Free Abdominal Tissue Transfer Research Articles

Volume changes in the reconstructed breast over two years after free abdominal tissue transfer: Comparison of unipedicled versus bipedicled flaps

Volume changes in reconstructed flaps, particularly regarding symmetry, are an important consideration to improve long-term esthetic results in patients who undergo breast reconstruction. Asian patients with thin abdominal tissues tend to require bipedicled flaps, which provide a greater volume of abdominal tissue. We investigated volume changes in free abdominal flaps and the factors that may affect flap volume, particularly the number of pedicles. The study included all consecutive patients who underwent immediate unilateral breast reconstruction using free abdominal flaps between January 2016 and December 2018. The initial flap volume was calculated intraoperatively, and the postoperative flap volume was calculated using computed tomography or magnetic resonance imaging based on the Cavalieri principle. The study included 131 of 249 patients. Compared with the initial inset volume, the mean flap volumes at 1 and 2 years postoperatively decreased to 80.11% and 73.80%, respectively. The multivariable analysis of factors that affect flap volume showed a significant association with the flap inset ratio, radiation (P=.019,.040, respectively). Stratification based on the number of pedicles showed that the flap inset ratio was significantly negatively correlated with the postoperative flap volume change in unipedicled (P<.05) but not in bipedicled flaps. The flap volume decreased over time, and its change had a negative correlation with the flap inset ratio in the unipedicled group. Therefore, prediction of postoperative volume changes in various clinical situations is important before breast reconstruction.

Minimizing Postoperative Pain in Autologous Breast Reconstruction With the Omental Fat-Augmented Free Flap.

The omental fat-augmented free flap (O-FAFF) is a recently developed technique for autologous breast reconstruction. Our aim of the study is to evaluate the outcomes of our early case series. We assess the O-FAFF donor site morbidity in terms of postoperative pain, narcotic, and antiemetic use. A retrospective analysis of patients undergoing O-FAFF from 2019 to 2021 was performed. Patients were evaluated for demographic data, operative time, hospital course, and complications. Mean pain scores (1-10 scale) and narcotic pain medication use in oral morphine equivalents and doses of antiemetic medications during their hospital course were analyzed. We compared outcomes of our O-FAFF group with those of a control group of patients who underwent breast reconstruction with traditional free abdominal tissue transfer. A total of 14 patients underwent O-FAFF breast reconstruction, representing 23 breasts. Patients had an average age of 48.5 years (±2.3 years) and body mass index of 22.6 kg/m2 (±1.09 kg/m2). Average follow-up was 232 days (±51 days). Average mastectomy weight was 245.6 g (±30.2 g) and average O-FAFF weight was 271 g (±31.7 g). Average pain scores on postoperative day 1 (POD1), POD2, and POD3 were 3.1 (±0.28), 2.8 (±0.21), and 2.1 (±0.35), respectively. The average narcotic use by patients in oral morphine equivalents on POD1, POD2, and POD3 are 24.3 (±5.5), 21.9 (±4.6), and 6.2 (±2.4), respectively. Total narcotic use during hospital stay was 79.4 mg (±11.1 mg). Average pain scores and narcotic use are significantly lower when compared with a previously published cohort of patients who underwent autologous breast reconstruction with free abdominal tissue transfer (P < 0.05). Average antiemetic use was lower in the O-FAFF group compared with the control group: 3.5 versus 4.8 doses (P = 0.6). Hospital length of stay was 3.0 days (±0.0 days). No complications were noted (0%). Patients were universally satisfied with their reconstructive outcome (100%). The O-FAFF is proven to be a viable method of autologous breast reconstruction. Early series of patients undergoing O-FAFF reconstruction suggest a lower donor site morbidity as demonstrated by lower postoperative pain scores and lower consumptions of narcotic pain medications.

The effect of previous scar on breast reconstruction using abdominal flap: a retrospective analysis of 122 consecutive cases and a strategy to reduce complication rates.

