Free Rectus Abdominis Myocutaneous Flap Research Articles

Impact of smoking on donor site following rectus flap harvest for head and neck reconstruction

ObjectivesThe rectus abdominis myocutaneous free flap has been widely used as a reconstructive option in head and neck reconstruction with great success. Challenging the popular assumption, this study sought to examine the effects of smoking on donor site complications in this population. MethodsMulti-institution retrospective study of 103 patients (50 active smokers, 28 former and 25 never smoked). ResultsOverall complication rate was 14.5 %. Hernia rate 4.8 %, evisceration 0 %, dehiscence 2.9 %, infection 6.7 %. Smoking history did not significantlly influence complication rates (chi square test, p = 0.33). Abdominal wall closure technique also did not influence the complication rate (chi square test, p = 0.58). ConclusionsThe rectus abdomonis myocutaneous free flap has an acceptable complication rate that does not appear to be influenced by smoking history. While patients should be counseled regarding smoking cessation, smoking habits should not delay treatment nor obviate consideration of rectus flap utilization.

Analysis of the Chest Wall Reconstruction Methods after Malignant Tumor Resection.

Background The chest wall defects can be caused by various reasons. In the case of malignant tumor resection of the chest wall, it is essential to reconstruct the chest wall to cover the vital tissue and restore the pulmonary function with prevention of paradoxical motion. With our experience, we analyzed and evaluated the results and complications of the chest wall reconstructions followed by malignant tumor resection. Methods From 2013 to 2022, we reviewed a medical record of patients who received chest reconstruction due to chest wall malignant tumor resection. The following data were retrieved: patients' demographic data, tumor type, type of operation, method of chest wall reconstruction of the soft and skeletal tissue and complications. Results There were seven males and six female patients. The causes of reconstruction were 12 primary tumors and one metastatic carcinoma. The pathological types were seven sarcomas, three invasive breast carcinoma, and three squamous cell carcinomas. The skeletal reconstruction was performed in six patients. The series of the flap were eight pedicled latissimus dorsi (LD) myocutaneous flaps, two pectoralis major myocutaneous flap, two vertical rectus abdominis myocutaneous free flap, and one LD free flap. Among all the cases, only one staged reconstruction and successful reconstruction without flail chest. Most of the complications were atelectasis. Conclusion In the case of accompanying multiple ribs and sternal defect, skeletal reconstruction would need skeletal reconstruction to prevent paradoxical chest wall motion. The flap for soft tissue defect be selected according to defect size and location of chest wall. With our experience, we recommend the reconstruction algorithm for chest wall defect due to malignant tumor resection.

Reconstruction of Complete Bilateral Maxillary Defects With Free Flaps.

Reconstruction of complete bilateral maxillary defects (CBMDs) can be challenging due to the extensive loss of bone and soft tissues. This is a retrospective case series of 46 consecutive patients with CBMDs that were reconstructed with different micro-vascular free flaps. The authors aimed to evaluate the surgical outcomes and discuss the different reconstruction options in this case series. Thirty-six patients underwent reconstruction following ablation surgery for malignant tumors, 6 for benign tumors, 3 patients were treated for osteomyelitis, and 1 patient underwent free flap reconstruction for posttraumatic defects. Free fibula flap (n = 26) is the most commonly used reconstruction method in this case series, which was used in all defect types. This is followed by anterolateral thigh flap (n = 10), 5 rectus abdominis myocutaneous free flap, 3 radial forearm free flaps, and 2 composite free flaps. In this series, 44 free flaps survived, whereas only 2 flaps were lost. All patients could resume a soft diet postoperatively. Reconstruction of CBMDs with vascularized free flaps is a safe and reliable procedure.

