Rates Of Fat Necrosis Research Articles

Impact of Prior Ipsilateral Chest Wall Radiation on Pedicled TRAM Flap Breast Reconstruction

This study compares complication rates between transverse rectus abdominis myocutaneous (TRAM) flaps based on previously irradiated versus nonirradiated superior pedicles to assess the impact of prior ipsilateral chest wall radiation on pedicled TRAM flap breast reconstruction. A retrospective study of 302 consecutive TRAM flap reconstructions was performed; 76 TRAM flaps based on a previously irradiated superior epigastric pedicle were compared to 226 TRAM flaps based on a nonirradiated pedicle in medical comorbidities, oncologic data, and complications. Patients having undergone previous chest wall irradiation had a higher cancer stage, but demographic data were otherwise similar within the groups. Previous chest wall irradiation did not result in increased rate of flap loss, infection, and fat necrosis. However, there was a trend toward higher revision rate in the previously irradiated TRAM group. Previous radiation to the superior epigastric pedicle is not associated with a significant increase in flap complications and should be considered a viable modality for pedicled TRAM flap breast reconstruction.

Brachytherapy-based partial breast irradiation is associated with low rates of complications and excellent cosmesis

Recent retrospective, claims-based analyses have suggested a potential increased rate of toxicities associated with brachytherapy-based accelerated partial breast irradiation (APBI). The purpose of this analysis was to examine cosmesis and toxicity data from the prospective American Society of Breast Surgeons (ASBS) breast brachytherapy registry trial to compare to the findings from the claims analyses. The ASBS breast brachytherapy registry is a prospective nonblinded multi-institutional registry trial. Patients with Stage 0-II breast cancer undergoing breast conserving therapy were eligible. A total of 1665 patients were enrolled and 1449 treated between 2002 and 2004 with a median followup of 63 months. All patients were treated with the MammoSite (Hologic, Inc.) single-lumen device to deliver adjuvant APBI (34Gy in 3.4Gy fractions). The rate of excellent/good cosmesis was 90.6% at 84 months. The rate of a complication (symptomatic seroma, infection, fat necrosis, telangiectasias) at 1 year/any time point was 24.2%/38.5%, whereas the rate of noninfectious complications at 1 year/any time point was 14.8%/28.9%. The rate of symptomatic seroma, fat necrosis, infection, and telangiectasia at any time was 13.4%, 2.5%, 9.6%, and 13.0%, respectively. The final toxicity analysis from ASBS breast brachytherapy registry trial confirms the previously noted excellent cosmesis and toxicity profiles and fails to confirm retrospective claims analyses that have suggested higher rates of toxicity for brachytherapy-based APBI.

Fat Necrosis in Autologous Abdomen-Based Breast Reconstruction

Fat necrosis is a common and potentially exasperating complication of autologous breast reconstruction. The authors performed a systematic review of the English literature on autologous breast reconstruction to determine significant patient and surgical factors that are predictors of postoperative fat necrosis. A PubMed search using the terms "fat necrosis" and "breast reconstruction" was conducted. Articles were screened using predetermined inclusion and exclusion criteria. Data collected included patient characteristics, reconstructive techniques used, and the specific postoperative morbidity of interest. Patient cohorts were pooled, and the incidence of fat necrosis was calculated in the presence and absence of each risk factor. Chi-square analysis was applied, and p < 0.05 was considered statistically significant. Of 172 articles found, 70 met the inclusion criteria. The mean rate of fat necrosis was 11.3 percent. Deep inferior epigastric artery perforator flaps had the highest rate of fat necrosis (14.4 percent), followed by pedicled transverse rectus abdominis musculocutaneous (12.3 percent), superficial inferior epigastric artery (8.1 percent), and free transverse rectus abdominis musculocutaneous flaps (6.9 percent). Significant predictors of fat necrosis included obesity (p = 0.035), prereconstruction irradiation (p = 0.022), postreconstruction irradiation (p < 0.001), active smoking (p < 0.001), and abdominal scars (p = 0.05). Protective factors included supercharging (p < 0.001) and bilateral reconstruction (p = 0.01). Although there is little agreement in the literature regarding risk factors for fat necrosis, the authors were able to demonstrate several significant predictors by systematically analyzing 70 articles. Improved knowledge of the risk factors for fat necrosis can help surgeons provide improved preoperative counseling and take measures to minimize the risk of this complication.