Free abdominal tissue transfer is considered the gold standard for autologous breast reconstruction. However, many plastic surgeons are concerned about the theoretical risk of flap-related or donor-site complications associated with previous abdominal surgery. Also, studies have reported conflicting results in the literature due to difference in surgical strategies used in each study. This study analyzes the effect of prior incision on the complications and risk factors in our institution. In this retrospective cohort study, we analyzed a total of 122 patients who had undergone reconstructive surgery between March 2012 and February 2019. To assess the effect of prior incision, we divided all patients into a scar group (n=59) and a control group (n=63). Based on our operative approach, patient demographics and postoperative complications were analyzed. No significant differences were found between patients in the scar group and the control group in flap-related (13.3% vs. 16.4%, P=0.62) and donor-site complications (31.7% vs. 31.4%, P=0.67). In binary logistic regression modeling, only diabetes mellitus was significantly related with donor-site complications (P=0.030). This result suggested that previous abdominal scars are no longer a reluctant factor for breast reconstruction using an abdominal flap, when an appropriate flap design was used and the surgical techniques were tailored to each scar. In patients with vertical midline or subcostal scar, it requires careful preoperative planning with CT angiography and attentive follow-up are needed.

637 Free Abdominal Tissue Transfer and Utilization of the Umbilical Stalk for “Tubular” Reconstruction in Ear, Nose and Throat Defects: A Case Series

Abstract Introduction Head and neck defects, whether from burns or cancer resections, are complex and often require free flap reconstruction. Radial forearm and anterolateral thigh (ALT) flaps are commonly used due to their thin and versatile nature. However, abdominal based free tissue transfer is one valuable alternative that can cover large defects and may become a more appropriate option on the reconstructive ladder when the defect includes reconstruction of a tubular structure, such as the external auditory canal, a neck tracheostomy/stoma site or an external nasal opening. We present a novel utilization of abdominal free tissue transfer for coverage of large ear and scalp burn defects as well as neck and midface defects with usage of the umbilical stalk for tubed reconstruction. Methods Four patients presented for reconstruction: two patients had sustained large ear and scalp burns resulting in complete ear loss; one had a large neck defect resulting from recurrent cancer resection which necessitated a laryngectomy and stoma creation; and one patient had a large central face defect post-cancer resection. All four patients underwent an abdominal based free tissue transfer with reconstruction of the external auditory canal in the ear and scalp burns, stoma creation in the neck defect, and the external nasal opening in the central face defect, all utilizing the vascularized umbilical stalk for the tubed reconstruction. Results All patients recovered post-operatively without any reported complications such as tubular stenosis or contracture while maintaining umbilical stalk tubular patency. Conclusions Reconstruction of a tubed structure in head and neck defects, whether the external auditory meatus, an external nasal opening or a neck stoma post burn or cancer resection, can be a difficult and challenging operation fraught with potential complications. We present a novel method of reconstruction of large defects employing the use of the uniquely thin and vascularized umbilical stalk for tubular reconstruction.

Abdominal Wall Closure in Autologous Breast Reconstruction: Optimizing Aesthetics

Background: In contrast to cosmetic abdominoplasty, abdominal flap harvest can result a high degree of morbidity to the abdominal wall. Poor abdominal wall aesthetics that can result following free flap harvest including a high abdominal incision and post-operative hernia or bulge. We report our experience in optimizing cosmesis of the abdominal donor site with the use of a low incision, fascial plication and routine mesh reinforcement. Methods: A retrospective chart review of patients who underwent breast reconstruction with free abdominal tissue transfer from 2013-2017. Pedicled flaps and superior inferior epigastric artery flaps were excluded. Patient demographics, oncologic history, ablative and reconstructive surgery details focusing on abdominal closure techniques, and postoperative complications were evaluated. Results: 135 patients were identified who underwent 223 abdominal free flaps. 59 (26.5%) DIEP flaps were harvested, while 160 (71.7%) msTRAM and 4 (1.8%) fTRAM flaps were harvested (p<0.0001). 160 (71.7%) donor sites closures utilized polypropylene mesh, 9 (4.0%) were closed with biologic mesh and 3 (1.3%) closures used no mesh (p<0.0001). No hernias were observed (0%), while 6 abdominal bulges were identified (2.7%). There were no differences in the rates of abdominal bulge after donor site closure in the DIEP compared with msTRAM and fTRAM groups (3.4% vs 2.4%, p=0.7). No patients required mesh explantation during the study follow up period. Conclusion: To parallel cosmetic abdominoplasty, our authors advocate for a low incision, fascial plication and routine mesh reinforcement of the abdominal wall following free flap harvest.

