Use of both antegrade and retrograde internal mammary vessels in the bipedicled deep inferior epigastric perforator flap for unilateral breast reconstruction.

BACKGROUND: Autologous abdominal tissue transfer is a well-established method of breast reconstruction. The deep inferior epigastric perforator (DIEP) flap has the additional benefit of minimal donor site morbidity as it spares the muscle and fascia. Conventional DIEP flaps may not provide adequate volume in cases where the patient is thin, has midline abdominal scars, and/or has a large volume of tissue to replace. One solution is to use a bipedicled DIEP flap, incorporating all the available abdominal tissue. Bipedicled DIEP flaps have been described in a number of different configurations. The literature appears to favor intra-flap anastomosis, with a minimal exposition of two recipient vessels. It has been demonstrated that both the antegrade internal mammary artery (aIMA) and retrograde internal mammary artery (rIMA) are adequate recipient vessels. Here, the authors present a single-center experience with bipedicled DIEP flaps to both the aIMA and rIMA, showing their feasibility and safety. METHODS: A retrospective review of patients who underwent unilateral breast reconstruction using bipedicled DIEP flaps was performed to assess outcomes. RESULTS: A total of 20 patients who underwent unilateral breast reconstruction using a bipedicled DIEP flap were selected for this study. All of them were previously diagnosed with cancer. There were zero flap failure and zero instance of abdominal hernia or issue with abdominal wall functionality following the surgeries. CONCLUSIONS: The series of surgeries described in this study resulted in successful breast reconstruction in 20 women using a bipedicled DIEP flap. The results show that this approach allows for reconstruction in places where a conventional DIEP does not provide adequate volume, achieved safely, and does not increase morbidity. The bipedicled DIEP flap is a viable option for large-volume autologous breast reconstruction, providing ample tissue for successful reconstruction while also allowing for shorter recovery and limited donor site morbidity.

Risk Factors Leading to Free Flap Failure: Analysis From the National Surgical Quality Improvement Program Database.

BACKGROUND: The objective of this study was to identify risk factors for free flap failure among various anatomically based free flap subgroups. METHODS: The 2005 to 2012 American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing microvascular free tissue transfer based on current procedural terminology codes. Univariate analysis was performed to identify any association between flap failure and the following factors: age, gender, race, body mass index (BMI), diabetes, smoking, alcohol use, hypertension, intraoperative transfusion, functional health status, American Society of Anesthesiologists class, operative time, and flap location. Factors yielding a significance of P < 0.20 were included in multivariate logistic regression models in order to identify independent risk factor significance for flap failure. Furthermore, patients were stratified based on recipient site (breast, head and neck, trunk, or extremity), and analysis was repeated in order to identify risk factors specific to each location. RESULTS: A total of 1921 of 2103 patients who underwent microvascular free flap reconstruction met inclusion criteria. Multivariate logistic regression identified BMI (adjusted odds ratio [AOR] = 1.07, P = 0.004) and male gender (AOR = 2.16, P = 0.033) as independent risk factors for flap failure. Among the "breast flaps" subgroup, BMI (AOR = 1.075, P = 0.012) and smoking (AOR = 3.35, P = 0.02) were independent variables associated with flap failure. In "head and neck flaps," operative time (AOR = 1.003, P = 0.018) was an independent risk factor for flap failure. No independent risk factors were identified for the "extremity flaps" or "trunk flaps" subtypes. CONCLUSIONS: BMI, smoking, and operative time were identified as independent risk factors for free flap failure among all flaps or within flap subsets.

Review of Maxillofacial Hardware Complications and Indications for Salvage.

From 2002 to 2006, more than 117,000 facial fractures were recorded in the U.S. National Trauma Database. These fractures are commonly treated with open reduction and internal fixation. While in place, the hardware facilitates successful bony union. However, when postoperative complications occur, the plates may require removal before bony union. Indications for salvage versus removal of the maxillofacial hardware are not well defined. A literature review was performed to identify instances when hardware may be salvaged. Articles considered for inclusion were found in the PubMed and Web of Science databases in August 2014 with the keywords maxillofacial trauma AND hardware complications OR indications for hardware removal. Included studies looked at human patients with only facial trauma and miniplate fixation, and presented data on complications and/or hardware removal. Fifteen articles were included. None were clinical trials. Complication data were presented by patient, fractures, and/or plate without consistency. The data described 1,075 fractures, 2,961 patients, and 2,592 plates, nonexclusive. Complication rates varied from 6 to 8% by fracture and 6 to 13% by patient. When their data were combined, 50% of complications were treated with plate removal; this was consistent across the mandible, midface, and upper face. All complications caused by loosening, nonunion, broken hardware, and severe/prolonged pain were treated with removal. Some complications caused by exposures, deformities, and infections were treated with salvage. Exposed plates were treated with flaps, plates with deformities were treated with secondary procedures including hardware revision, and hardware infections were treated with antibiotics alone or in conjunction with soft-tissue debridement and/or tooth extraction. Well-designed clinical trials evaluating hardware removal versus salvage are lacking. Some postoperative complications caused by exposure, deformity, and/or infection may be successfully treated with plate salvage. We propose an algorithm using this review and clinical expertise. We also propose that a national databank be created where surgeons can uniformly compile their patient information and examine it in a standardized format to further our understanding of clinical management.

Impact of race and socioeconomic status on presentation and management of ventral hernias.

OBJECTIVE: To assess for disparity in presentation and management of ventral hernias. DESIGN: Retrospective review. SETTING: Academic center. PATIENTS: Three hundred twenty-one patients who underwent ventral hernia repair from 2005 to 2008. MAIN OUTCOME MEASURES: Disparity in ventral hernia presentation, management, and outcome. Univariate analysis was conducted by unpaired t test and chi(2) test. RESULTS: Black individuals were more likely than white individuals to present with acute hernia complications requiring emergent surgery (11% vs 4%; P < .01). This finding persisted after controlling for socioeconomic status (SES). Assessment by SES demonstrated patients with Medicaid were more likely to present with incarcerated or strangulated hernias (39% vs 25%; P < .001) and had longer hospital stays (4.7 vs 3 days; P < .05) as compared with patients with private insurance. Patients classified as low income had increased 30-day readmission rates as compared with average- or high-income patients (32% vs 9% vs 7%, respectively; P < .01). No difference in use of minimally invasive technique, performance of primary vs mesh repair, or postoperative morbidity or mortality was demonstrated. Twelve-month follow-up demonstrated no difference in recurrence rate by race or SES. CONCLUSIONS: Our study demonstrates the existence of disparity in patient presentation with complicated ventral hernia. Despite clear disparity by race and SES, at our institution, disparate presentation did not equate to disparate treatment or postoperative complications. No difference was demonstrated by use of operative technique, perioperative outcome, or 12-month recurrence rate. This study illustrates the need for long-term measures directed at reevaluation of organizational and institutional factors that perpetuate inequality.