Effect of acetylsalicylic acid on microvascular thrombosis in autologous breast reconstruction.

Although advances in microsurgery have increased success rates of autologous breast reconstruction, microvascular thrombosis still remains a major concern as a cause of flap failure. At present, no evidence-based guidelines on pharmacological prevention of microvascular thrombosis exist. This study investigates the effect of acetylsalicylic acid on the incidence of microvascular complications in patients undergoing autologous breast reconstruction. Patients undergoing deep inferior epigastric artery perforator or free transverse rectus abdominis myocutaneous flap breast reconstruction at two academic centers in the Netherlands between 2005 and 2011 were included. Patients at one center received once daily 0.6 mL of nadroparine and 40 mg acetylsalicylic acid, while patients at the other center received 0.6 mL nadroparine only. A total of 430 consecutive patients underwent 592 breast reconstructions. No statistically significant differences were found between the two groups in the incidence of flap failure (2.8 and 2.5%), microvascular thromboembolic complications (2.6 and 3.8%), venous congestion (3.4 and 2.8%), or overall complications (28.0 and 32.3%). Hematoma tended to occur more often in the group receiving acetylsalicylic acid (9.2 and 4.7%).It was found that no protective effect of acetylsalicylic acid on microvascular complications was present. Given its known risks and the somewhat increased occurrence of hematoma in the present study, we stopped to routinely administer acetylsalicylic acid after autologous breast reconstruction.

Pulmonary embolism after abdominal flap breast reconstruction: prediction and prevention.

BACKGROUND: Symptomatic pulmonary embolism constitutes a significant risk following abdominal flap breast reconstruction. Reported rates vary from 0 to 6 percent. The authors assessed risk factors associated with symptomatic pulmonary embolism and constructed a prediction model to identify high-risk patients. METHODS: Patients undergoing deep inferior epigastric perforator or transverse rectus abdominis musculocutaneous flap breast reconstructions at two academic centers from January of 2005 through January of 2011 were included. Thromboprophylaxis measures included early ambulation, low-molecular-weight heparin, elastic stockings, A-V Impulse System foot pumps, and pneumatic stockings. Risk factors for symptomatic pulmonary embolism were analyzed and weights were assigned to these risk factors. Sensitivity and specificity were maximized using receiver operating characteristic curves. RESULTS: Of 430 consecutive patients, symptomatic pulmonary embolism occurred in 17 cases (4.0 percent). Two independent predictors for symptomatic pulmonary embolism were found, body mass index higher than 25, additionally higher than 28, and the BRCA gene mutation. Operation duration and bilaterality of reconstructions were dependent on the BRCA mutation and both indirect predictors for symptomatic pulmonary embolism. Optimization of sensitivity and specificity resulted in a prediction model. No significant differences in efficacy were found between the different thromboprophylaxis measures. CONCLUSIONS: The rate of symptomatic pulmonary embolism was 4.0 percent, despite standard thromboprophylaxis. Body mass index and BRCA were significant predictors for symptomatic pulmonary embolism. The authors integrated these factors into a prediction model, which provides a useful tool for identification of high-risk patients. This latter category may benefit from a more aggressive thromboprophylaxis approach. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The unilateral deep inferior epigastric perforator flap: comparing university to community hospital.

The deep inferior epigastric perforator (DIEP) flap is considered to be the gold standard for autologous breast reconstruction. This study evaluates the outcome of unilateral DIEP flap reconstructions, comparing university with a community hospital setting. A total of 77 unilateral DIEP flaps were performed at one university hospital and two community hospitals by the same two surgeons. Outcome parameters were: hospital stay, operating time, wound infection, wound dehiscence, fat necrosis, haematoma, (partial) flap necrosis and the need for surgical intervention. Forty-nine unilateral DIEP flaps were performed in the university hospital and 28 in the community hospitals. Baseline characteristics were equal. No significant difference was found in total complication rate, flap loss or need for surgical intervention. Although wound dehiscence occurred more often in the community hospitals, unilateral DIEP flap breast reconstructions can be performed with a comparable degree of safety and complication risk in both university and community hospital settings.

