Long-term follow-up of changing practice patterns in breast reconstruction due to increased use of tissue expanders and perforator flaps.

BACKGROUND: As the science of breast reconstruction evolves, significant changes in reconstruction strategies and outcomes are expected. The purpose of this study is to determine the changes in breast reconstruction trends and outcomes that occurred at a multidisciplinary academic institution during the last decade. METHODS: We compared 265 patients over two distinct 6-month intervals separated by 5 years (2002 vs. 2007) and performed long-term follow-up (4.75 ± 3.38 years 2002, 2.99 ± 2.25 years 2007). We studied patients seeking prophylactic mastectomy, patients with early breast cancer, and patients with locally advanced disease. We analyzed demographic data, breast cancer history and treatment, type and timing of reconstruction, and complications. RESULTS: Implant to flap reconstruction ratio was 48:49 in 2002 and 76:102 in 2007. Use of transverse rectus abdominis myocutaneous flap declined from 57 to 4%; conversely, deep inferior epigastric perforator flap increased from 27 to 91% (P < 0.001). Correspondingly, donor site chronic pain (4 vs. 0, P = 0.012) and postoperative abdominal wall bulge (9 vs. 3, P = 0.004) rates decreased. Timing of reconstruction showed increased staged cases in 2007 compared to 2002 (P = 0.045). Post-final reconstruction radiation therapy was reduced in 2007 (P = 0.016), with subsequent lower rates of implant rupture (P < 0.001). CONCLUSIONS: At our institution and over the last decade, increasing staged reconstructions have successfully reduced the rates of post-final reconstruction radiotherapy with optimized outcomes. Contrary to national trends, the rates of autologous flap reconstructions have increased with reduced donor site morbidity. This suggests that academic breast reconstruction trends are independent from national trends.

Clinical experience with the lateral septocutaneous superior gluteal artery perforator flap for autologous breast reconstruction.

BACKGROUND: Superior gluteal artery perforator (SGAP) flaps are a useful adjunct for autologous microvascular breast reconstruction. However, limitations of short pedicle length, complex anatomy, and donor site deformity make it an unpopular choice. Our goals were to define the anatomic characteristics of SGAPs in cadavers, and report preliminary clinical and radiographic results of using the lateral septocutaneous perforating branches of the superior gluteal artery (LSGAP) as the basis for a modified gluteal flap. METHODS: We performed 12 cadaveric dissections and retrospectively reviewed 12 consecutive breast reconstruction patients with gluteal flaps (19 flaps: 9 LSGAP, 10 traditional SGAP) over a 12-month period. The LSGAP flap was converted to traditional SGAP in 53% of flaps because of dominance of a traditional intramuscular perforator. Preoperative 3D computed tomography angiography (CTA) and cadaveric dissections were used to define anatomy. Anatomic, demographic, radiographic, perioperative, and outcomes data were analyzed. Mean follow-up was 4 +/- 3.4 months (range 4 weeks to 10 months). RESULTS: Compared with the pedicle in the SGAP flap, the mean pedicle length in the LSGAP flap was 1.54 times longer by CTA, 2.05 times longer by cadaver dissection, and 2.36 times longer by intraoperative bilateral measurement. These differences were statistically significant (P < 0.001). Clinically, 100% of the flaps survived. CONCLUSIONS: LSGAP flap reconstruction is advantageous, when feasible, because of the septocutaneous pedicle dissection and gain in pedicle length that make microsurgical anastomoses easier without compromising gluteus function.

Finger joint injuries.

Finger joint dislocations and collateral ligament tears are common athletic hand injuries. Treatment of the athlete requires a focus on safe return to play and maximizing function. Certain dislocations, such as proximal interphalangeal and distal interphalangeal volar dislocations, may be associated with tendon injuries and must be treated accordingly. Treatment of other dislocations is ultimately determined by postreduction stability, with many dislocations amenable to nonoperative treatment (ie, immobilization followed by rehabilitation). Protective splinting does not necessarily preclude athletic participation. Minor bone involvement typically does not affect the treatment plan, but significant articular surface involvement may necessitate surgical repair or stabilization. Percutaneous and internal fixation are the mainstays of surgical treatment. Treatment options that do not minimize recovery or allow the patient to return to protected play, such as external fixation, are generally avoided during the season of play. Undertreated joint injuries and unrecognized ligament injuries can result in long term disability.