Sub-Scarpal Fat Pad Thickness May Predict Perfusion Patterns In Abdominal Wall Flaps

INTRODUCTION: Abdominal wall flaps are routinely used in reconstructive procedures. Large caliber of the deep inferior epigastric vessels lends these flaps to good outcomes. Occasionally, these deep system perforators are of limited caliber, which may lead to either poor flap perfusion or venous congestion from poor drainage. The superficial inferior epigastric vessels are occasionally of sufficient size to allow for microvascular revascularization, however they have a higher rate of fat necrosis from poor perfusion. We designed this study to look at the relationship of the sub and supra-scarpal fat layers, to the number of deep system perforators and SIEV size METHODS: 14 abdominal/pelvic CTA s were examined of women (ages 34 -70). The CTAs were examined for number of perforators, SIEV size at 10 cm below the umbilicus, height of sub-scarpal fat pad and supra-scarpal fat pad at 10 cm below the umbilicus at the edge of rectus fascia. These data were gathered for each hemi abdomen giving 28 data points. RESULTS: The average supra-fascial height was 20.73 mm with a range of 4.3 to 50 mm. Average sub-fascial height was 7.06mm with a range of 2.0 to 14.5 mm. The average ratio of fat pads was 3.72 with a range of 1.13 to 11.5. Average SIEV diameter was 2.86 range (1.48-5.4mm). Average number of perforators was 3.4, range (1-7). Hemi-abdomens with supra-fascial fat greater than 21 mm in height had greater vein diameter 3.8 v 2.26mm but fewer perforators 3.1 v 3.6. Sub-fascial fat greater than 7mm had less perforators 2.3 v 4.1 and greater SIEV diameter 3.5 v 2.42mm. Neither an above or below average ratio of the fat layer heights had a difference in SIEV size (2.74 v 2.9 mm respectively). Above average ratios had 3.7 perforators verses 3.2 for below average ratios. CONCLUSION: A sub-scarpal fascial layer thicker than 7mm may indicate poorer abdominal flap perfusion off the deep inferior epigastric system as these hemi-abdomens had fewer perforators and larger SIEVs. This may serve to warn us during harvesting to preserve the superficial vessels in patients who fit this criteria.

Ischaemic time and fat necrosis in breast reconstruction with a free deep inferior epigastric perforator flap

Fat tissue can be injured by ischaemia in free flap surgeries, leading to the development of fat necrosis. The aim of this study was to evaluate the association between ischaemic time and fat necrosis in microsurgical breast reconstruction using a deep inferior epigastric perforator (DIEP) flap. A retrospective chart review was performed for patients who underwent breast reconstruction with free DIEP flaps between June 2009 and November 2011. Data regarding patient demographics, potential risk factors and fat necrosis were collected. Fat necrosis was diagnosed with ultrasound imaging between 3 and 6 months postoperatively. Univariate and multivariate analyses were used to assess the correlation between ischaemic time and fat necrosis rate. Receiver operating characteristic curve analysis was used to determine a cut-off value for the ischaemic time at which differential fat necrosis rates were maximal. A total of 86 patients were included in this study. The mean ischaemic time was 89 min, and fat necrosis was diagnosed in 15 patients (17.4%). A significant association was found between ischaemic time and fat necrosis rate on univariate (p-value=0.001) and multivariate analyses (p-value=0.017). The trend analysis of ischaemic time as a categorical variable relative to fat necrosis rate was also significant (p-value<0.001). A threshold value was found whereby patients with an ischaemic time longer than 99.5 min appeared to experience a significantly higher fat necrosis rate than patients with shorter times (p-value=0.005, odds ratio=9.449). Ischaemic time appears to be significantly associated with increased fat necrosis rate in breast reconstruction using DIEP flaps. A long ischaemia time may be a risk factor for the development of fat necrosis.