Reconstruction of Extensive Oromandibular Defect With Simultaneous Dual Free Flap Transfer

Complex oromandibular defects are usually too extensive or complex to be reconstructed with a single free flap. In this situation, dual free flaps can provide an adequate amount of tissues and a three-dimensional structure for large composite defects.In our institution, a total of 6 patients underwent immediate dual free-flap reconstruction between December 2013 and February 2020. In all patients, oromandibular defects were reconstructed with a combination of a fibula free flap and a vertical rectus abdominis myocutaneous, anterolateral thigh, or radial forearm free flap. All 6 patients showed tolerable flap status without any major complications, and could transit a diet from a dysphagia diet to a general diet on the final visit. Dual free flaps can be considered an optimal reconstructive option with favorable functional and aesthetic outcomes for complex oromandibular defects involving the bone, oral lining, external skin, or soft tissue.

Free rectus abdominis myocutaneous flap for the reconstruction of major and complex defects in the craniofacial regions after ablation of advanced sinonasal carcinomas

Objective: To explore the method and plausibility of using free rectus abdominis flap (FRAF) to reconstruct the major and complex defects in the craniofacial regions after ablation of advanced sinonasal carcinoma. Methods: From 2007 to 2018 at No. 980 Hospital of Joint Logistic Supportive Force of People's Liberation Army of China, 13 patients with advanced carcinoma of nasal cavity and paranasal sinuses, including 11 males and 2 females, aged from 33 to 67 years, were treated with FRAF to repair the invasion of skull base, face and orbit. Based on adequate and meticulous preoperative evaluations on patients and tumors, complete resection of tumor bulks was performed. According to the sites, characters and extents of the defects, FRAF was introduced in different ways into reconstruction of major and complex defects in the craniofacial regions after resection of advanced sinonasal carcinomas, restoring the structure and contour of the craniofacial region. Results: Complete resection of tumors was achieved in all cases. For repairing the major and complex defects resulted from tumor ablation, FRAF graft was conducted in 13 patients with advanced sinonasal carcinomas. The recipient vessels were facial artery and vein in 9 cases, superficial temporal artery and vein in 4 cases. Vascular bridging with the external jugular vein was carried out in 2 cases who underwent submandibular neck dissections, in which facial artery and vein were used as recipient vessels. Free fibular flap was used along with FRAF in a case undergone bilateral maxillectomy. Pedicled galea capitis and periosteal flap were applied simultaneously in 3 cases with dura defects at the skullbase resulted from tumor resection. All flaps used in 13 cases survived uneventfully without major complications, with successful repair of defects, reconstruction of structures and restoration of contour of craniofacial regions. Conclusion: With adequate evaluation of resectability of tumors as well as nature and extent of defects after tumor removal, FRAF transplantation is an ideal method and strategy of choice for reconstructing the major and complex defects in craniofacial regions resulted from tumor ablation of advanced sinonasal carcinomas.

Chronological flap volume and distribution changes after reconstruction of total maxillectomy defect using a rectus abdominis myocutaneous flap

After total or subtotal maxillectomy, reconstruction using a free rectus abdominis myocutaneous (RAMC) flap is a fundamental and useful option. The purpose of the present study was to clarify the degree of flap volume change and volume distribution change with time after total or subtotal maxillectomy and free RAMC flap reconstruction and to examine the factors affecting the results. A total of 20 patients who underwent total or subtotal maxillectomy with free RAMC flap reconstruction were examined, and the flap volume change rate (volume at final evaluation [POD 181-360] / volume at initial evaluation [POD 5-30]) was investigated using the results of imaging tests. Moreover, the flap was divided into four blocks (A-D) in the cranio-caudal direction, and the volume change of each block was individually analyzed. The overall volume change rate of fat/muscle/total was 0.84±0.21/0.36±0.08/0.67±0.15, at the mean follow-up period of 309±35 days after the operation. The multiple regression analysis revealed that weight loss (for fat), postoperative RT (for fat and muscle), and young age (for muscle) were independently associated with flap volume loss. The results also indicated that the fat volume was stable, whereas the muscle volume decreased to <40% over time, assuming there were no influencing factors. Regarding flap volume distribution change, the fat volume tended to gather toward the central-cranial direction, while the muscle volume gathered toward the cranial direction, and total flap volume gathered toward the central direction.