Rectus abdominis free tissue transfer in lower extremity reconstruction: Long term follow up in 58 cases

This study evaluates the long-term results of rectus abdominis free-tissue transfer performed for lower extremity reconstruction. MethodsOver a period of 8 years 58 were available for long term follow-up. Indications for reconstruction included acute wounds with soft tissue defects, diabetic foot ulcers, and chronic osteomyelitis. ResultsAt a mean follow-up of 18 years, there were no major complications in the soft tissue defect coverage group except for one patient who continued to have recurrent folliculitis over the weight bearing heel area, which was treated by repeated debridement. Among the diabetic patients, two patients had recurrent ulcerations of the forefoot which were detected early and treated conservatively. In the osteomyelitis group, however, there were no recurrences of the foot infection. ConclusionsThe rectus abdominis free-tissue transfer provided an excellent method of soft tissue reconstruction with a very minimal long-term complication rate, and a very high rate of success in the treatment of diabetic foot ulcers and chronic osteomyelitis

Body mass index and abdominal wall thickness correlate with perforator caliber in free abdominal tissue transfer for breast reconstruction

IntroductionThe aim of the study was to investigate the relationship of BMI and abdominal wall thickness (AWT) with the diameter of the dominant deep inferior epigastric artery perforator (DIEP) as well as DIEA branching pattern in preoperatively performed computed tomography angiography (CTA). Patients and methodsWe conducted a retrospective study including all patients undergoing DIEP flap breast reconstruction with available CTAs from November 2013 to April 2018 in our department. The caliber-strongest DIEP was detected after passage of the rectus fascia as well as the superficial inferior epigastric artery (SIEA) and correlated with the AWT 5 cm above and below the umbilicus, lateral at the level of the umbilicus and at the level of the anterior superior iliac spine (ASIS), and with BMI. ResultsSeventy-seven patients met the inclusion criteria (age: 47.3 ± 8.9 years). We observed a significant relationship (p < 0.05) between DIEP (mean ∅ = 2.98 mm) and BMI (r = 0.353), the AWT supra- and infraumbilical (r ≥ 0.32), and the AWT lateral at the level of the umbilicus and ASIS (r ≥ 0.25). In addition, there was a highly significant correlation (p < 0.01) between SIEA and BMI (r = 0.389) and between the AWT lateral at the level of ASIS (r ≥ 0.41). ConclusionWe demonstrated a correlation of the diameter of the dominant DIEP with both BMI and AWT. Focusing on the diameter, in patients with a high AWT at the level of the ASIS, the SIEA, if present, may represent an alternative therapeutic option.

Hybrid breast reconstruction-the best of both worlds.

The two common reconstructive modalities following mastectomy include implant-based reconstruction and autologous reconstruction. While the majority of patients can be successfully treated with either one of these approaches, a subset of patients will benefit from a third reconstructive approach which combines implant-based and autologous reconstruction, i.e., hybrid reconstruction. Here, the authors discuss indications, surgical technique, results and additional reconstructive considerations of combining free abdominal tissue transfer with simultaneous implant placement. A reconstructive algorithm is presented.

Early Results of a Collaborative Multispecialty Mangled Extremity Algorithm for Acute Limb Salvage with Incorporation of Long Saphenous Arterial-Venous Loops for Free Flap Reconstruction in the Community Hospital Setting