Intramuscular Perforator Dissection with the Hydrodissection Technique

Perforator flap breast reconstruction requires increased time for safe perforator dissection, especially the intramuscular course. We describe an adjunctive technique using hydrodissection to assist with the intramuscular perforator dissection. Hydrodissection techniques were used for perforator dissection in 45 consecutive patients (64 flaps) undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. These patients were compared with 39 patients (55 flaps) immediately prior to the use of this technique. The study time frame was between March 2008 and March 2010. Patient demographics, complications, and operative times were collected through an extensive chart review. There were no major differences in complications between groups; there were no flap losses encountered during this series, and fat necrosis rates were similar (9.4% with hydrodissection and 14.5% without, p = 0.41). Total operative time for bilateral reconstructions decreased by 59 minutes (p = 0.13) and 21 minutes (p = 0.57) for unilateral reconstructions with the utilization of hydrodissection, though this was not statistically significant. The use of hydrodissection to assist with intramuscular perforator vessel dissection is safe to perform, as there was no increase in complications. The procedures utilizing hydrodissection were faster, and surgeons using this technique found it easier to visualize the perforators and dissect through the intramuscular course.

Analysis of fat necrosis after adjuvant high-dose-rate interstitial brachytherapy for early stage breast cancer

To report the incidence and potential predictors of fat necrosis in women with early stage breast cancer treated with adjuvant high-dose-rate (HDR) multicatheter interstitial brachytherapy. Between 2003 and 2010, 238 treated breasts in 236 women were treated with accelerated partial breast irradiation using HDR interstitial brachytherapy. Selection criteria included patients with Tis-T2 tumors measuring ≤3cm, without nodal involvement, who underwent breast-conserving surgery. Ninety-nine percent of treatments were to a total dose of 34Gy. The presence and severity of fat necrosis were prospectively recorded during followup. Cosmesis was qualitatively scored in all patients. Cosmesis was quantitatively measured via the percentage breast retraction assessment in 151 cases. Median followup was 56 months. The crude rate of fat necrosis was 17.6%. The rate of symptomatic fat necrosis was 10.1%. In univariate analysis, acute breast infection and anthracycline-based chemotherapy, number of catheters, volume encompassed by the prescription isodose, volume encompassed by the 150% isodose (V150), volume encompassed by the 200% isodose, and integrated reference air kerma were significantly associated with fat necrosis. There was significant collinearity between the brachytherapy-related factors; of these, V150 was most predictive. In multivariate analysis, only V150 was significantly associated with fat necrosis. At 3 years, patients with fat necrosis were more likely to have a fair or poor cosmetic outcome and a larger percentage breast retraction assessment. Mammary fat necrosis is a common adverse event after breast-conserving surgery and HDR interstitial brachytherapy. Fat necrosis is associated with worse qualitative and quantitative cosmetic outcomes. Minimizing exposure volumes, such as V150, may decrease the incidence of fat necrosis and improve cosmesis.

The Impact of Preoperative CT Angiography on Breast Reconstruction With Abdominal Perforator Flaps

Because of the anatomic variability of the deep inferior epigastric artery, preoperative CT angiography (pCTA) has gained popularity for planning abdominal perforator flap breast reconstruction. This study evaluates how pCTA has affected preoperative planning, operative time, and outcome. We performed a retrospective study of abdominal free flap breast reconstruction at our institution over a 4-year period, with pCTA performed routinely after the first year. Operative time and outcomes were compared between procedures with and without pCTA. Incidental findings were recorded. Between 2006 and 2010, 102 abdominal perforator flap surgeries were performed on 69 patients; of whom, 51 patients had pCTA and 18 did not. pCTA changed preoperative planning in 50% of cases by identifying the best perforator in unilateral cases or perforators with long intramuscular course. Preoperative plan based on pCTA corresponded to operative procedures in 89% of cases. The sensitivity and positive predictive value of pCTA to localize perforators were 79% and 92%, respectively. Operative time was significantly reduced with pCTA for both unilateral (636 vs. 496 minutes, P = 0.017) and bilateral cases (746 vs. 629 minutes, P = 0.05). Rates of fat necrosis, partial flap necrosis, and complete flap loss were comparable between the 2 groups. Incidentalomas were found in 36% of patients. pCTA appears to reduce operative time by minimizing time spent identifying perforators, assisting in side selection for unilateral reconstruction, and optimizing planning when a long intramuscular course is identified. The effect of a learning curve cannot be excluded and is the chief limitation of this study.