The Role of Folded Multi-Island Vertical Rectus Abdominis Myocutaneous Flap in Reconstruction of Complex Maxillectomy and Midfacial Defects.

The rationale and outcomes for reconstruction of complex maxillectomy and midfacial defects using a folded multi-island vertical rectus abdominis myocutaneous free flap (MI-VRAM) are analyzed in this study.A retrospective review of prospectively collected database was conducted on all VRAM free flaps used in head and neck reconstruction from 2013 to 2019. A total of 39 cases were identified, of which 21 patients underwent immediate VRAM flap reconstruction for complex maxillectomy and midfacial defects. Variables including age, sex, pathologic subtypes, tumor staging, type of resection, defect classification, adjuvant therapy, complications, follow-up time, and reconstructive details were collected.Single skin-island VRAM was used in 10 (47.6%) patients. Eleven (52.4%) patients required the use of folded MI-VRAM flap. In 6 (28.6%) patients a triple skin-island VRAM was used and 5 (23.8%) received a double skin-island VRAM. The average size of harvested skin paddle was 15 × 7.2 cm. Secondary flap contouring was required in 6 (28.6%) patients. There were no cases of total flap loss and no major donor site complications recorded.Folded MI-VRAM flap is a reliable method for reconstruction of complex maxillectomy and midfacial defects. It provides multiple independent skin islands with excellent plasticity and abundant volume of tissue for restoration of facial contours.

Free muscle sparing vertical rectus abdominis myocutaneous flap

Introduction: Abdominal region is a unique donor area in the reconstructive surgery to provide numerous flaps. The aim of this study is to show effectivity of the free vertical rectus abdominis muscle (VRAM) flap in the complex wounds reconstruction without damaging integrity of the rectus abdominis muscle and sacrificing the opposite deep inferior epigastric artery. Materials and Methods: The study population was composed of all patients who applied to our department for evaluation and management of the complex wounds reconstruction with the free muscle sparing (MS) vertical rectus abdominis flap, between September 2011 and October 2015. Results: We utilized the free MS vertical rectus abdominis flap to closure complex wounds in seven patients (6 males and 1 female) in our department. Etiologies were malign skin tumors, amputation stump, unstable scar, and crush injury in three, two, one, and one patients, respectively. All MS vertical rectus abdominis flaps survived completely. A hematoma developed in the recipient site in one case, and it was immediately evacuated without any problem. Conclusions: Free MS vertical rectus abdominis flap is a quite easy and reliable flap to harvest from abdominal wall, reducing the possibility of bulging or hernia formation with less morbidity of the donor site.

A simple calculation for the preoperative estimation of transverse rectus abdominis myocutaneous free flap volume in 2-stage breast reconstruction using a tissue expander.

BackgroundFlap volume is an important factor for obtaining satisfactory symmetry in breast reconstruction with a transverse rectus abdominis myocutaneous (TRAM) free flap. We aimed to develop an easy and simple method to estimate flap volume.MethodsWe performed a preoperative estimation of the TRAM flap volume in five patients with breast cancer who underwent 2-stage breast reconstruction following an immediate tissue expander operation after a simple mastectomy. We measured the height and width of each flap zone using a ruler and measured the tissue thickness by ultrasound. The volume of each zone, approximated as a triangular or square prism, was then calculated. The zone volumes were summed to obtain the total calculated volume of the TRAM flap. We then determined the width of zone II, so that the calculated flap volume was equal to the required flap volume (1.2×1.05×the weight of the resected mastectomy tissue). The TRAM flap was transferred vertically so that zone III was located on the upper side, and zone II was trimmed in the sitting position after vascular anastomosis. We compared the estimated flap width of zone II (=X) with the actual flap width of zone II.ResultsX was similar to the actual measured width. Accurate volume replacement with the TRAM flap resulted in good symmetry in all cases.ConclusionsThe volume of a free TRAM flap can be straightforwardly estimated preoperatively using the method presented here, with ultrasound, ruler, and simple calculations, and this technique may help reduced the time required for precise flap tailoring.