Autologous dermal grafts for rectus sheath reconstruction and application in closure of ventral myofascial defects.

Ventral abdominal hernias pose a reconstructive challenge, with recurrence rates after primary closure exceeding 50 % and synthetic options at high risk for infection. We describe our experience with using autologous dermis, sourced from the redundant overlying abdominal skin, for reconstruction of ventral abdominal wall defects. We describe the surgical technique, applied anatomy and an analysis of short- and long-term outcomes. Twelve consecutive patients undergoing repair of medium-large size, reducible abdominal wall defects were recruited. The dermal graft technique was used in each case, utilizing an autologous running strip of abdominal skin for reconstruction. Both short- and long-term outcomes were assessed prospectively. Scores were given on a scale of 1-10, with 1 = least/worst and 10 = most/best. The described technique was successfully undertaken in all patients. Long-term follow-up demonstrated a 100 % resumption of normal activities, with an improvement in quality of life and physical activity scores postoperatively, and no recurrences. Short-term complications were notable, with five patients requiring postoperative intensive care unit admission, and seven patients requiring respiratory support. In conclusion, the use of autologous rectus sheath reinforcement may achieve good surgical outcomes and high patient satisfaction. While early respiratory complications should be noted, the potential utility of this technique is worthy of future investigation.

One-year cholesterol lowering treatment reduces medial temporal lobe atrophy and memory decline in stroke-free elderly with atrial fibrillation: evidence from a parallel group randomized trial.

OBJECTIVES: In elderly patients with atrial fibrillation (AF), medial temporal lobe (MTL) atrophy and white matter lesions (WML) may account for the cognitive decline. Though a combination therapy of statins with cholesterol lowering agents like ezetimibe may be beneficial in patients with AF, its effects on MTL structure and WML remains unknown. METHODS: A parallel group double-blinded randomized trial was performed during 1 year whereby elderly stroke-free AF patients either received placebo or atorvastatin and ezetimibe on top oral anticoagulation therapy. Neuropsychological performance and inflammatory markers in the blood were assessed at baseline and 1 year later together with amygdala and hippocampal volume as well as WML. RESULTS: Sixty-three patients were assessed for eligibility, but 29 patients had to be excluded so that 34 patients were randomized to both groups. In the treatment group, the systemic level of inflammation was significantly decreased after 1 year and an improvement in cognitive speed as well as short- and long-term memory was observed. While there was no significant difference in MTL volume at baseline, the placebo group exhibited more atrophy for right amygdala and left hippocampus at follow-up. Finally, descriptive data showed a slight decline of WML volume in the treatment group. CONCLUSIONS: In spite of limitations due to small sample size, our data suggest that intensive cholesterol lowering therapy in AF patients may slow cognitive decline and atrophy of the MTL. Though these results have to be replicated in a larger sample, they offer potential for future interventions.

Self-esteem and patients' satisfaction after deep inferior epigastric perforator flap breast reconstruction.

The objective of this article is to assess the impact of deep inferior epigastric perforator (DIEP) flap breast reconstruction on self-esteem and to analyze the correlation between aesthetic outcome and self-esteem. Global self-esteem was evaluated using the Rosenberg Self-Esteem Scale in 31 patients who underwent DIEP flap breast reconstructions. A study-specific questionnaire and photographic evaluation were used by the patient, the plastic surgeon, and the oncological surgeon to measure satisfaction with the aesthetic outcome. Patients' satisfaction and self-esteem were analyzed for any existing correlation. Overall patients' satisfaction had a mean score of 6.55 (range, 0-10) on the Patient Satisfaction Questionnaire. A mean score of 32.48 (range, 10-40) was found on the Rosenberg Self-Esteem Scale. More than 80% of patients were content with their decision to undergo this procedure and would recommend this to a friend. Surgeons tended to rate the aesthetic outcome better than patients. Patients' satisfaction and self-esteem were found to be positively correlated. Patients are generally content with the outcome of primary DIEP flap breast reconstruction. The favorable aesthetic result of this procedure has a beneficial effect on patients' self-esteem.