Fat necrosis in women with early-stage breast cancer treated with accelerated partial breast irradiation (APBI) using interstitial brachytherapy

PurposeTo report the incidence of clinical, pathological and radiological fat necrosis (FN) in women treated with accelerated partial breast irradiation (APBI) using interstitial brachytherapy (BRT) for early-stage breast cancer and to study certain variables associated with it. Methods and materialsBetween May 2000 and August 2008, 171 women were treated with APBI using high dose rate (HDR) BRT. Patients were treated to a dose of 34Gy/10 fractions/1week with two fractions/day after intraoperative/postoperative placement of catheters. ResultsAt a median follow up of 48months (SD: 28) 20 women developed FN with median time to detection being 24months (range: 4–62months, SD: 20). Actuarial 5 and 7year FN rate was 18% and 23%, respectively. Grade 1 FN was seen in 4, grade 2 in 8 and grade 4 in 8 women. Additional investigations such as aspiration/biopsy were done in 9 patients. Volume of excision was the only significant factor affecting FN (p=0.04). ConclusionsActuarial FN rate of 18% at 5years in our study was comparable to other reported series of FN. Median time of detection of FN was 24months. Higher volume of excision resulted in an increased incidence of fat necrosis.

A safe approach to sparing the rectus muscle in abdominal-based microvascular breast reconstruction—TRAM, MS-TRAM, DIEP or SIEA?

There has been an international drive towards the use of abdominal-based perforator (deep inferior epigastric perforator (DIEP) or superficial inferior epigastric artery (SIEA)) flaps for breast reconstruction as they provide the ideal tissue whilst minimizing donor site morbidity, post-operative pain and recovery times. Ultimately, what is desired is a safe and reliable reconstruction. We retrospectively reviewed 245 consecutive abdominal-based free flaps performed by three surgeons at a single institution between January 2002 and March 2008. Primary breast reconstructions were planned as DIEPs, but a safe, flexible approach to flap selection was adopted with the most appropriate flap performed depending on the perforator anatomy at the time of surgery. Chest wall resurfacing procedures for extensive recurrent disease, inflammatory breast carcinoma or following radionecrosis were planned as transverse rectus abdominis myocutaneous (TRAM) flaps. The incidence of flap complications was compared including total and partial flap loss, returns to operating room, seroma, abdominal hernia/bulge, fat necrosis and delayed wound healing. Patient age, body mass index (BMI), smoking status, co-morbidity and pre- and post-operative radiotherapy were recorded. Two hundred patients, mean age 48 years (range, 26–74 years), underwent a total of 245 abdominal-based microvascular breast reconstructions. Twelve salvage TRAM flaps were performed for chest wall resurfacing. Of the remaining 233 flaps, 151 (65%) were immediate and 82 (35%) were delayed reconstructions. Flaps included 171 DIEPs, 38 muscle-sparing (MS)-TRAMs, 2 TRAMs and 22 SIEA flaps. Of the 233 reconstructions, 39 flaps (16.7%) in 31 patients received radiotherapy. Mean follow-up was 2.6 years. There were three (1.3%) complete flap losses and three (1.3%) partial flap losses. Rates of fat necrosis were 3.0% and abdominal hernia/bulge 1.7%. We present an algorithm to aid decision-making in autologous breast reconstruction that reflects our safe flexible approach. We have achieved excellent success rates in autologous breast reconstruction and conclude that in order to minimize complications, a safe flexible approach towards muscle harvest must be maintained in our drive to use perforator flaps.