Salvage of the mangled lower extremity is both technically challenging and time-consuming. It requires the collaborative efforts of multiple surgical specialties in addition to comprehensive post-traumatic wound follow-up. Our institution has integrated a dynamic effort among these specialists in the planning and facilitation of a successful limb salvage program with creation of a mangled extremity algorithm. An integral part of this process is the vascular inflow to prepare coverage for large tissue defects lacking adequate recipient targets. Use of a long saphenous arterial-venous (AV) loop has been cited, but minimal data are available with larger inflow vessels in the acute trauma setting. We describe our early experience using our protocol with AV loop creation with free flap reconstruction to salvage traumatic leg injuries. Since June 2016, eight patients admitted from the trauma service with mangled lower extremity injuries were identified and placed into the protocol. All eight patients sustained severe crush injuries with large tissue defects and insufficient distal runoff for healing but deemed salvageable by multispecialty assessment. Mangled Extremity Severity Scores were tabulated. Patients (seven male and one female) ranged in age from 21 to 44 years. Per protocol, repeated débridement was performed until successful sterilization of the wounds was accomplished. Eight long saphenous vein AV loops were anastomosed to the popliteal vessels for free flap reconstruction. All patients were followed up after AV loop creation for vascular complications and wound assessments. All eight patients had sterilization of the wounds with open reduction and internal fixation of the fracture site before vascular reconstruction. Mean débridement to surgical site sterilization was 4.3 washouts (range, 2-7). Successful popliteal AV loop creation with great saphenous vein was completed in 100% of patients without vascular complications or steal events (Fig 1). Free flap tissue transfers were completed using six rectus abdominis and two latissimus dorsi muscles within 7 days of the loop creation (Fig 2). Patency rate of the AV loop was 100% with eight successful flap transfers and 88% (seven of eight) amputation-free survival at 1 year. One flap did not survive because of recurrent bacterial infection of the hardware. The seven patients with successful procedures reached preoperative ambulatory status within 3 months after their final operation. Although this is a small cohort of patients, incorporation and use of our mangled extremity protocol to guide limb salvage proved successful in our early experience. Long-term data need to be complied to assess patency of the free flap transfer and quality of life outcomes.Fig 2Immediate postoperative rectus abdominis free flap tissue transfer to right lower extremity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Assessing value in breast reconstruction: A systematic review of cost-effectiveness studies

Breast reconstruction is one of the most common procedures performed by plastic surgeons and is achieved through various choices in both technology and method. Cost-effectiveness analyses are increasingly important in assessing differences in value between treatment options, which is relevant in a world of confined resources. A thorough evaluation of the cost-effectiveness literature can assist surgeons and health systems evaluate high-value care models. A systematic review of PubMed, Web of Science, and the Cost-Effectiveness Analysis Registry was conducted. Two reviewers independently evaluated all publications up until August 17, 2017. After removal of duplicates, 1996 records were screened, from which 53 studies underwent full text review. All the 13 studies included for final analysis mention an incremental cost-effectiveness ratio. Five studies evaluated the cost-effectiveness of technologies including acellular dermal matrix (ADM) in staged prosthetic reconstruction, ADM in direct-to-implant (DTI) reconstruction, preoperative computed tomography angiography in autologous reconstruction, indocyanine green dye angiography in evaluating anastomotic patency, and abdominal mesh reinforcement in abdominal tissue transfer. The remaining eight studies evaluated the cost-effectiveness of different reconstruction methods. Cost-effective strategies included free vs. pedicled abdominal tissue transfer, DTI vs. staged prosthetic reconstruction, and fascia-sparing variants of free abdominal tissue transfer. Current evidence demonstrates multiple cost-effective technologies and methods in accomplishing successful breast reconstruction. Plastic surgeons should be well informed of such economic models when engaging payers and policymakers in discussions regarding high-value breast reconstruction.

Immediate autologous breast reconstruction after neoadjuvant chemoradiotherapy for breast cancer: initial results of the first 29 patients.