Sliding free transverse rectus abdominis myocutaneous flap for closure of a massive abdominal wall defect: A case report

Despite considerable advances in reconstructive surgery, massive abdominal wall defects continue to pose a significant surgical challenge. We report the case of a 72-year-old morbidly obese female patient with Clostridium septicum-related gas gangrene of the abdominal wall. After multidisciplinary treatment and multiple extensive debridements, a massive full-thickness defect (40 cm × 35 cm) of the right abdominal wall was present. The abdominal contents were covered with a resorbable mesh to prevent evisceration. Finally, the composite defect was successfully reconstructed through a contralateral extended free transverse rectus abdominis myocutaneus (TRAM) flap (50 cm × 38 cm). An arterio-venous loop to the superficial femoral vessels using the great saphenous vein was necessary to allow the flap to reach the defect. Postoperatively, a minor wound healing disorder of the flap was successfully treated with split skin grafting. Six month after surgery, the patient presented with a completely healed flap coverage area and a small abdominal hernia without the need of further surgical revision. This case illustrates the use of a sliding free TRAM flap for closure of a massive abdominal wall defect.

Breast Reconstruction with Free Transverse Rectus Abdominis Myocutaneous Flap Complicated by Deep Vein Thrombosis-associated Pulmonary Thrombo-embolism

Breast Reconstruction with Free Transverse Rectus Abdominis Myocutaneous Flap Complicated by Deep Vein Thrombosis-associated Pulmonary Thrombo-embolism

Opportunistic Biopsy of Internal Mammary Lymph Nodes During Immediate Breast Reconstruction After Mastectomy for Breast Malignancies.

This study was designed to explore the clinicopathological factors associated with internal mammary lymph node (IMN) metastasis in radiologically IMN-negative breast malignancies and to discuss the clinical value of opportunistic biopsy during immediate breast reconstruction using free flaps, where the internal mammary vessels are the recipient. We retrospectively reviewed patients who received curative total mastectomy for breast malignancy followed by immediate reconstruction using transverse rectus abdominis myocutaneous (TRAM) free flap. Suspicious lymph nodes encountered during dissection of the third intercostal space for the recipient vessels were biopsied. Clinicopathological variables and the clinical impact associated with IMN metastasis were analyzed. Among 269 patients who underwent immediate reconstruction using a TRAM free flap, suspicious lymph nodes were identified and biopsied in 54 (20.1%) patients, and IMN metastasis was confirmed in 12 (22.2%) of these (4.5% of all reconstructions). Five patients were positive despite negative axillary lymph nodes and 11 underwent therapeutic plan modifications. Multivariate analysis revealed that IMN metastasis was independently associated with medial tumor location, invasive tumor >2 cm, and positive human epidermal growth factor receptor-2 status (P<0.05). Aggressive IMN evaluation and biopsy in a subset of patients during immediate breast reconstruction using a TRAM free flap provided an additional opportunity for accurate breast cancer staging and appropriate adjuvant treatment, while minimizing unnecessary complications.

Induced Hypothermia: Implications for Free Flap Survival.