Perfusion-Related Complications Are Similar for DIEP and Muscle-Sparing Free TRAM Flaps Harvested on Medial or Lateral Deep Inferior Epigastric Artery Branch Perforators for Breast Reconstruction

Anatomical studies suggest that the deep inferior epigastric artery (DIEA) medial branch perfuses more tissue across the midline than the lateral branch. The authors hypothesized that unilateral deep inferior epigastric perforator (DIEP) and muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flaps based on medial branch perforators would have fewer perfusion-related complications. The authors evaluated consecutive DIEP or muscle-sparing TRAM free flaps definitively harvested from a single DIEA branch. Flaps were grouped by tissue volume (hemiflaps, cross-midline flaps, or total flaps). Primary outcome measures were fat necrosis and partial flap necrosis. Logistic regression was used to evaluate the association between patient and reconstruction characteristics and outcomes. There were 228 patients, with 120 medial (52.6 percent) and 108 lateral (47.4 percent) branch flaps. Mean follow-up was 33.2 months. Cross-midline flaps (79.8 percent) were the most common design. Medial and lateral branch flaps had similar rates of fat necrosis (8.3 percent and 13.0 percent, respectively; p = 0.26) and partial flap necrosis (3.3 percent and 2.8 percent, respectively; p = 1.0). There was no difference in the incidence of fat necrosis between DIEP and muscle-sparing free TRAM flaps (10.2 percent and 11.3 percent, respectively; p = 0.81) or in partial necrosis (3.2 percent and 2.8 percent, respectively; p = 1.0). Medial and lateral branch flap perfusion-related complications were also similar among the flap volume classifications. The authors suggest that surgeons base their decisions regarding DIEA branch harvest on the clinical assessment of perforator perfusion quality rather than relying on the theoretical benefit of medial branch perforator harvest. Therapeutic, III.

Toxicity and cosmesis outcomes after single fraction partial breast irradiation in early stage breast cancer

BackgroundTo report the clinical outcome after a Single Shot 3D-CRT PBI (SSPBI) in breast cancer patients after conservative surgery (ClinicalTrials.gov Identifier: NCT01316328).MethodsA dose of 18Gy (in the first 4 patients) and 21Gy (in the remaining 60 patients) was prescribed in a single session and delivered to the index area (i.e. the area of breast including the primary tumor bed and the surrounding tissue) using 3D-CRT with patients in prone position. Acute and late toxicity was assessed using the National Cancer Institute's CTC for Adverse Events. Cosmesis was defined based on modified Harvard criteria. Differences between dosimetric or clinical parameters of patients with/without G2 or more late toxicity or unsatisfactory (poor or fair) cosmetic outcome were evaluated with the Mann-Whitney test. Odds ratios and 95% confidence interval were calculated for cosmesis and fibrosis. Univariate and multivariate analyses(UVA/MVA) were used to determine covariates associated with an increase in fibrosis or fat necrosis rate.ResultsSixty four patients were enrolled. With a median follow-up of 3 years, G2 and G3 subcutaneous fibrosis was detected in 20(31%) and in 8(13%) patients, and ≥G2 fat necrosis was observed in 2(3%) patients. Good to excellent, fair and poor cosmesis was observed in 38(59%), 23(36%) and 3(5%) patients, respectively. Based on UVA, the breast volume receiving more than 21Gy (V21Gy) was found to be a predictor of the ≥G1 or ≥G2 fibrosis/fat necrosis. Based on MVA, V21Gy was confirmed as a predictor for ≥G1 fibrosis/fat necrosis, the results correlated as a trend for ≥G2. Cosmesis was correlated with whole breast (WB) mean dose (p = 0.030).ConclusionOur choice of a single dose of 21Gy significantly increased the treatment related toxicity. However, this should not discourage novel SSPBI approaches with lower equivalent doses.

Counterpoint: The device with the most dose modulation capacity

from the tissue by a balloon, modulation can be more finely tuned, with a trade-off that the V200 and V150 are higher than in the balloon devices. The SAVI is clearly neither a balloon device nor an interstitial implant, lacking some of the flexibility that makes interstitial the gold standard, but also not needing the requisite skill and experience demanded by the interstitial technique. Guidelines were developed empirically for the MammoSite (Hologic, Bedford, MA), and mandating balloon to skin distance of $5 mm was considered safe and have kept the toxicity acceptably low. However, although we know that the V150 and V200 guidelines established by MammoSite are safe, it does not mean that doses that exceed this in the absence of a balloon to displace the catheters from the normal tissue are unsafe. Nearly 2-year data on the SAVI catheter show acceptable toxicity with Grade 1 telangiectasias, hyperpigmentation, Grade 2 fibrosis, asymptomatic seromas, and asymptomatic fat necrosis rates of 1.9%, 9.8%, 1.9%, 2%, and 1.9%, respectively. Recurrence rate in this same population is acceptable at 1% as well (1).