Upper extremity replantation: current concepts.

BACKGROUND: Upper extremity replantation is a procedure that has revolutionized hand surgery. Since its introduction, a rapid evolution has occurred with a shifting focus from implant survival to optimization of functional outcomes and surgical efficiency. In this review, the current concepts surrounding the indications for replantation, variations in surgical technique, the factors affecting outcomes, and future directions of the specialty are analyzed. METHODS: A literature review was performed of all recent articles pertaining to digit, hand, and upper extremity replantation surgery. Particular emphasis was placed on comparative studies and recent meta-analyses. RESULTS: The indications and contraindications for replantation surgery are largely unchanged, with mechanism of injury remaining one of the most important determinants of implant survival. With advances in surgical technique, improved outcomes have been observed with avulsion injuries. Distal tip replantations appear to be more common with improved microsurgical techniques, and for these distal injuries, digital nerve and vein repair may not be necessary. Cold ischemia time for a digit amputation should not preclude transfer to a replantation facility or significantly affect the decision to perform a replantation. However, transferring physicians should thoroughly review the options with patients to prevent unnecessary transfers, which is an area where telemedicine may be useful. CONCLUSION: This review provides an update on the current concepts of the practice of replantation and the treatment and management of patients with upper extremity amputations.

Concomitant upper extremity soft tissue sarcoma limb-sparing resection and functional reconstruction: assessment of outcomes and costs of surgery.

BACKGROUND: The purpose of this study is to investigate functional outcomes and cost impacts of immediate functional reconstruction performed in conjunction with limb-sparing resection of upper extremity soft tissue sarcomas. METHODS: Patients undergoing simultaneous limb-sparing upper extremity soft tissue sarcoma resection and functional reconstruction between December 1998 and March 2004 were retrospectively identified, their medical records reviewed, and costs of surgery analyzed. Functional outcomes and patient satisfaction were assessed via patient surveys and the Toronto Extremity Salvage Score (TESS). RESULTS: Thirteen patients met the inclusion criteria. Average follow-up was 43.3 months. Reconstructions included rotational innervated muscle flaps (n = 6), free innervated myocutaneous flaps (n = 1), and tendon transfers or grafts (n = 6). Overall survival was 85 % (n = 11) and disease-free survival was 77 % (n = 10). Average total cost of surgery was $26,655. Patients undergoing reconstruction for hand and forearm sarcomas had significantly higher total costs of surgery than those undergoing reconstruction for elbow and upper arm sarcomas. Survey response rate was 91 % (n = 10). Average TESS score was 76. Of the patients who worked preoperatively, 88 % returned to work postoperatively, and all patients who returned to work currently use their affected limb at work. CONCLUSIONS: Patients undergoing immediate functional reconstruction for upper extremity soft tissue sarcoma resection achieved very good to excellent functional outcomes with quick recovery times and a high return-to-work rate following immediate functional reconstruction, thereby minimizing surgical cost impacts. Immediate functional reconstruction in the same surgical setting is thus a viable strategy following upper extremity soft tissue sarcoma resection.

Achieving differential facial changes with Le Fort III distraction osteogenesis: the use of nasal passenger grafts, cerclage hinges, and segmental movements.

