Autologous Free Tissue Transfer Research Articles

A single center prospective study of bilateral breast reconstruction with free abdominal flaps: A critical analyses of 144 patients

BackgroundBilateral breast reconstruction utilising autologous free tissue transfer is a complex procedure with multiple options for donor tissue available. Autogenous breast reconstruction techniques have evolved over the last three decades to meet this goal. The aim of this study was to determine the outcomes of patients undergoing bilateral breast reconstruction with DIEAP, TRAM or SIEA flaps.Material/MethodsA prospective study was performed in our Interdisciplinary Breast Centre from July 2004 until December 2011 in 144 patients. Demographic information, diabetes mellitus type I status, tobacco use, tumor stage, primary/secondary reconstruction, operative technique, adjuvant therapy received, length of follow-up, and complications were evaluated. Complications were divided into donor site and recipient site. To investigate which risk factors were independently related to flap loss (complete or partial), multiple linear regression analysis was performed.ResultsThe study identified 144 patients who had bilateral breast reconstruction with DIEAP, TRAM or SIEA flaps. For all flaps (n=248), outcome included 98.4% survival and 0.7% vein microanastomosis revision. Recipient site complications included 1.6% complete flap loss, 0.8% fat necrosis, 2.9% partial skin loss/dehiscence flap necrosis and 2.0% haematoma rate. Donor site complications included 3.7% partial skin loss/dehiscence. There was evidence of abdominal bulges in TRAM patients (1.1%) but no hernias in any patients. BMI is a major determinant of flap loss (complete or partial) in these patients.ConclusionsThe primary goal of bilateral breast reconstruction is to provide a treatment option that can create a natural, symmetric breast mounds with minimal donor-site morbidity following bilateral mastectomies. These results support weight loss therapy prior to bilateral breast reconstruction.

Soft Tissue Correction of Craniofacial Microsomia and Progressive Hemifacial Atrophy

Moderate to severe soft tissue deficits can exist with craniofacial microsomia or progressive hemifacial atrophy. The authors reviewed the surgical correction of these defects, including serial autologous fat grafting and parascapular free tissue transfer. Recently treated patients at the Institute of Reconstructive Plastic Surgery at NYU Medical Center were identified. Patients with microvascular free flap underwent reconstruction with parascapular flaps. These flaps have been modified from previously reported inframammary extended circumflex scapular flaps. Demographic information, operative interventions, complications, and outcomes were reviewed and analyzed. The clinical outcomes of these patients were compared with previously reported patients who underwent serial autologous fat grafting. Five patients were recently treated with 7 parascapular flaps. The mean age of the patients at the time of parascapular flap reconstruction was 13.1 years. These were compared to those previously reported who have undergone serial autologous fat grafting. The mean number of procedures was less for the free tissue transfer cohort. There were no microvascular complications because all free flaps survived. One patient had wound dehiscence of the donor site managed with local wound care and healing by secondary intention. For patients undergoing multiple-stage reconstruction of craniofacial microsomia, serial fat grafting is a useful tool for soft tissue reconstruction. Alternatively, in those patients with isolated soft tissue hypoplasia, such as progressive hemifacial atrophy, microvascular free tissue transfer is a safe and efficient option.

Factors Affecting Surgical Wait Times for Breast Reconstruction

OBJECTIVETo examine factors that affect wait times for women seeking breast reconstruction at a Canadian academic centre.METHODSA retrospective audit of 57 women seeking breast reconstruction over a three-year period was completed. Comparisons of wait times were made considering the surgical pathology, timing of reconstruction (immediate versus delayed), urgency of pathology, method of reconstruction (implant versus autologous) and the number of surgeons involved. Specifically, the wait times from referral to specialist consultation, consultation to surgery, and referral to surgery were examined.RESULTSWomen with active cancer (ductal carcinoma in situ: 43 days, invasive cancer: 40 days) had shorter wait times compared with those who had no active cancer (benign/high risk: 242 days, previously treated cancer: 343 days) (P<0.05). Women seeking delayed reconstruction had longer wait times (359 days) from referral to surgery than women seeking immediate reconstruction (98 days) (P<0.0001). Women seeking reconstruction at the time of mastectomy, with benign/high-risk disease, waited longer (242 days) than those with ductal carcinoma in situ (43 days) or invasive cancer (40 days) (P<0.001). Wait times for autologous free tissue transfer (213 days) were not significantly longer compared with implant reconstruction (116 days) (P=0.27). Women with acute cancer experienced similar wait times for implant reconstruction (44 days) as for a free tissue transfer (56 days) (P=0.46). Women with no acute cancer had similar wait times for implant (239 days) as free tissue transfer (369 days) (P=0.25). Patients requiring only plastic surgeons involved in the reconstructive effort waited longer (one surgeon: 299 days, two surgeons: 550 days) than patients requiring either two plastic surgeons and one general surgeon (130 days) or one plastic surgeon and one general surgeon (82 days) (P<0.05). Although more coordination is required with three surgeons, this is frequently associated with a diagnosis of acute cancer and, therefore, wait times are shorter.