Assessment of Advanced Age as a Risk Factor in Microvascular Breast Reconstruction

The population of elderly people is the fastest growing population in the United States. Because breast cancer typically affects the elderly population, surgeons will be performing more mastectomies in older patients. In this study, we evaluate the risks of microvascular breast reconstruction as a function of increasing age. Between July 2002 and September 2009, a retrospective analysis of 818 free-flap breast reconstructions was used to assess the risk of age on surgical outcomes. Patient comorbidities, the American Society of Anesthesiologists (ASA) classification, and length of hospital stay were used to assess the rates of complications among our age cohorts. Advanced age was not associated with increased complications (P > 0.69). ASA class was a significant predictor of overall complications (P < 0.03) as well as the rate of fat necrosis (P < 0.01) and hematoma (P < 0.001). Flap loss occurred in 1.5% of operations, but there was no difference among the various age groups. Previous surgery was associated with an increased risk of flap loss (P < 0.001), and hypertension also increased the risk of thrombosis (P < 0.04). There was no difference in mean length of hospital stay (4.27 days). Advanced age should not be considered a risk factor for microvascular breast reconstruction. Because ASA status did predict overall surgical complications, surgeons should consider the patients' overall health status in deciding whether to operate.

Reply: Relationship between Venous Congestion and Intraflap Venous Anatomy in DIEP Flaps Using Contrast-Enhanced Magnetic Resonance Angiography

Sir: We thank Drs. Chevray and Hatef for their thoughtful comments regarding our recently published article, “Relationship between Venous Congestion and Intraflap Venous Anatomy in DIEP Flaps Using Contrast-Enhanced Magnetic Resonance Angiography.”1 Our algorithm for deep inferior epigastric artery perforator (DIEP) flap harvest is similar to that of many large series. Our preference is for single-perforator DIEP flap harvest where there is an obvious dominant perforator whose adequate perfusion of the flap can be demonstrated intraoperatively; where this is not available, multiple perforators within the same intramuscular septum are included to allow sufficient arterial inflow and venous outflow for safe flap harvest. Where inclusion of multiple perforators is necessary but they lie in different intramuscular septae, we have a low threshold for harvesting a muscle-sparing transverse rectus abdominis musculocutaneous flap to avoid damage to the perforators during dissection, to maintain linking vessels between the perforators within the muscle, and for speed of harvest. This algorithm ensures that the flap is adequately perfused while minimizing donor-site morbidity by preserving muscle continuity and the motor nerves to the rectus, and we agree with the authors that inclusion of multiple perforators may be necessary where the anatomy is unfavorable. Our findings have suggested that where a single dominant perforator is not present, inclusion of multiple perforators may increase the chance of including a perforator that adequately drains the flap through a direct venous connection to the superficial inferior epigastric vein. We read the recently published article by Baumann et al. with great interest and hypothesize that this factor may partially explain the decreased rate of fat necrosis seen in multiperforator DIEP flaps in their study,2 although further research will be necessary to determine this. Mark V. Schaverien, M.R.C.S. Stephen J. McCulley, F.C.S.(S.A.)Plast., F.R.C.S.(Plast.) Department of Plastic Surgery Nottingham University Hospitals NHS Trust Nottingham, United Kingdom DISCLOSURE The authors have no financial interests with respect to the content of this communication or the article being discussed.