BACKGROUND: In traditional Le Fort III distraction, the transport segment is advanced en bloc without addressing differences in the relative retrusion of the facial structure. The authors describe three methods for correcting these asymmetries with differential facial advancement. METHODS: Eight patients (age range, 4 to 20 years) with asymmetric facial hypoplasia were treated by Le Fort III midface distraction using an external device. Two patients with nasal bone hypoplasia exceeding midface retrusion were treated with nasal passenger grafts at the time of osteotomy. Two patients with asymmetric rotational midface deformities underwent wire cerclage swing advancement of the affected side to achieve differential advancement. Four patients with central nasomaxillary retrusion exceeding zygomatic retrusion underwent segmental Le Fort III osteotomy with simultaneous zygoma repositioning and Le Fort II distraction. RESULTS: Differential midface advancement was achieved in all patients. Midface distraction and nasal passenger grafts resolved obstructive sleep apnea, improved globe protection, and improved fit of prescription glasses. After Le Fort III swing advancement, the centric relation and malar asymmetry were corrected with differential advances of 10 and 15 mm compared with the unaffected side. In the segmental osteotomy Le Fort III group, the central face was distracted independently of the zygoma repositioning, thus correcting the shortened retruded central midface without distorting the orbitomalar relationship and improving airway obstruction, anterior open bite, short nose, and proptosis. CONCLUSIONS: Midface distraction techniques have evolved to include the principles of segmentation, graft augmentation, and controlled rotation. The benefits of gradual distraction can be realized without compromising the aesthetic and functional result.

Reconstruction of the inferior alveolar nerve with bioabsorbable polyglycolic acid nerve conduits.

BACKGROUND: Iatrogenic injury to the inferior alveolar nerve can result in debilitating anesthesia, dysesthesia, and allodynia. The authors report their experience with polyglycolic acid nerve tubes in inferior alveolar nerve reconstruction. METHODS: Five patients with iatrogenically injured inferior alveolar nerves underwent reconstruction with polyglycolic acid nerve tubes performed by the senior author (A.P.T.). Patient charts were reviewed retrospectively. Resolution of pain, narcotic medication use, neuropathic pain medication use, and patient satisfaction with surgery were assessed by means of patient surveys. Sensation recovery was assessed with the Ten Test. Costs of surgery were calculated and adjusted to 2010 U.S. dollars using the consumer price index. RESULTS: Survey response rate was 100 percent. All patients suffered from preoperative pain and sensation loss. Preoperatively, 80 percent of patients used prescription narcotic and 100 percent of patients used neuropathic pain medications. Average time from injury to reconstruction was 14 months. Operative time averaged 240 minutes, and total surgical costs averaged $8177. At average follow-up of 47.8 months, Ten Test results averaged 3.3. Average time to maximum recovery of sensation and reduction of pain was 8 months and 7 months, respectively. One hundred percent of patients experienced pain relief, with an average 46 percent reduction in pain. Postoperatively, 100 percent of patients discontinued all narcotic and neuropathic pain medications. CONCLUSIONS: The use of polyglycolic acid nerve tubes in the reconstruction of iatrogenically injured inferior alveolar nerves achieves diminution of pain and variable sensory recovery. This technique is cost effective and carries no donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, IV.

Internal mammary intercostal perforators instead of the true internal mammary vessels as the recipient vessels for breast reconstruction.

BACKGROUND: Free tissue transfer has become a mainstay in breast reconstruction, with the internal mammary system frequently used as the recipient vessels. Sacrificing the internal mammary artery, however, eliminates the potential to use this vessel as a coronary artery bypass conduit in the future and potentially increases recipient-site morbidity. The authors' goal was to evaluate the learning curve and effectiveness of their use of the internal mammary intercostal perforators for microsurgical breast reconstruction. METHODS: The authors reviewed one surgeon's consecutive series of 100 abdominal adipocutaneous perforator flap breast reconstructions (72 patients) from July of 2005 through January of 2007. The internal mammary perforators were used as recipient vessels in 23 flaps, the traditional internal mammary vessels were used in 66, and the thoracodorsal vessels were used in 11. To see if there was a learning curve, flaps were analyzed in five consecutive cohorts of 20. RESULTS: A learning curve was shown: internal mammary perforators were used in 5 percent of the first cohort and 45 percent of flaps in the final cohort. Flap survival was 99 percent; the one failure occurred in a traditional internal mammary flap reconstruction. Small palpable areas of fat necrosis were observed in one internal mammary perforator flap (4.3 percent) and in five traditional internal mammary or thoracodorsal flaps (6.5 percent). CONCLUSIONS: In all the authors' cohorts, internal mammary perforator vessels were used safely without increasing the incidence of flap failure or fat necrosis seen with the traditional approach. The learning curve for this technique resulted in increased use of these internal mammary perforators, indicating that operator experience is critical.

The impact of surgical ventricular restoration on mitral valve regurgitation.