Plastic surgeons may not be aware that the new advanced cardiac life support (ACLS) guidelines released in 2010 include induced hypothermia as an adjuvant treatment to improve neurologic outcomes following cardiac arrest [1]. Induced hypothermia (IH) is thought to mitigate ischemic damage by lowering metabolic demand and preventing noxious byproducts of resuscitation. IH is recommended for patients who experience the return of spontaneous circulation after cardiac arrest, but remain unconscious [2]. The hypothermia protocol involves the reduction of body temperature to 32℃–34℃ for 12 to 24 hours, followed by slow rewarming [1,2]. However, the use of induced hypothermia in microvascular free tissue transfer has not been studied. We present the case of a patient who underwent IH following free-flap reconstruction of a head and neck cancer defect. A 69-year-old male with a history of coronary artery disease and three-vessel coronary artery bypass grafting presented with recurrent basal cell carcinoma of the left ear canal. He underwent total auriculectomy and lateral temporal bone resection, and the defect was reconstructed with a left vertical rectus abdominis myocutaneous free flap. On the second postoperative day, the patient was found unresponsive in pulseless electrical activity cardiac arrest. The ACLS protocol was initiated, including mechanical ventilation and vasopressors for hemodynamic support. The patient was successfully resuscitated but suffered a second cardiac arrest with ventricular fibrillations. He was resuscitated again but remained unresponsive. Hypothermia was induced, with the patient cooled to 32℃ for 48 hours (Fig. 1). The free flap remained well perfused with an audible Doppler signal during the cardiac arrests, vasopressor therapy, hypothermic cooling, and the remainder of his hospitalization (Fig. 2). Unfortunately, the patient had no meaningful neurologic recovery and magnetic resonance imaging showed diffuse hypoxic brain injury. Therefore, the family elected to withdraw care on postoperative day 10. Fig. 1 Temperature curve showing induced hypothermia to 32℃–34℃, from postoperative day three until postoperative day five. Fig. 2 A 69-year-old male underwent composite resection of the left auriculotemporal area and temporal bone for recurrent basal cell carcinoma, and the defect was reconstructed with a left vertical rectus abdominis myocutaneous free flap. The effects of systemic hypothermia on free tissue transfer are not fully understood. Limited animal and human studies have demonstrated conflicting results. Some data have suggested that hypothermia causes decreased perfusion, vasospasm, and thrombosis, while other animal experiments have shown a protective effect of mild hypothermia on free flaps [3,4,5]. Clotting enzymes, platelets, and leukocytes function less effectively in a hypothermic setting; however, no reports have been published on the effect of severe hypothermia (<34℃) on free flap survival in humans. This is the first reported case of induced hypothermia after free tissue transfer. Plastic surgeons should be aware of ongoing changes to the ACLS algorithm and its impact on perioperative care. In this case, a free tissue transfer remained viable despite induced hypothermia and vasopressors, which is a single data point suggesting that free flaps can tolerate such interventions. However, further research is needed to clarify the effects of hypothermia on free tissue transfer.

Does the use of an acellular dermal graft in abdominal closure after rectus flap harvest impact the occurrence of post-operative hernia?

Patients with rectus free flap harvest extending below the arcuate line are predisposed to postoperative hernia formation. As such, many authors have advocated the use of closure adjuncts to increase the integrity of the closure and prevent hernia or abdominal wall bulging. Busy level 1 public trauma center in metropolitan Fort Worth, Texas Following harvest of the rectus free flap, 48 patients underwent primary closure; 24 of these patients had defects extending below the arcuate line. Forty patients were closed with an acellular dermal graft; 22 of these patients had defects extending below the arcuate line. Postoperative hernia formation and local infection rate were examined in a minimum follow-up period of 1 year. Regardless of closure method, no hernias were observed in the postoperative period. Using an unpaired t test and an alpha value of 0.05, there was no statistically significant difference in the infection rate between the two groups. Following rectus abdominis myocutaneous free flap harvest, the use of an acellular dermal graft in abdominal wall closure may not be of any further advantage in the prevention of hernia. Retrospective (Level III).

Reconstruction Using Locoregional Flaps for Large Skull Base Defects.

We present a modified locoregional flap for the reconstruction of large anterior skull base defects that should be reconstructed with a free flap according to Yano's algorithm. No classification of skull base defects had been proposed for a long time. Yano et al suggested a new classification in 2012. The lb defect of Yano's classification extends horizontally from the cribriform plate to the orbital roof. According to Yano's algorithm for subsequent skull base reconstructive procedures, a lb defect should be reconstructed with a free flap such as an anterolateral thigh free flap or rectus abdominis myocutaneous free flap. However, our modified locoregional flap has also enabled reconstruction of lb defects. In this case series, we used a locoregional flap for lb defects. No major postoperative complications occurred. We present our modified locoregional flap that enables reconstruction of lb defects.