Influence of the recipient vessel on fat necrosis after breast reconstruction with a free transverse rectus abdominis myocutaneous flap

The effect of the selection of recipient vessels on the rate of fat necrosis after microsurgical reconstruction of the breast remains largely unknown. Our aim was to evaluate the incidence of fat necrosis after unilateral breast reconstruction with a free transverse rectus abdominis myocutaneous (TRAM) flap after anastomosis with either the internal mammary vessels or the thoracodorsal artery and vein. Consecutive patients who had unilateral reconstruction with a free, muscle-sparing TRAM flap at two tertiary care centres over a 6-year period were identified. The incidence of fat necrosis, defined as postoperative firmness of 1 cm or more persisting for 3 months or more after anastomosis was calculated. To control for the effect of potentially confounding variables (body mass index (BMI), history of preoperative or postoperative radiation, previous abdominal operation, smoking, and hospital) we did a matched-cohort study. A total of 840 unilateral muscle–sparing TRAM flaps were done using either the internal mammary (n = 109) or the thoracodorsal (n = 731) vessels. Evaluation of the entire cohort showed that the incidence of fat necrosis after the two anastomoses was 13 (12%) compared with 130 (18%), respectively (p = 0.17). To control for the effect of confounding variables, 98 patients who had internal mammary anastomoses were matched 1:1 with 98 patients who had thoracodorsal anastomoses. Pair-wise comparisons showed that the incidence of fat necrosis was significantly higher when the thoracodorsal vessels were used (29; 30%) compared to when the internal mammary vessels were used (12; 12%; p = 0.002). Our results showed that a higher rate of fat necrosis may be seen after muscle–sparing TRAM flap reconstruction after anastomosis to the thoracodorsal vessels than with the internal mammary vessels. The exact mechanisms of this association are unknown and warrant additional investigation.

5126 Ipsilateral breast tumour relapse: local recurrence versus new primary and the effect of whole breast radiotherapy on the rate of new primaries

To examine the incidence and clinical relevance of fat necrosis after accelerated partial-breast irradiation (PBI) using interstitial high-dose-rate brachytherapy (HDR-BT) in comparison with partial-breast electron irradiation (ELE) and whole-breast irradiation (WBI).Between 1998 and 2004, 258 early-stage breast cancer patients were randomized to receive 50 Gy WBI (n = 130) or PBI (n = 128). The latter consisted of either 7 × 5.2 Gy HDR-BT (n = 88) or 50 Gy ELE (n = 40). The incidence of fat necrosis, its impact on cosmetic outcome, accompanying radiologic features, and clinical symptoms were evaluated.The 4-year actuarial rate of fat necrosis was 31.1% for all patients, and 31.9%, 36.5%, and 17.7% after WBI, HDR-BT and ELE, respectively (pWBI/HDR-BT = 0.26; pWBI/ELE = 0.11; pELE/HDR-BT = 0.025). The respective rate of asymptomatic fat necrosis was 20.2%, 25.3%, and 10% of patients. The incidence of symptomatic fat necrosis was not significantly different after WBI (8.5%), HDR-BT (11.4%), and ELE (7.5%). Symptomatic fat necrosis was significantly associated with a worse cosmetic outcome, whereas asymptomatic fat necrosis was not. Fat necrosis was detectable with mammography and/or ultrasound in each case. Additional imaging examinations were required in 21% of cases and aspiration cytology in 42%.Asymptomatic fat necrosis is a common adverse event of breast-conserving therapy, having no significant clinical relevance in the majority of the cases. The incidence of both symptomatic and asymptomatic fat necrosis is similar after conventional WBI and accelerated partial-breast HDR-BT.

Free Transverse Rectus Abdominis Myocutaneous and Deep Inferior Epigastric Perforator Flaps for Breast Reconstruction

Free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps represent increasingly popular options for breast reconstruction. Although several retrospective, small-scale studies comparing these flaps have been published, most have failed to find a significant difference in flap complication rates or donor-site morbidity. We systematically reviewed the current literature, and subsequently pooled and analyzed data from included studies. Included studies reported flap complications and/or donor site morbidities for both flap types. Eight studies met the inclusionary criteria. For flap complications, there was a statistically significant difference between deep inferior epigastric perforator and free transverse rectus abdominis myocutaneous flaps in fat necrosis rates (25.5 +/- 0.49 vs. 11.3% +/- 0.41%, P < 0.001) and total necrosis rates (4.15 +/- 0.08 vs. 1.59% +/- 0.08%, P = 0.044). Partial necrosis rates were not statistically significant (3.54 +/- 0.07 vs. 1.60% +/- 0.07%, P = 0.057). For donor-site morbidity, there was no statistically significant difference in abdominal bulge (8.07 +/- 0.23 vs. 11.25% +/- 0.29%, P = 0.28). Multicenter, prospective studies are needed to further investigate differences between these flap options.