The deep inferior epigastric artery perforator flap for autologous reconstruction of large partial mastectomy defects.

BACKGROUND: Breast conservation surgery in the treatment of early stage breast cancer has become increasingly utilized as a means to avoiding mastectomy. While partial mastectomy defects (PMDs) may often be cosmetically acceptable, some cases warrant consideration of reconstructive options, and while several reconstructive options have been described in this role, a series of deep inferior epigastric perforator (DIEP) flaps has not been reported to date. METHODS: A cohort of 18 patients undergoing PMD reconstruction with a DIEP flap were included. Patient-specific data, operation details, cosmetic results, and complication rates were assessed. Oncologic outcomes, in particular recurrence rates, were also evaluated. RESULTS: In our series there were no cases of partial or total flap necrosis, and overall complications were low. There were two cases of wound infection (both had undergone radiotherapy), managed conservatively, and one case of reoperation due to hematoma. There were no cancer recurrences or effect on oncologic management. Cosmetic outcome was rated as high by both patients and surgeon. The results were thus comparable with other reconstructive options. CONCLUSION: Although autologous reconstruction has an established complication rate, our results suggest that the DIEP flap may be of considerable value for delayed reconstruction of selected larger partial mastectomy defects.

A clinical review of 9 years of free perforator flap breast reconstructions: an analysis of 675 flaps and the influence of new techniques on clinical practice.

The aim of this study is to review our 9-year experience with deep inferior epigastric perforator (DIEP) breast reconstructions to help others more easily overcome the pitfalls we experienced. A chart review was conducted for all 543 patients who had 622 DIEP breast reconstructions in our clinic between January 2000 and January 2009. In this time, there were an additional 28 superior gluteal artery perforator and 25 superficial inferior epigastric artery reconstructions, bringing the total free flap reconstructions to 675. In the early years, the success rate was 90.7%, the average operative time was 7 hours and 18 minutes, and the complication rate was 33.3%; these have improved to 98.2%, 4 hours and 8 minutes, and 19.3%, respectively. We describe our selection criteria, preoperative vascular mapping, surgical techniques, and postoperative monitoring as they relate to these improvements in outcome, operative time, and complications. The DIEP flap is a safe and reliable option in breast reconstructions. By acquiring experience with the flap and introducing new and improving existing techniques we have improved the ease of the procedure and the success rate and have shortened the operative time.

Introduction of the implantable Doppler system did not lead to an increased salvage rate of compromised flaps: a multivariate analysis.

BACKGROUND: The Cook-Swartz implantable Doppler system was introduced at the Uppsala University Hospital to ease free flap monitoring and improve salvage rates by an earlier detection of vascular compromise. The aim of the current analysis was to investigate whether the system indeed improved the salvage rate of revisions. METHODS: All cases that needed revision among a consecutive series of patients being monitored with the implantable Doppler system between June of 2006 and January of 2009 were compared with a similar set of patients operated on before the introduction of the implantable Doppler system over an equal time span monitored with conventional methods. Data were extracted from the medical files of the patients. Logistic regression was used to identify factors associated with the outcome of the revision. Values of p < 0.05 were considered statistically significant. RESULTS: A total of 327 flaps were monitored with the implantable Doppler system, of which 35 needed revision. In the control group, 303 flaps were included, of which 40 needed revision. The revision was successful in 69 percent of the cases in the implantable Doppler system group; in the group monitored by only conventional methods, this rate was 60 percent. Univariate analysis showed no statistical difference between these success rates (p = 0.441; odds ratio, 1.455; 95 percent confidence interval, 0.560 to 3.775). Multivariate analysis did not show a statistical difference either (p = 0.799; odds ratio, 1.143; 95 percent confidence interval, 0.410 to 3.182). CONCLUSION: The introduction of the implantable Doppler system did not lead to a significant increase in the salvage rate of revised flaps.