BACKGROUND: Surgical management of functional mitral regurgitation (MR) in ischemic cardiomyopathy is controversial. Surgical ventricular restoration (SVR) decreases left ventricular volume and may improve MR severity. We assessed the impact of SVR on the degree of MR. METHODS: We retrospectively reviewed patients with ejection fractions (EF) < 0.35 who underwent SVR with coronary artery bypass grafting (SVR+CABG) over a 3-year period. Patients with concomitant mitral valve procedures were excluded. Patients with EF < 0.35 who had CABG alone during the same time period served as control. Mitral regurgitation was graded 0 to 4+ by echocardiogram and ventriculogram. Outcomes included survival, MR grade, and cardiac function. RESULTS: Thirty-nine patients received SVR+CABG: 3% (1 of 39) had 4+, 10% (4 of 39) had 3+, 51% (20 of 39) had 2+, and 36% (14 of 39) had 0 to 1+ MR. Thirty-five patients with a similar MR distribution underwent CABG alone. Operative mortality was 2.6% for SVR+CABG and 5.7% for CABG patients (p = 0.62). At follow-up, MR grade decreased by 57% (2.24 +/- 0.5 to 1.24 +/- 0.9, p < 0.001) for the SVR+CABG group compared to 12% (2.25 +/- 0.5 to 2.00 +/- 0.9, p = 0.27) for the CABG alone group. SVR+CABG patients had significantly less MR than CABG patients at follow-up (1.24 +/- 0.9 vs 2.00 +/- 0.9, p = 0.007), with 15 patients improving to 0 to 1+ MR postoperatively versus 6 patients in the CABG cohort (p = 0.02). Improvement in postoperative EF was significantly greater after SVR+CABG (0.13% vs 7%, p = 0.04). Three-year survival was 85% for SVR+CABG and 72% for CABG patients (p = 0.39). CONCLUSIONS: SVR+CABG demonstrated greater reduction in MR severity at follow-up than CABG alone. Decreased left ventricular volumes and improved papillary muscle orientation likely contribute to decreased MR after SVR.

Coronary artery bypass grafting with or without surgical ventricular restoration: a comparison.

BACKGROUND: Coronary artery bypass grafting (CABG) is an effective treatment for ischemic cardiomyopathy. However, patients with ventricular enlargement are known to have inferior outcomes. We assessed whether surgical ventricular restoration (SVR) with CABG (SVR + CABG) leads to improved outcomes versus CABG alone for patients with ischemic cardiomyopathy and ventricular enlargement. METHODS: We conducted a case-control study comparing patients with ischemic cardiomyopathy and ejection fraction less than 0.35 who underwent SVR + CABG versus CABG alone from June 2002 to December 2005. Patients who underwent SVR + CABG were compared with control patients who met criteria for SVR + CABG by ventriculogram or echocardiogram but received CABG alone. End points included survival, rehospitalization for heart failure, and New York Heart Association class. RESULTS: During the study period 120 patients underwent SVR + CABG (n = 62) versus CABG alone (n = 58). Patients in the SVR + CABG group were younger (60 versus 64 years; p = 0.04) and more likely to be New York Heart Association class III or IV preoperatively (98% versus 86%; p = 0.01). Operative mortality was similar between groups (6.4% versus 5.2%; p = 1.00). Ejection fraction was similar preoperatively (0.22 versus 0.24; p = 0.31) and postoperatively (0.34 versus 00.32; p = 0.40). The SVR + CABG patients experienced fewer rehospitalizations for heart failure (24% [13 of 54] versus 55% [24 of 44]; p = 0.006) but had similar 4-year survival (p = 0.60). At follow-up, 80% (50 of 62) of SVR + CABG versus 57% (27 of 47) of CABG alone patients improved to New York Heart Association class I or II (p = 0.01). CONCLUSIONS: Patients with ischemic cardiomyopathy and ventricular enlargement experience similar early survival after SVR + CABG or CABG alone. However, SVR + CABG resulted in fewer rehospitalizations and better improvements in New York Heart Association class. Surgical ventricular restoration with CABG should be offered to eligible patients with ischemic cardiomyopathy and ventricular enlargement.