Factors affecting surgical wait times for breast reconstruction

To examine factors that affect wait times for women seeking breast reconstruction at a Canadian academic centre. A retrospective audit of 57 women seeking breast reconstruction over a three-year period was completed. Comparisons of wait times were made considering the surgical pathology, timing of reconstruction (immediate versus delayed), urgency of pathology, method of reconstruction (implant versus autologous) and the number of surgeons involved. Specifically, the wait times from referral to specialist consultation, consultation to surgery, and referral to surgery were examined. WOMEN WITH ACTIVE CANCER (DUCTAL CARCINOMA IN SITU: 43 days, invasive cancer: 40 days) had shorter wait times compared with those who had no active cancer (benign/high risk: 242 days, previously treated cancer: 343 days) (P<0.05). Women seeking delayed reconstruction had longer wait times (359 days) from referral to surgery than women seeking immediate reconstruction (98 days) (P<0.0001). Women seeking reconstruction at the time of mastectomy, with benign/high-risk disease, waited longer (242 days) than those with ductal carcinoma in situ (43 days) or invasive cancer (40 days) (P<0.001). Wait times for autologous free tissue transfer (213 days) were not significantly longer compared with implant reconstruction (116 days) (P=0.27). Women with acute cancer experienced similar wait times for implant reconstruction (44 days) as for a free tissue transfer (56 days) (P=0.46). Women with no acute cancer had similar wait times for implant (239 days) as free tissue transfer (369 days) (P=0.25). Patients requiring only plastic surgeons involved in the reconstructive effort waited longer (one surgeon: 299 days, two surgeons: 550 days) than patients requiring either two plastic surgeons and one general surgeon (130 days) or one plastic surgeon and one general surgeon (82 days) (P<0.05). Although more coordination is required with three surgeons, this is frequently associated with a diagnosis of acute cancer and, therefore, wait times are shorter.

The transverse myocutaneous gracilis flap: technical refinements

Autologous free tissue transfer is an ideal method for breast reconstruction. The deep inferior epigastric perforator (DIEP) flap is considered the gold-standard procedure worldwide. However, in selected patients this flap cannot be performed to achieve satisfactory outcomes. The transverse myocutaneous gracilis (TMG) flap is one of the most recent additions to the armamentarium of breast-reconstructive surgeons. This flap can provide adequate autologous tissue with a hidden scar. Since its description for breast reconstruction in 2004, no series have been published and its recognition is still lacking. The main criticism of this flap is the lack of volume that can be achieved and the potential for donor morbidity. We report upon a 2-year experience with the use of TMG flaps for breast reconstruction, assessing the potential indications and introducing some technical refinements in order to expand the role of this flap in breast reconstruction. Information regarding all TMG flaps performed in the period between January 2006 and December 2007 was prospectively collected. Indications and outcomes were reviewed. The surgical technique was revised and standardised to achieve a routine set-up. During the study period, 19 TMG flaps were performed in 12 patients (seven double procedures: five bilateral cases and two stacked flaps for unilateral breast reconstruction). One flap was lost 9 days postoperatively. Follow-up ranged from 6 months to 2 years. We detail our surgical technique and describe refinements to speed up flap harvest, increase flap volume, optimise flap inset and minimise donor-site complications. Although the DIEP flap is still our preferred choice for breast reconstruction, the TMG flap is suitable as a first-line option in small-to-moderate breasted women or as a second-line choice for larger-breasted women for whom the DIEP flap may not be the preferred choice. It is also a reliable salvage flap in cases of previous flap failure.