Breast reconstruction after mastectomy in the treatment of locally advanced breast cancer is often done in stages and before radiotherapy. We have previously published an algorithm for immediate free autologous reconstruction after neoadjuvant chemotherapy and preoperative radiotherapy. This protocol was designed to provide a shorter and simpler reconstructive path whilst improving cosmesis and maintaining oncological efficiency. A total of 29 patients were included and underwent surgery for 30 cancers by the first author between 2010 and September 2015. Data were prospectively entered into a database and analysed for tumour size, chemotherapeutic response, lymph node involvement, surgical complications and tumour recurrence. The mean age was 55 ± 7 years. Eighty percent of patients had either a partial or complete chemotherapeutic response defined as >25% decrease in tumour size. Twenty-eight patients had free abdominal tissue transfer. One patient was excluded due to advanced disease. There were no take-backs due to microsurgical issues. One patient was reoperated on for a haematoma. Four patients had recurrent cancer during follow-up, three of whom are deceased. Many, but not all, breast reconstructive surgeons consider autologous reconstruction as the 'gold' standard in the presence of radiotherapy. Rearranging the order of radiotherapy and surgery means operating in a recently irradiated field. We believe the surgical challenges are outweighed by a shorter and simpler reconstructive journey that additionally results in a better cosmesis. It is possible to perform immediate free autologous reconstruction after neoadjuvant chemotherapy and preoperative radiotherapy with excellent results and at least equivalent oncological efficacy.

Mapping the superficial inferior epigastric system and its connection to the deep system: An MRA analysis

The superficial inferior epigastric vasculature plays a critical role in free abdominal tissue transfer. However, its anatomic variations are incompletely characterized. An investigation was conducted on the preoperative imaging of patients undergoing free-flap breast reconstruction by a single surgeon between 2008 and 2013. This study included patients who underwent abdominal magnetic resonance angiogram (MRA). A coordinate system was used to draw the main trunk and primary branches from each patient's superficial inferior epigastric system. Each hemiabdomen's branching pattern was categorized as simple, complex, or absent. The number of superficial-to-deep inferior epigastric connections and the presence or absence of a superficial system crossing the midline were recorded. Interrater reliability was assessed for two raters. This analysis included 53 patients (106 hemiabdomens). A total of 80 (75%) hemiabdomens were categorized as having simple and 10 (9%) as complex branching patterns. A total of 16 (15%) hemiabdomens had no identifiable vessels. At least one superficial-to-deep connection was found among 89 hemiabdomens (84%). Superficial systems crossing the midline were found in 14 patients (26%). Our findings support the high degree of anatomic variation in the superficial inferior epigastric system, including a significant number of patients lacking superficial-to-deep connections and bilaterally communicating systems. These variations may be identified on preoperative MRA.

15. Implications of incidental metastases to internal mammary lymph nodes in breast cancer patients undergoing free abdominal tissue transfer breast reconstruction

15. Implications of incidental metastases to internal mammary lymph nodes in breast cancer patients undergoing free abdominal tissue transfer breast reconstruction

The number of operations required for completing breast reconstruction.

Background:Breast reconstruction often requires multiple surgeries, which demands additional expense and time and is often contrary to the patient’s expectation. The aim of this study was to review the number of operations that were needed for completion of breast reconstruction and to determine patient and clinical factors that influenced this number.Methods:We retrospectively reviewed the medical records of 254 cases of breast reconstructions (in 185 patients) that were performed between February 2005 and August 2009. We investigated the numbers of operations that were performed for individual case of breast reconstruction and analyzed the influence of variable factors. The purpose of the additional operations was also analyzed.Results:The mean number of operations per breast was 2.37 (range, 1–9). The mean number of operations for mound creation was 2.24. Factors associated with an increased number of operation were use of an implant, contralateral symmetrization, complications, and nipple reconstruction. Considering the reconstruction method, either the use of a primary implant or the use of free abdominal tissue transfer demonstrated fewer surgeries than the use of an expander implant, and the number of operations using free transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flaps was less than the number of operations using pedicled transverse rectus abdominis musculocutaneous flaps.Conclusions:These data will aid in planning breast reconstruction surgery and will enable patients to be more informed regarding the likelihood of multiple surgeries.

The latissimus dorsi, pectoralis minor, and rectus abdominis free flaps for dynamic reconstruction of the paralyzed face

The use of free tissue for dynamic reconstruction of the paralyzed face has allowed for the development of novel flaps aimed at maximizing the functional and cosmetic results. While the gracilis free-tissue transfer is highly popularized and well described, other donor sites are available for versatile pedicle length and soft-tissue adjuncts with minimal donor site morbidity. This article's aim is describe the surgical technique of other free-tissue options for dynamic reconstruction of the paralyzed face, specifically the latissimus dorsi, the pectoralis minor, and the rectus abdominis free-tissue transfer.

