate the feasibility and safety of the procedure, but this technique is still novel in the USA. METHODS AND ANALYSIS: This is a single-arm prospective pilot study to determine the safety, efficacy and potential risks of RNSM. Up to 12 RNSM will be performed to assess the safety and feasibility of the procedure. Routine follow-up visits and study assessments will occur at 14 days, 30 days, 6 weeks, 6 months and 12 months. The primary outcome is to assess the feasibility of removing the breast gland en bloc using the RNSM technique. To assess safety, postoperative complication information will be collected. Secondary outcomes include defining benefits and challenges of RNSM for both surgeons and patients using surveys, as well as defining the breast and nipple-areolar complex sensation recovery following RNSM. Mainly, descriptive analysis will be used to report the findings. ETHICS AND DISSEMINATION: The RNSM protocol was reviewed and approved by the US Food and Drug Administration using the Investigational Device Exemption mechanism (reference number G200096). In addition, the protocol was registered with ClinicalTrials.gov (NCT04537312) and approved by The Ohio State University Institutional Review Board, reference number 2020C0094 (18 August 2020). The results of this study will be distributed through peer-reviewed journals and presented at surgical conferences. TRIAL REGISTRATION NUMBER: NCT04537312.

Polypropylene Mesh Complications in the Sublay Position After Abdominally Based Breast Reconstruction: Les complications des treillis de polypropylène en sous-couche après une reconstruction mammaire par voie abdominale.

INTRODUCTION: Abdominal wall morbidity after microsurgical breast reconstruction is an important consideration for patients and surgeons. Previous studies are limited by multiple mesh locations or types. In this study, we evaluate specifically subfascial polypropylene mesh placement to determine a more definitive complication rate and basis for objective comparison. METHODS: A retrospective review was performed for patients undergoing microsurgical breast reconstruction at our institution by 3 surgeons from 2015 to 2018. All patients with sublay placement of polypropylene mesh were included. Patient demographics, medical comorbidities, type of reconstruction, and postoperative abdominal wall complications were recorded. RESULTS: A total of 114 flaps were performed on 81 patients who met the inclusion criteria. Of these, 48 were deep inferior epigastric artery (DIEP) flaps (42%), 43 were MS-2 TRAM flaps (37.8%), 20 were muscle sparing (MS-1) transverse rectus abdominus muscle (TRAM) flaps (17.5%), and 3 were free TRAM flaps (2.6%). Average follow-up was 392 days (range: 29-1191). Average body mass index was 30.7. No patients developed hernias. Two patients (2.5%) complained of post-operative bulges, neither of which required operative treatment. Two patients experienced superficial abdominal wall infection, one of which required admission and intravenous antibiotics. Ten patients (12.3%) had abdominal incision dehiscence, 3 of which required operative intervention. There were no cases of mesh exposure, contamination, or removal. CONCLUSION: Polypropylene mesh is safe and effective, with subfascial placement resulting in low morbidity and low rates of bulge/hernia formation after microsurgical breast reconstruction. Consideration should be given to using polypropylene mesh for fascial repairs after microsurgical breast reconstruction, particularly in high-risk populations.

INTRODUCTION: Les patientes et les chirurgiens doivent tenir compte de la possibilité d'affections de la paroi abdominale après une reconstruction mammaire microchirurgicale. Les études antérieures sont limitées par la multiplicité des emplacements et des types de treillis. Dans la présente étude, les chercheurs évaluent l'installation sous-aponévrotique d'un treillis de polypropylène pour obtenir un taux de complications plus catégorique et une référence en vue d'une comparaison objective. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse rétrospective des patientes qui ont subi une reconstruction mammaire microchirurgicale effectuée par trois chirurgiens dans leur établissement entre 2015 et 2018. Toutes les patientes ayant un treillis de polypropylène en sous-couche y ont participé. Les chercheurs ont pris note des caractéristiques démographiques des patientes, de leurs autres affections, du type de reconstruction et de leurs complications postopératoires. RÉSULTATS: Au total, 114 lambeaux reconstruits sur 81 patientes respectaient les critères d'inclusion. De ce nombre, 48 étaient des lambeaux de l'artère épigastrique inférieure profonde (42 %), 43, des lambeaux du muscle grand droit abdominal avec épargne musculaire 2 (37,8 %), 20, des lambeaux du muscle grand droit abdominal avec épargne musculaire 1 (17,5 %) et trois, des lambeaux du muscle grand droit (2,6 %). La période de suivi moyenne était de 392 jours (plage de 29 à 1 191), et l'indice de masse corporelle, de 30,7. Aucune patiente n'a fait de hernie. Deux patientes (2,5 %) se sont plaintes de bosses postopératoires, mais ni l'une ni l'autre n'a nécessité de traitement opératoire. Deux patientes ont souffert d'une infection abdominale superficielle, dont l'une a entraîné une hospitalisation et l'administration d'antibiotiques par voie intraveineuse. Dix patientes (12,3 %) ont présenté une déhiscence de l'incision abdominale, et trois ont dû subir une intervention opératoire. Il n'y a eu aucun cas d'exposition, de contamination ou d'exérèse du treillis. CONCLUSION: Le treillis de polypropylène est sécuritaire et efficace, et son installation sous-aponévrotique est liée à une faible morbidité et à un faible taux de formations de bosses ou de hernies après une reconstruction mammaire microchirurgicale. Il faut envisager de l'utiliser pour les réparations du fascia après une reconstruction mammaire microchirurgicale, particulièrement dans les populations à haut risque.