Head and neck myxofibrosarcoma: a case report and review of the literature

IntroductionMyxofibrosarcoma is the most common soft tissue sarcoma that occurs in late adult life, peaking in the seventh decade, and it is mainly encountered in the lower extremities. Myxofibrosarcoma of the head and neck are extremely rare. To the best of our knowledge, only 19 cases have been described in the head and neck so far. This is a literature review and retrospective chart review of our experience in head and neck myxofibrosarcoma treatment in our department.Case presentationIn this case report we describe a 35-year-old Caucasian man who presented the first case of myxofibrosarcoma arising from the pterygopalatine fossa. The peculiar anatomical location and the extent in the midcheek region make this case a hard “challenge” for the surgeon, in order to guarantee wide surgical margins of resection. A total right maxillectomy was accomplished by means of the Weber-Ferguson approach, preserving the orbital floor. The excised portion was reconstructed using the free rectus abdominis myocutaneous flap. Postoperative radiotherapy was given to the area adjacent to the lesion, with a total dose of 60Gy. No relapse occurred in the 27-month postoperative follow-up.ConclusionsThe case described suggests the importance of combined surgical and adjuvant radiotherapy to avoid local and distant recurrences of the tumor. In our opinion, combined surgical and adjuvant radiotherapy followed by close clinical observation to search for a metastatic disease is advisable in all cases. Further studies are needed to confirm the efficacy of combined radio-chemotherapy for head and neck myxofibrosarcoma in terms of long-term disease-free survival.

Nipple-Sparing Mastectomy in Patients with a History of Reduction Mammaplasty or Mastopexy

INTRODUCTION: Nipple-sparing mastectomy has gained popularity, but the question remains whether it can be offered safely to women with prior history of reduction mammaplasty or mastopexy. Presented is our updated experience with offering nipple-sparing mastectomy to this patient population. METHODS: Patients at our institution who had reduction mammaplasty or mastopexy prior to nipple-sparing mastectomy were identified and their records reviewed. Outcomes measured include nipple-areolar complex viability, mastectomy flap necrosis, infection, cancer in the nipple-areolar complex and breast cancer recurrence. RESULTS: The records of our nipple-sparing mastectomy patients from 2006 through 2012 were reviewed. We present eleven patients (n=19 breasts) who underwent nipple-sparing mastectomy following reduction mammaplasty or mastopexy. Seventeen breasts had reduction mammaplasties while the remaining two had mastopexies. In all cases, reduction mammaplasty or mastopexy were in the patient’s surgical history and not performed as part of a planned two stage nipple-sparing mastectomy procedure. The mean age of the patients was 47.5 and the mean BMI was 27.6. None of the patients in this subset were diabetic, and one patient was a smoker. Twelve breasts had therapeutic resections, and seven were for prophylactic indications. Average time elapsed between reduction mammaplasty or mastopexy and nipple-sparing mastectomy was 104.3 months (range, 33 days to 40 years). Fourteen patients were reconstructed immediately with tissue expanders, one with a latissimus dorsi flap with immediate implant and four with immediate transverse rectus abdominis myocutaneous free flaps. Prior reduction mammaplasty or mastopexy incisions were used in all cases. Complications included one hematoma requiring evacuation, one breast with mastectomy flap necrosis, and one displaced implant requiring revision. There were no positive subareolar biopsies. Nipple viability complications included a partial necrosis rate of 15.8% (3/19). Mean follow-up time was 14.5 months. CONCLUSION: Our updated experience demonstrates that the outcomes of nipple-sparing mastectomy in patients with a history of reduction mammaplasty or mastopexy are comparable to the standards for patients who undergo nipple-sparing mastectomy alone.