Recipient Vessel Selection in Immediate Breast Reconstruction with Free Abdominal Tissue Transfer after Nipple-Sparing Mastectomy

BackgroundNipple-sparing mastectomy (NSM) is gaining popularity due to its superior aesthetic results. When reconstructing the breast with free abdominal tissue transfer, we must readdress the recipient vessel, because NSM can cause difficulty in access to the chest vessel.MethodsBetween June 2006 and March 2011, a total of 92 women underwent NSM with free abdominal tissue transfer. A lateral oblique incision was used for the nipple-sparing mastectomy. For recipient vessels, the internal mammary vessels were chosen if the mastectomy flap did not block access to the vessels. If it did, the thoracodorsal vessels were used. Age, degree of breast ptosis, weight of the mastectomy specimen, and related complications of the internal mammary vessel group and the thoracodorsal vessel group were compared.ResultsThoracodorsal vessels were used as recipient vessels in 59 cases, and internal mammary vessels in 33 cases including 4 cases with perforators of the internal mammary vessels. Breast reconstruction was successful in all cases except one case involving a total flap failure, which was replaced by a silicone gel implant. The internal mammary group and the thoracodorsal group were similar in terms of age, height, breast weight, and degree of ptosis. The flap related complications such as flap loss and take-back operation rates were not significantly different between the two groups. The rate of nipple necrosis was higher in the internal mammary group.ConclusionsThe thoracodorsal vessels could produce comparable outcomes in breast reconstruction after nipple-sparing mastectomies. If access to internal mammary vessels is difficult, the thoracodorsal vessel can be a better choice.

Autologous Latissimus Dorsi Flap as an Alternative to Free Abdomen-Based Flap for Breast Reconstruction in the Morbidly Obese

Sir:FigureIt was with great pleasure that we read the article by Jandali et al.1 entitled “Breast Reconstruction with Free Tissue Transfer from the Abdomen in the Morbidly Obese,” and we congratulate the authors on their interesting study. Breast reconstruction in overweight and obese patients represents a difficult challenge for plastic surgeons, who remain guarded over selecting these patients for free abdominal tissue transfer. Although higher complication rates have been reported by Jandali et al. in these patients, obesity does not constitute an automatic contraindication for free abdomen-based flap breast reconstruction (Fig. 1).Fig. 1: Preoperative and postoperative views of a 43-year-old patient, with a body mass index of 40.9, who underwent delayed left breast reconstruction with an autologous latissimus dorsi flap and contralateral reduction mammaplasty. A significant volume of fat was included in the autologous latissimus dorsi flap, which gave bulk to the breast without the aid of a prosthesis, producing a natural reconstructed breast.Recently, Seidenstuecker et al.2 investigated the relevance of comorbid conditions such as age 65 years or older, active smoking, and body mass index greater than 30 on free flap breast reconstruction, and they similarly reported higher total flap loss and delayed donor-site wound healing in obese patients. We would like to take the opportunity to discuss the indications and advantages of the autologous latissimus dorsi flap breast reconstruction in morbidly obese patients, which may present a valid option for these patients. The autologous latissimus dorsi flap is a well-vascularized flap that is safe, versatile, and reliable, with a very high success rate.3 For these reasons, it is also suitable for high-risk patients, such as obese patients, smokers, diabetics, and patients of advanced age. Compared with the standard latissimus dorsi flap with implant, the autologous latissimus dorsi flap is capable of delivering a significant volume of fat, which gives bulk to the breast without the aid of a prosthesis. If the flap volume is then not sufficient, it can be improved by fat injection (lipomodeling). Nevertheless, the autologous latissimus dorsi flap is a major operation, it is less involved than free tissue transfer, and it requires no microsurgical skills or any intensive postoperative flap monitoring as in free flaps. Transfer of the latissimus dorsi muscle minimally impairs shoulder function, inducing little detectable change in the range of motion and muscular strength, and functional sequelae are minimized by compensation by means of the teres major muscle.4 It is well known that donor-site seroma is a drawback of this technique; however, numerous treatments and preventive measures have been described to reduce this problem. These include avoidance of electrocautery for dissection, the use of quilting sutures, fibrin sealant, endoscopic harvest, long-term distant exit drainage, and pressure dressings.5,6 In our experience, quilting stitches combined with fibrin sealant significantly reduced postoperative seroma. Despite this drawback, we believe that the autologous latissimus dorsi flap is a good option in obese patients despite the relatively high incidence of back seroma, which is for us a minor complication, treatable on an outpatient basis, and with a lower impact compared with a total flap loss or an abdominal bulge, weakness, or hernia following an abdominal flap. Stefano Bonomi, M.D. Andrè Salval, M.D. Fernanda Settembrini, M.D. Chiara Gregorelli, M.D. Gaetano Musumarra, M.D. Department of Plastic Reconstructive Surgery and Burn Unit Center, Ospedale Niguarda Ca' Granda, Milan, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.