Targeted Muscle Reinnervation following Breast Surgery: A Novel Technique.

Post-mastectomy pain syndrome is a prevalent chronic pain condition that affects numerous patients following breast surgery. The mechanism of this pain has been proposed to be neurogenic in nature. As such, we propose a novel surgical method for the prophylactic management of postsurgical breast pain: targeted muscle reinnervation of the breast. This article serves to review the relevant current literature of post-mastectomy pain syndrome and targeted muscle reinnervation, describe our current surgical technique for this operation, and present an initial cohort of patients to undergo this procedure.

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.

The Free Serratus-Rib Flap for Orbital Floor Reconstruction After Oncologic Resection.

INTRODUCTION: Maxillary cancer is relatively rare but devastating for those affected with the disease. For patients who require suprastructural or total maxillectomy for oncologic resection, the resection of the orbital floor can be challenging to reconstruct. The serratus-rib flap is a well-known and useful method of head and neck reconstruction, albeit infrequently used. However, the serratus-rib flap has not previously been described for reconstruction of the orbital floor and has the potential to provide excellent globe support after orbital floor resection in patients after undergoing maxillectomy. METHODS: We retrospectively reviewed all patients who had undergone orbital floor reconstruction using the serratus-rib osteomyofascial free flap by the senior author throughout their career. Surgical technique, postoperative course, complications, and additional required procedures were evaluated. RESULTS: Six patients were found to have undergone the serratus-rib osteomyofascial free flap for orbital floor reconstruction. Average follow-up was 26.7 months from initial surgery. Fifty percent of patients had later minor revision surgery such as fat grafting or scar revision. No patients had any significant complications, and all patients were noted to have good ocular function without diplopia postoperatively. CONCLUSION: The serratus-rib osteomyofascial free flap is an efficacious method for reconstruction of the orbital floor after oncologic resection. Surgeons should consider this flap when performing orbital floor reconstruction, particularly when dead space also needs to be filled with the use of a free flap.

Postmastectomy Pain Syndrome: A Primer for Plastic Surgeons.

Postmastectomy pain syndrome (PMPS) is defined as chronic pain after breast cancer surgery lasting greater than 3 months and has been shown to affect up to 60% of breast cancer patients. Substantial research has been performed to identify risk factors and potential treatment options, although the exact cause of PMPS remains elusive. As breast reconstruction becomes increasingly popular, plastic surgeons are likely to encounter more patients presenting with PMPS. This article summarizes current evidence on risk factors and treatment options for PMPS and highlights further areas of study.

Complications after vascularized jejunal mesenteric lymph node transfer: A 3-year experience.

BACKGROUND: Vascularized lymph node transfer (VLNT) is a well-established method for the surgical management of refractory extremity lymphedema. Generally, donor lymph nodes are harvested from the axilla, groin, or supraclavicular area. However, these sites offer their own disadvantages and introduce risk for inducing lymphedema at the surgical donor site. In our experience, the jejunal mesentery can be an excellent source of lymph nodes without the risk of donor site lymphedema. Long term complications are unknown for this procedure; we report our experience, complication rates, and lessons learned. METHODS: A retrospective review was performed for all patients at our institution undergoing surgical treatment of lymphedema using jejunal mesenteric VLNT from February 2015 to February 2018. Demographic data, length of follow up, and surgical complications were reviewed. RESULTS: Twenty-nine patients have undergone jejunal VLNT at our institution during the three-year study period, with a total of 30 transfers. Five patients had a concurrent omental lymph node transfer. Average length of follow up was 17.6 months (range 1.0-36.8 months). There was one flap loss in this time frame (3.3%). Four patients developed hernias post-operatively (13.8%), and three had nonoperative small bowel obstructions (10.3%). One patient had a postoperative wound infection at the abdominal incision (3.4%). CONCLUSIONS: Jejunal VLNT can be an effective option for surgical treatment of lymphedema, without the risk of postoperative donor site lymphedema. Patients and surgeons should be aware of the risks of hernia and small bowel obstruction with this method compared to other lymph node sources.