Aesthetic refinements and reoperative procedures following 370 consecutive DIEP and SIEA flap breast reconstructions: important considerations for patient consent.

BACKGROUND: Breast reconstruction often requires multiple operations. In addition to potential complications requiring reoperation, additional procedures are frequently essential in order to complete the reconstructive process, with aesthetic outcome and breast symmetry shown to be the most important factors in patient satisfaction. Despite the importance of these reoperations in decision-making and the consent process, a thorough review of the need for such operations has not been definitively explored. METHODS: A review of 370 consecutive autologous breast reconstructions (326 patients) was undertaken, comprising 365 deep inferior epigastric artery perforator (DIEP) flaps and 5 superficial inferior epigastric artery (SIEA) flaps. The need for additional procedures for either complications or aesthetic refinement following initial breast reconstruction was assessed. RESULTS: Overall, there was an average of 1.06 additional interventions for every patient carried out after primary reconstructive surgery. Of 326 patients, 46 underwent early postoperative operations for surgical complications (0.17 additional operations per patient as a consequence of complications). Procedures for aesthetic refinement included those performed on the reconstructed breast, contralateral breast, or abdominal donor site. Procedures for aesthetic refinement included nipple reconstruction, nipple-areola complex tattooing, dog-ear correction, liposuction, lipofilling, scar revision, mastopexy, and reduction mammaplasty. CONCLUSION: While DIEP flap surgery for breast reconstruction provides favorable results, patients frequently require additional procedures to improve aesthetic outcomes. The need for reoperation is an important part of the consent process prior to reconstructive surgery, and patients should recognize the likelihood of at least one additional procedure following initial reconstruction.

Postoperative monitoring of lower limb free flaps with the Cook-Swartz implantable Doppler probe: A clinical trial.

BACKGROUND: Free flaps to the lower limb have inherently high venous pressures, potentially impairing flap viability, which may lead to limb amputation if flap failure ensues. Adequate monitoring of flap perfusion is thus essential, with timely detection of flap compromise able to potentiate flap salvage. While clinical monitoring has been popularized, recent use of the implantable Doppler probe has been used with success in other free flap settings. METHODS: A comparative study of 40 consecutive patients undergoing microvascular free flap reconstruction of lower limb defects was undertaken, with postoperative monitoring achieved with either clinical monitoring alone or the use of the Cook-Swartz implantable Doppler probe. RESULTS: The use of the implantable Doppler probe was associated with salvage of 2/2 compromised flaps compared to salvage of 2/5 compromised flaps in the group undergoing clinical monitoring alone (salvage rate 100% vs. 40%, P = 0.28). While not statistically significant, this was a strong trend toward an improved flap salvage rate with the use of the implantable Doppler probe. There were no false positives or negatives in either group. One flap loss in the clinically monitored group resulted in limb amputation (the only amputation in the cohort). CONCLUSION: A trend toward early detection and salvage of flaps with anastomotic insufficiency was seen with the use of the Cook-Swartz implantable Doppler probe. These findings suggest a possible benefit of this technique as a stand-alone or adjunctive tool in the clinical monitoring of free flaps, with further investigation warranted into the broader application of these devices.

A single center comparison of one versus two venous anastomoses in 564 consecutive DIEP flaps: investigating the effect on venous congestion and flap survival.