Patient access to immediate breast reconstruction following cancer surgery. Learning from the National Mastectomy and Breast Reconstruction Audit (NMBRA)

s / International Journal of Surgery 11 (2013) 589e685 605 ABSTRACTS 0329: PATIENT ACCESS TO IMMEDIATE BREAST RECONSTRUCTION FOLLOWING CANCER SURGERY. LEARNING FROM THE NATIONAL MASTECTOMY AND BREAST RECONSTRUCTION AUDIT (NMBRA) Senthurun Mylvaganam, Niraj Vethirajan, Khalid Boussouara, George Metaxas, Hemant Ingle. Good Hope Hospital, Heart of England NHS Trust, Sutton Coldfield, Birmingham, UK. Introduction: NICE guidance requires breast reconstruction discussionwith all patients requiring mastectomy. The national mastectomy and reconstruction audit showed significant variation in accessibility and practice in NHS Trusts offering breast reconstruction. Our trust service has evolved since the audit combining breast and dedicated plastic surgeons on site. Aims: Assess current local accessibility and practice for offering immediate breast reconstruction following mastectomy. Methods: Retrospective analysis of patients undergoing mastectomy for cancer at Heart of England NHS trust (HEFT) between September 2011 to July 2012. Data collected on tumour biology, whether reconstruction options offered and if not performed why. Results: N1⁄476. Mean Nottingham Prognostic Index(NPI)1⁄44.03. Mean age1⁄461(31-90) Immediate reconstruction offered 1⁄446%. Immediate reconstruction performed 1⁄425%. Reconstruction techniques; immediate with expander(2), immediate delayed with expander(5), Transverse Rectus Abdominis Myocutaneous(TRAM) free flap(7), Lattissimus Dorsi(LD) pedicled flap(2), LD with implant(2), Deep Inferior Epigastric Perforator(DIEP) free flap(1). Reasons reconstruction not performed; patient choice(8), patient choosing delayed(6). Conclusion: Our trust breast cancer service is a partnership between breast and plastic surgeons with joint MDT and clinic services. The trust rate of discussion of immediate reconstruction is greater than the published NMBRA local cancer network rate(36%). An integrated oncoplastic service is a key measure towards fulfilling NICE guidance. 0331: THE IMPORTANCE OF NEEDLE CORE BIOPSY IN THE DIAGNOSIS OF PHYLLOIDES TUMOURS Senthurun Mylvaganam, Lucinda Frank , Clare Toro , Sarah Vestey , Steven Thrush . Worcester Royal Hospital, Worcestershire Acute NHS Trust, Worcester, Worcestershire, UK; Gloucestershire Hospitals NHS Trust, Gloucester, Gloucestershire, UK. Introduction: Phylloides tumours are rare fibroepithelial breast tumours and are usually clinically and radiological indistinguishable from fibroadenomas. This makes core biopsy the main method of diagnosis. Only small studies have looked at the diagnostic histological accuracy of needle core biopsy(NCB) and none have addressedwhether there is any variability of NCB accuracy between institutions. Aims: To assess the diagnostic accuracy of NCB compared to the gold standard excision biopsy report in 2 separate hospitals trusts. Methods: Multicentre retrospective analysis of all cases of phylloides tumours on core and/or excision biopsy from March 2006 to July 2012 at Worcestershire Acute NHS Trust (WAHNST) and Gloucestershire hospitals NHS Trust (GHNHST). Results: N1⁄494. Mean age1⁄448. Mean clinical size1⁄431.7mm, mean radiological size1⁄435.4mm. WAHNST n1⁄442. NCB Sensitivity1⁄487% and Positive Predictive Value(PPV)1⁄490%. GHNHST n1⁄452 NCB Sensitivity1⁄474% and PPV1⁄4100%. Conclusion: The high sensitivity of NCB shown demonstrates its importance in the diagnosis of Phylloides tumours (comparative study in literature 63%). There does appear to be variation between pathologists in interpretation of NCB, which may be caused by the interpretation of the criteria for diagnosing Phylloides. NCB is not 100% sensitive at diagnosing these tumours so there must be local protocols to ensure tumours are not missed. 0434: BREAST CANCER SURGERY IS SAFE IN THE ELDERLY PATIENT Ramesh Yap Kannan, Nadi Khaldoun, Khawaja Saira, Sumrien Haytham, Holt Simon, Sharaiha Yousef. Prince Philip Hospital, Llanelli, Carmarthenshire, UK. Aims: To assess the safety of surgical resection of breast cancer in patients over 70 years Methodology: A retrospective study of 188 consecutive patients diagnosed with breast cancer at the age of 70 or older (2004 to 2008). Notes were examined for demographics, treatment, complications and final outcome. Patients received surgery with an intent to cure (SC) or conservative treatment (C). Results: 68 patients received C and 120 patients underwent SC. SC was performed in 63.8%(120 of 188), of whom 93.3% had a general anaesthetic. Mastectomy (M) was performed in 51.6%, M following a wide local excision (WLE) in 4.2% and WLE in 44.2%. Axillary surgery (n1⁄493) was either an axillary sampling (AS) in 5%, AS and clearance (AC) in 1%, primaryAC in87.1%, sentinel node biopsy (SNB) in 3.2% and SNB followed by AC in 3.2% (3 of 93). 30 day mortality was 0.008% (1 of 120) following a myocardial infarction. 10 patients had minor complications. Median follow up (SC) was 24 months versus 20 months (C). Overall survival was 89%(SC) versus 50% (C). Conclusion: Elderly patients with breast cancer, can be treated surgically with an intent to cure, safely and this has an impact on survival. 0470: A RETROSPECTIVE ANALYSIS OF PHYLLODES TUMOURS AND B3 LESIONS ON CORE BIOPSY Lucinda Frank, Sarah Vestey, Richard Bryan. Gloucester Royal Hospital,