Outcomes following Autologous Fat Grafting for Oncologic Head and Neck Reconstruction.

BACKGROUND: The aims of this study were to examine the surgical, oncologic, and aesthetic outcomes of patients undergoing autologous fat grafting for oncologic head and neck reconstruction. METHODS: A review was performed of 119 consecutive patients undergoing autologous fat grafting for oncologic head and neck reconstruction from 2005 to 2014. Aesthetic outcomes were rated by a group of 10 plastic surgeons and 10 laypersons using a five-point Likert scale. RESULTS: A total of 190 fat grafting procedures were performed in 116 patients. Of these, 69 percent had received radiation therapy before their reconstructive surgery. The average number of treatments per patient was 1.6 ± 1 (range, 1 to 6), with a mean injection volume of 24.8 ± 20.2 ml. The mean follow-up time from the first fat grafting procedure was 35.8 ± 23.1 months. Complications occurred in 6 percent, none of which required a return to the operating room or hospital admission. Oncologic recurrence was observed in six patients (three local, one regional, and two distant). Locoregional recurrences were in areas outside of where the fat was grafted. Aesthetic analysis revealed that both plastic surgeons and laypersons thought patients appeared closer to normal following autologous fat grafting. CONCLUSION: This study suggests that autologous fat grafting plays a valuable role in enhancing aesthetic outcomes either by complementing or replacing reconstructive flaps for oncologic head and neck reconstruction while having both low complication rates and no evidence of being associated with cancer recurrence.

Lymphovenous Anastomosis Bypass Surgery.

The field of lymphedema surgery has witnessed tremendous advancements over the years and has been coupled to the rapid growth of supermicrosurgical techniques. A lymphovenous bypass or lymphaticovenular anastomosis is a new technique that requires identification of patent, residual lymphatic channels and performing an anastomosis to a recipient venule, thereby allowing outflow of lymphatic fluid and improvement in a patient's lymphedema. This article provides a summary of the maturation of the technique, as well as the technical aspects of the approach and the current outcomes in the treatment of postmastectomy lymphedema.

The Impact of Physician Assistants on a Breast Reconstruction Practice: Outcomes and Cost Analysis.

BACKGROUND: Physician assistants (PAs) are commonly employed in plastic surgery. However, limited data exist on their impact, which may guide decisions regarding how best to integrate them into practice. METHODS: A review of the practices of 2 breast reconstructive surgeons was performed. A comparison was made between a 1-year period before to a 1-year period after the addition of a PA into practice. The practice model was a one-to-one pairing of a plastic surgeon and a PA. RESULTS: A total of 4141 clinic encounters and 1356 surgical cases were reviewed. After the addition of PAs, there was a significant increase in relative value units (1057 vs 1323 per month per surgeon, P < 0.001). Operative times were similar with and without PAs (P = 0.45). However, clinic encounter times for surgeons were shorter for all visit types when patients were first seen by a PA before the surgeon: global follow-up (P = 0.03), other follow-up (P = 0.002), consultation (P = 0.76), and preoperative (P = 0.02), translating to 9 additional patients seen per day. Charges (P = 0.001) and payments (P = 0.007) also increased, which offset the cost of using a PA. However, the financial contribution from PA involvement as first assistant in surgery was limited (5.2%). The peak effect of PAs was observed between the third and fourth quarters. CONCLUSIONS: In breast reconstruction, PAs primarily enhance the efficiency of plastic surgeons, particularly in the clinic, with downstream clinical and financial gains of an indirect nature for surgeons.

Simultaneous Scalp, Skull, Kidney, and Pancreas Transplant from a Single Donor.

BACKGROUND: Vascularized composite allotransplantation is an emerging field, but the complications of lifelong immunosuppression limit indications. Vascularized composite allotransplantation in solid organ recipients represents a unique opportunity because immunosuppression has already been accepted. This report of a simultaneous scalp, skull, kidney, and pancreas transplant represents both the first skull-scalp transplant and combination of a vascularized composite allotransplantation with double organ transplantation. METHODS: A previous recipient of a kidney-pancreas transplant presented with osteoradionecrosis of the calvaria and a large area of unstable scalp following successful, curative treatment of a scalp tumor. His kidney and pancreas functions were also critically poor. A multidisciplinary, multi-institutional plan was developed to perform a simultaneous scalp, skull, and repeated kidney and pancreas transplantation, all from a single donor. RESULTS: Eighteen months after the patient was listed with the United Network for Organ Sharing, a donor was identified and the multiorgan vascularized composite allotransplantation was performed. Twenty physicians and 15 hours were required to perform donor and recipient procedures. The patient recovered well and was discharged on postoperative day 15. He has had one episode of scalp rejection confirmed by biopsy and treated successfully. His creatinine value is currently 0.8 mg/dl, from 5.0 mg/dl, and his blood glucose levels are normal without supplemental insulin. Aesthetic outcome is very satisfactory. The patient is now 1 year post-transplantation and doing well. CONCLUSIONS: Vascularized composite allotransplantation in solid organ recipients is an expansion of current indications to already immunosuppressed patients. Rejection of the vascularized composite allotransplant without solid organ rejection can occur and is treatable. Methodical planning, an interdisciplinary approach, and careful management of all organs are critical to success. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Massive localized lymphedema: a clinicopathologic study of 46 patients with an enrichment for multiplicity.