BACKGROUND: Venous complications have been reported as the more frequently encountered vascular complications seen in the transfer of deep inferior epigastric artery (DIEA) perforator (DIEP) flaps, with a variety of techniques described for augmenting the venous drainage of these flaps to minimize venous congestion. The benefits of such techniques have not been shown to be of clinical benefit on a large scale due to the small number of cases in published series. METHODS: A retrospective study of 564 consecutive DIEP flaps at a single institution was undertaken, comparing the prospective use of one venous anastomosis (273 cases) to two anastomoses (291 cases). The secondary donor vein comprised a second DIEA venae commitante in 7.9% of cases and a superficial inferior epigastric vein (SIEV) in 92.1%. Clinical outcomes were assessed, in particular rates of venous congestion. RESULTS: The use of two venous anastomoses resulted in a significant reduction in the number of cases of venous congestion to zero (0 vs. 7, P = 0.006). All other outcomes were similar between groups. Notably, the use of a secondary vein did not result in any significant increase in operative time (385 minutes vs. 383 minutes, P = 0.57). CONCLUSIONS: The use of a secondary vein in the drainage of a DIEP flap can significantly reduce the incidence of venous congestion, with no detriment to complication rates. Consideration of incorporating both the superficial and deep venous systems is an approach that may further improve the venous drainage of the flap.

Performing two DIEP flaps in a working day: an achievable and reproducible practice.

BACKGROUND: While the deep inferior epigastric artery perforator (DIEP) flap is a reliable technique for autologous breast reconstruction, the meticulous dissection of perforators may require lengthy operative times. In our unit, we have performed 600 free flaps for breast reconstruction over 8 years and have reduced operative times with a combination of preoperative computed tomographic angiography (CTA), various anastomotic techniques and the Cook-Swartz implantable Doppler probe for perfusion monitoring. We sought to assess the feasibility of performing two DIEP flaps within the working hours of a single day. METHODS: A review of 101 consecutive patients undergoing DIEP flap breast reconstruction in a 12-month period was performed, comparing one DIEP flap per day (n=43) to two DIEP flaps per day (n=58). Complications, outcomes and techniques used were critically analysed. For cases of two DIEP flaps per day, a comparison was made between the use of two separate operating theatres (n=44) and a single consecutive theatre (n=14). RESULTS: Complications did not increase when two DIEP flaps were performed in a single working day. The use of vascular closure staple (VCS) sutures and ring couplers resulted in statistically significant reductions in anastomotic times. The use of two separate theatres for performing two DIEP flaps resulted in a reduction of 59min in operative time per case (p=0.004). CONCLUSION: Two DIEP flaps can be safely and routinely performed within the hours of a single working day. By minimising operative times, these techniques can improve productivity and substantially decrease surgeon fatigue.

How long are fasciocutaneous flaps dependant on their vascular pedicle: a unique case of SIEA flap survival.

BACKGROUND: While it has long been held that muscle flaps maintain their dependency on their vascular pedicle for the long term, fasciocutaneous flaps have been less well investigated. Recent studies of the deep inferior epigastric artery perforator (DIEP) flap have suggested that these flaps may maintain long term dependence on their vascular pedicles for survival. There is no literature concerning these effects in the superficial inferior epigastric artery (SIEA) flap. CASE REPORT: We describe a unique case in which the pedicle of a superficial inferior epigastric artery (SIEA) flap for breast reconstruction was avulsed 11 days postoperatively, with the flap surviving on its inferior wound edge alone. CONCLUSION: Fasciocutaneous flaps may lose dependency on their vascular pedicles in the short term following transfer, developing alternative pathways for vascular supply and ultimately survival. A conservative approach early in the course of flap compromise due to perforator ligation or avulsion, in cases where immediate re-anastomosis may not be feasible, is thus supported.

Safety of the combination of intensive cholesterol-lowering therapy with oral anticoagulation medication in elderly patients with atrial fibrillation: a randomized, double-blind, placebo-controlled study.