Complications of methylene blue dye infiltration for sentinel lymph node biopsy in breast cancer.

Abstract Abstract #4140 Background: Isosulfan blue has proven invaluable for sentinel lymph node identification in breast cancer. However, an intermittent supply shortage of this agent over the last few years has led to alternative usage of methylene blue. Worldwide, methylene blue is traditionally viewed as a less expensive and safer equivalent to isosulfan, with few reports of significant side effects. Its increased usage has led to anecdotal reports of local skin reactions. This study serves to review the rate of local complications observed following subareolar infiltration of methylene blue for sentinel lymph node identification in breast cancer staging.&amp;#x2028; Material Methods: This is a retrospective review of prospectively collected data in a university based surgical oncology practice. Records of all patients undergoing sentinel lymph node biopsy for breast cancer between August, 2007 and April, 2008 were reviewed (the switch from Isosulfan to Methylene blue was made in August of 2007). Local complication of fat necrosis was recorded. Tumor stage, neoadjuvant therapy, volume and dilution of dye used were analysed for association with fat necrosis.&amp;#x2028; Results: One hundred and three patients underwent sentinel node biopsy for breast cancer during the study period. Seven (7%) patients developed fat necrosis at the site of injection. The rate of injection site fat necrosis is associated with the volume of methylene blue [0% for &amp;lt;3cc and 7.2% for &amp;gt; 3cc (p = 0.0071)]; there was no association with tumor stage [3.2% for stage &amp;lt;1, 13.1% for stage 2 and 0% for stage 3 (p=0.343)] and tumor type [7.3% for invasive ductal cancer, 8.3% for invasive lobular and 0% for in situ cancer (p=1.000)].&amp;#x2028; Discussion: While methylene blue has typically been viewed as an inert agent for sentinel node biopsy, our study documents a 7% rate of fat necrosis. This is clinically significant in terms of painful symptoms and also the work-up that it may necessitate as a new mass in a breast cancer patient which has suspicious appearance on traditional imaging studies. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4140.

An Intraoperative Algorithm for Use of the SIEA Flap for Breast Reconstruction

The deep inferior epigastric perforator (DIEP) flap has been shown to be a reliable option for breast reconstruction. A further refinement in the transfer of lower abdominal tissue for breast reconstruction is the superficial inferior epigastric artery (SIEA) flap. A retrospective study was conducted to assess the reliability and examine the outcomes of SIEA flaps for breast reconstruction while considering an intraoperative algorithm established in this study. Ninety-nine SIEA flap reconstructions were performed in 82 patients in a 3(1/2)-year period. Patients were divided into two groups (before and after algorithm implementation), and their medical records were evaluated with respect to demographic information, tumor type, tobacco use, ischemic time, flap weight, and complications. Potential risk factors for complications were also assessed. Of the first 72 SIEA flaps, five were lost because of arterial thrombosis. All failed flaps had an SIEA diameter of less than 1.5 mm at the level of the lower abdominal incision. In February of 2004 (point T), the senior author (A.J.S.) implemented an intraoperative algorithm for flap selection that allowed use of the SIEA flap only when the SIEA diameter was 1.5 mm or greater than. In the remaining cases, a DIEP flap was used for breast reconstruction. After point T, 27 SIEA flap procedures were performed without any flap losses. Overall fat necrosis and partial flap loss rates were 1.0 and 5.1 percent, respectively. No abdominal bulges/hernias were observed. Only smoking at the time of surgery was associated with increased donor-site complications (p = 0.016). The intraoperative algorithm helped decrease flap and abdominal complication rates for the SIEA flap.