Risk Factors and Blood Flow in the Free Transverse Rectus Abdominis (TRAM) Flap

Mastectomy patients may have significant psychologic-related problems. Breast reconstruction provides in these cases substantial benefits in restoring body image and health-related quality of live. Autologous free tissue transfer is the treatment of choice due to excellent outcome. The purpose of this study was to elucidate the effect of the risk factors on the microcirculation and clinical outcome. In this prospective study, 21 patients with a free transverse rectus abdominis (TRAM) flap breast reconstruction were included. Patient demographics and flap characteristics were recorded. Blood flow was recorded in the central part (zone I) and the distal part (zone IV) of the flap with the laser Doppler flowmetry (LDF; Perimed). In this study, increased flap complications were seen in smokers when compared with nonsmokers (P < 0.000). LDF was higher in the older patient population (P = 0.008) in zone IV. Smoking, especially in combination with a high flap weight (HFW), revealed lower blood-flow values (P = 0.020) in zone IV. Other possible influencing risk factors such as a HFW and history of radio- and chemotherapy did not alter the microcirculation. Patients with smoking and a HFW did also show decreased blood flow but also more severe flap complications.Smoking, especially in patients with a HFW, impairs the free TRAM flap microcirculation in zone IV. In our opinion, these patients can still be included for reconstruction. However, extra care has to be taken during flap design to minimize disturbed wound healing.

Improving Outcomes in Bilateral Breast Reconstruction Using Autogenous Tissue

Bilateral breast reconstruction utilizing autologous free tissue transfer is a complex procedure with multiple options for donor tissue available. This study set out to compare the outcomes of patients undergoing bilateral breast reconstruction with muscle-sparing free TRAM flaps versus those undergoing bilateral reconstructions utilizing procedures which aim to minimize abdominal donor site morbidity in the form of deep inferior epigastric perforator (DIEP) or superficial inferior epigastric (SIEA) flaps. A retrospective review identified 31 patients and 62 free flaps for bilateral autologous breast reconstruction at our teaching institutions in Rochester, NY. Patients receiving procedures which aimed to minimize donor-site morbidity experienced a shorter length of hospital stay versus those patients undergoing bilateral free TRAM procedures (P = 0.0494 by t test and P = 0.0389 by parametric test). There was no significant difference in complication rates between these 2 groups. Other demographic and premorbid factors showed no difference between groups. Here, we demonstrate that bilateral autologous breast reconstruction with flaps which minimize donor site morbidity are a safe and effective option for bilateral reconstruction. Furthermore, patients who received bilateral breast reconstruction with abdominal wall sparing techniques (DIEP or SIEA flaps) had a significantly shorter length of hospital stay, with no significant difference in complication rates when compared with patients undergoing bilateral free TRAM procedures.

Reconstruction of complex oncologic chest wall defects: a 10-year experience.

The repair of complex chest wall defects presents a challenging problem for the reconstructive surgeon. Although the majority of such defects could be repaired with the use of local and regional musculocutaneous flaps, more complicated cases require increasingly sophisticated reconstructive techniques. This study reviews the experience at a single cancer center with chest wall reconstruction over a decade. A retrospective review was undertaken for each patient who underwent chest wall reconstruction from 1992 to 2002. Patient demographics and variables, including pathologic diagnosis, extent of resection, size of defect, method of reconstruction, and outcome were evaluated. There was a total of 113 patients, 88 females and 25 males. The average age was 58 years (range, 19-88 years). The most common diagnoses were breast cancer and sarcoma. The average area of the chest wall defect after resection was 266 cm. One hundred fifty-seven musculocutaneous or muscle flaps were performed for reconstruction of the chest wall. Eleven percent of patients underwent reconstruction with autologous free tissue transfer. One hundred six patients underwent a single operation. Seven patients required a second operation for salvage of a complication. In 19 cases (15%), more than 1 flap was used simultaneously to complete the reconstruction. Eighty-four percent of the patients achieved stable chest wall reconstruction with no complications. Seven patients (4%) had partial (>10%) flap loss. The most common remaining postoperative complications were delayed wound healing (3% of patients), infection (2.5%), and hematoma (2.5%). Immediate chest wall reconstruction is safe, reliable, and can most often be accomplished with 1 operation. A variety of flaps, both single and in combination, could be used to achieve definitive coverage of the chest wall after extirpative surgery. The reconstructive choice is dependent on factors such as size of the defect, location on the chest wall, arc of rotation of the flap, and availability of recipient vessels. Based on this single institutional experience over a decade, an algorithm to chest wall reconstruction is provided.