BACKGROUND: The incidence of atrial fibrillation (AF) is very high in the elderly, and often oral anticoagulation (OAC) is indicated to prevent thromboembolism. OBJECTIVE: The aim of this study was to evaluate the safety of combining intensive cholesterol-lowering therapy with OAC in elderly patients with AF. METHODS: In a randomized, double-blind trial, 34 patients received OAC plus atorvastatin 40 mg/day and ezetimibe 10 mg/day versus placebo over 1 year. Dose adjustments of OAC served as an indicator of an interaction between HMG-CoA reductase inhibitors (statins) and OAC. Safety was evaluated by the occurrence of bleeding and a rise in AST, ALT and creatine phosphokinase. RESULTS: Compared with a 6-month pre-intervention period, the mean daily dose +/- standard error of OAC was 4.4 +/- 1.5% lower in the treatment group (p = 0.003) and virtually the same in the placebo group (change from baseline: -0.1 +/- 1.3%, p = 0.96). The mean daily dose of OAC stabilized after 3 months. In the 6-month post-intervention period, OAC dosing showed no statistically significant change from baseline: -1.9 +/- 1.9% in the placebo arm and -2.6 +/- 2.1% in the intervention arm. CONCLUSION: We conclude that in elderly AF patients treated with OAC, intensive cholesterol-lowering therapy (atorvastatin 40 mg/day and ezetimibe 10 mg/day) is well tolerated. No increased risk in bleeding was found.

A dislocation of the carpal-metacarpal joints of the index, middle and ring finger.

A dislocation of the carpal-metacarpal joints of the index, middle and ring finger is reported. This dislocation is not very common and can easily be missed without the right diagnostics. The lesion was treated by reduction and immobilization for four weeks. Two months after the trauma, the patient had regained full function of his hand.

Perineal and posterior vaginal wall reconstruction with superior and inferior gluteal artery perforator flaps.

Perineal and posterior vaginal wall reconstruction following abdominoperineal and local cancer resection entails replacement of volume between the perineum and sacrum and restoration of a functional vagina. Ideal local reconstructive options include those which avoid functional muscle sacrifice, do not interfere with colostomy formation, and avoid the use of irradiated tissue. In avoiding the donor site morbidity of other options, we describe a fasciocutaneous option for the reconstruction of the perineum and posterior vaginal wall. We present our technique of superior and inferior gluteal artery perforator (SGAP or IGAP) flaps to reconstruct such defects. Fourteen patients between 2004 and 2008 underwent 11 SGAP and three IGAP flaps. There were no flap failures or partial flap losses and no postoperative hernias. All female patients reported resumption of sexual intercourse following this procedure. Our experience in both the immediate and delayed setting is that this technique produces a good functional outcome with low donor-site morbidity.

Thermal injuries in the insensate deep inferior epigastric artery perforator flap: case series and literature review on mechanisms of injury.

With the increasing use of the deep inferior epigastric artery perforator (DIEP) flap, complications that are particularly rare (less than 1%) may start to become clinically relevant. During DIEP flap harvest, cutaneous nerves innervating the flap are necessarily sacrificed, resulting in reduced sensibility. This impaired sensibility prevents adequate thermoregulatory reflexes, like vasodilatation, sweating, and protective behaviors, leaving the reconstructed breast considerably more susceptible to thermal insult. We present four DIEP flap cases who sustained postoperative thermal injury to the reconstructed breast. All four cases were operated on between 2001 and 2008, over the course of 600 DIEP flaps in our unit (an incidence of 0.7%). The injuries occurred between 2 and 18 months after reconstruction. Two patients sustained thermal injury while sunbathing, one while staying in a warm environment, and one sustained the injury while taking a shower. No flap losses ensued, but these were not without morbidity. A literature review discusses other similar cases in the literature and describes the mechanisms for these findings. As a majority of patients will regain both fine-touch and heat sensation by 3 years postoperatively, it is pertinent that prophylactic measures be instituted during this period, such as the avoidance of sunbathing and the use of cooler shower temperatures for the first 3 years postoperatively. While performing sensory nerve coaptation is the gold standard for maximizing the success of sensory regeneration, this is not always sought and the 0.7% incidence of thermal injury we have encountered suggest the role for greater consideration of such injury.