Massive localized lymphedema is a monstrous tumefactive pseudosarcoma seen in middle-aged morbidly obese adults. Since its initial description in 1998, the etiology remains unknown, although associations with trauma, surgeries, and hypothyroidism have been reported. Herein, we report the largest study of massive localized lymphedema and expand upon its clinicopathologic features. Fifty-four cases from 46 patients were retrospectively identified from the institutional archives of The Ohio State University Wexner Medical Center between 2002 and 2015. Forty-six patients (21 males and 25 females, mean age 50 years) presented with large masses developing over a 5-60-month period. The majority of patients were Caucasian (n=39). All patients were obese with a mean weight of 384.7 lb and a mean body mass index of 59.6 kg/m(2). Thirty-six patients had a history of atherosclerotic cardiovascular disease and diabetes mellitus type 2 was present in 22 patients. Eight patients had multifocal massive localized lymphedema. The sites included thigh (n=33), abdomen (n=17), suprapubic region (n=1), mons pubis (n=6), scrotum (n=2), perianal region (n=1), and right flank (n=1). Mostly, the clinical impression was benign processes, including pannus or lymphedema pseudotumor. Grossly, the mean weight was 8237 g and the mean size was 53.2 cm. Histologically, eight cases showed a unique pattern of dystrophic calcifications mimicking hyperchromatic, atypical nuclei that might lead to misdiagnosis of liposarcoma, four cases showed focal metaplastic ossification, and three cases showed multinucleated cells in addition to prototypic features of massive localized lymphedema. We report that this is the largest series of massive localized lymphedema. This is a lesion mostly seen in morbidly obese patients and the thigh is the most common site of involvement. We note a marked racial predilection for Caucasians and a tendency towards multiplicity. We suggest that obesity itself and the related metabolic syndrome have an important role in its pathogenesis.

Osseointegrated implant-based dental rehabilitation in head and neck reconstruction patients.

BACKGROUND: Dental restoration is an integral part of head and neck cancer reconstruction. METHODS: We evaluated the success rate of osseointegrated implants in patients with head and neck cancer, comparing outcomes between implants placed in fibula free flaps to those placed in native mandibular and maxillary bone. RESULTS: A total of 1132 implants were placed in 246 patients. The overall implant loss rate was 3.7% and was higher in fibula flaps (8.2%) compared to the native mandible (2.6%) and maxilla (2.2%), although these differences did not reach statistical significance (p = .059 and p = .053, respectively). The failure rate was 8.0% for implants placed after radiation and 3.6% in patients who did not undergo radiation (p = .097). Osteoradionecrosis (ORN) occurred in 19 patients (7.7%) after implant placement, and tobacco use was found to be a risk factor (p = .027). CONCLUSION: Osseointegrated implants are reliable in patients with head and neck cancer, including those undergoing bony free flap reconstruction. © 2015 Wiley Periodicals, Inc. Head Neck 38: E321-E327, 2016.

Analysis of risk factors for flap loss and salvage in free flap head and neck reconstruction.

BACKGROUND: Risk factors and techniques for free flap salvage in head and neck reconstruction are poorly described. METHODS: We conducted a retrospective review of all head and neck free flaps performed from 2000 to 2010. RESULTS: Overall, 151 of 2296 flaps (6.6%) underwent salvage for microvascular complications. Age, comorbidities, surgeon experience (p = .88), vein grafts, and supercharging (p = .45) did not affect flap salvage. Muscle-only flaps (p = .002) were associated with significantly worse outcomes. Coupled venous anastomoses were superior to handsewn anastomoses (p = .03). Arteriovenous thrombosis had worse outcomes than a venous or arterial thrombosis alone (p < .0001). Anticoagulation, thrombolytics, and thrombectomy did not improve survival. Multiple takebacks (p = .003) and late takebacks (>3 days) had significantly worse outcomes (p = .003). Flap salvage was 60.3% successful with 60 total flap losses (2.6%). CONCLUSION: Although flap salvage should be attempted, multiple attempts are not recommended, especially for muscle-only flaps. Combined arteriovenous and late thrombosis has a dismal prognosis regardless of different salvage techniques. © 2015 Wiley Periodicals, Inc. Head Neck 38: E771-E775, 2016.