Two-stage delayed breast reconstruction with an expander and free abdominal tissue transfer: Outcomes of 65 consecutive cases by a single surgeon

Traditional single-stage breast reconstruction with autologous tissue leaves an obvious skin island. Alternatively, a staged reconstruction with the creation of a skin envelope with a tissue expander which is then replaced with a de-epithelialised flap, leaves a breast with the original mastectomy scar and no skin island. Consecutive patients who underwent the two-stage reconstruction between 2004 and 2010 were included in the study. Data were collected retrospectively on patient demographics, adjuvant treatments, surgical procedures and outcomes. A total of 65 patients who initially had a non-skin sparing mastectomy underwent two-stage breast reconstruction, of which the majority were delayed (n=63, 95%) and unilateral (n=64, 98.5%). Each patient was individually assessed for their suitability for the two-stage reconstruction. In 89% (n=58) of cases, the expander was inserted in a subcutaneous pocket, while in the remaining a subpectoral pocket was elected. After the first stage, seven complications were recorded (10.7%), notably three expander extrusions, three seromas and one implant infection. Of the 65 patients, 63 proceeded to the second stage of reconstruction with 38 transverse rectus abdominis myocutaneous (TRAM) (60%), 12 superficial inferior epigastric artery (SIEA) (19%), and 13 deep inferior epigastric perforator (DIEP) (21%) flaps. Mean follow-up time since the completion of the second stage was 42 months (range 6-80 months), with complete flap loss recorded in 4.6% and minor fat necrosis in 9.5% of cases. The two-stage breast reconstruction using skin expansion and autologous tissue transfer eliminates the need for a visible skin paddle and produces a sensate breast with a more natural-looking breast mound.

Surgical Treatment of an Elbow Hygroma Utilizing Microvascular Free Muscle Transfer in a Newfoundland

Microvascular free muscle transfer utilizing the rectus abdominis muscle, in combination with a mesh skin graft and transarticular external fixator, were used following the surgical excision of an elbow hygroma in a Newfoundland dog. Postoperatively, the dog did well with minimal complications and has yet to have a recurrence 10 months following surgery. This report describes the utility and successful use of the rectus abdominis free tissue transfer in the surgical correction of a difficult elbow hygroma in the dog.

Rectus Abdominis Free Muscle Flap for Reconstruction in Nine Dogs

To evaluate the clinical use and outcome of a rectus abdominis microvascular free flap for wound closure in dogs. Retrospective case series. Dogs (n=9) with complex extremity or oral wounds. Medical records (2002-2006) of dogs that had a rectus abdominis free tissue transfer to close an extremity or oral wound were reviewed. Nine dogs were identified: 5 had distal extremity wounds, 3 had oral palatal defects, and 1 had a large hygroma excised. A rectus abdominis free tissue transfer with a caudal epigastric vascular pedicle was successfully used for management of these wounds. No major complications occurred with the donor site and a good cosmetic and functional outcome occurred in all dogs. The rectus abdominis is a versatile muscle that can be used for reconstructing cutaneous and oral defects with repeatable success. Free tissue transfer of the rectus abdominis muscle is a clinically useful technique for closure of a variety of difficult soft tissue wounds.