OP034: Orbital exenteration defects with maxillectomy: Options and outcome

Purpose The present study attempts to review the options and outcomes of orbital exenteration defect reconstruction with free flaps. We also present the risk categorization and patient selection criteria used at our institute. Material and methods A study of 23 consecutive patients who underwent maxillectomy/ Craniofacial resection with orbital exenteration and free flap reconstruction. The study period was between 2004 and 2011. Results There were 17 male and 6 females in the study. The flaps used were free rectus abdominis myocutaneous flap ( n = 10), anterolateral thigh flap ( n = 4); free fibula flap ( n = 3), deep circumflex iliac flap with internal oblique muscle ( n = 5). Free tensor fascia lata with iliac crest and internal oblique muscle was used in five patients to get a composite eye socket reconstruction with ocular prosthesis. One patient had a simultaneous double free flap reconstruction with a combination of free fibula flap and free radial forearm flap. This patient died in the immediate postoperative period due to systemic complications. Excluding this patient, the flap success rate w as 95.5% (21/22). Eight patients are alive and disease free after a mean follow up of 30.5 months (range: 6–76 months). We present an algorithm for the choice of reconstructive approach. In high risk, old patients with co-morbidities, regional flaps like Temporalis with spectacle prosthesis/Obturator; In intermediate risk patients we suggest, soft tissue flaps with bulk (rectus abdominis) and spectacle prosthesis and in young low risk individuals, a composite socket reconstruction with the free tensor fascia lata with iliac crest and internal oblique muscle is an ideal option. Conclusions Free microvascular tissue transfer has improved the results of reconstruction of orbital exenteration defects. Free rectus abdominis flap remains the commonest choice. Free fibula flap is useful in cases with associated bony defects of maxillectomy. When a composite socket reconstruction is to be achieved, the innovative free tensor fascia lata with iliac crest and internal oblique muscle is an excellent option but needs two simultaneous pair of vessel anastamosis.

Maxillary reconstruction using free rectus abdominis myocutaneous flap combined with vascularized costal cartilages

We describe two cases of zygomaticomaxillary bone defect after the resection of a maxillary carcinoma, reconstructed using a rectus abdominis myocutaneous flap combined with vascularized costal cartilages. Eighth and ninth costal cartilages could be harvested connecting with the rectus abdominis muscle. The zygomaticomaxillary buttress was reconstructed using vascularized costal cartilages, while the nasal and oral lining, or facial skin defect were reconstructed with a RAM flap. The shape of the harvested costal cartilages fitted the zygomaticomaxillary bone defect; thus, the result was favorable cosmetically.