Relaxing fish-mouth incision for a tight coupler anastomosis.

The microvascular coupler device has reduced operative times and increased patency rates. Attempting to place a smaller tightly fitting vessel around a larger coupler ring can tear vessels and may require substitution with a smaller coupler device, which can not only add additional cost but also compromise the flap. We describe the theoretic and clinical aspects of the 'fish-mouthing' technique that we employ to help with the discrepancy in size of a smaller vessel compared to the coupler ring. The technique involves a longitudinal fish-mouth opening incision into the vessel lumen, prior to impaling the vessels' last three pins on the coupler ring creates two wings and increases the absolute vessel circumference to ease anastomosis .

Radiation Therapy Versus No Radiation Therapy to the Neo-breast Following Skin-Sparing Mastectomy and Immediate Autologous Free Flap Reconstruction for Breast Cancer: Patient-Reported and Surgical Outcomes at 1 Year-A Mastectomy Reconstruction Outcomes Consortium (MROC) Substudy.

PURPOSE: To determine whether adjuvant radiation therapy (RT) is associated with adverse patient-reported outcomes and surgical complications 1 year after skin-sparing mastectomy and immediate autologous free flap reconstruction for breast cancer. METHODS AND MATERIALS: We compared 24 domains of patient-reported outcome measures 1 year after autologous reconstruction between patients who received adjuvant RT and those who did not. A total of 125 patients who underwent surgery between 2012 and 2015 at our institution were included from the Mastectomy Reconstruction Outcomes Consortium study database. Adjusted multivariate models were created incorporating RT technical data, age, cancer stage, estrogen receptor, chemotherapy, breast size, body mass index, and income to determine whether RT was associated with outcomes. RESULTS: At 1 year after surgery, European Organisation for Research and Treatment of Cancer (EORTC) Breast Cancer-Specific Quality of Life Questionnaire breast symptoms were significantly greater in 64 patients who received RT (8-point difference on 100-point ordinal scale, P<.0001) versus 61 who did not receive RT in univariate and multivariate models. EORTC arm symptoms (20-point difference on 100-point ordinal scale, P=.0200) differed on univariate analysis but not on multivariate analysis. All other outcomes-including Numerical Pain Rating Scale, BREAST-Q (Post-operative Reconstruction Module), Patient-Report Outcomes Measurement Information System Profile 29, McGill Pain Questionnaire-Short Form (MPQ-SF) score, Generalized Anxiety Disorder Scale, and Patient Health Questionnaire-were not statistically different between groups. Surgical complications were uncommon and did not differ by treatment. CONCLUSIONS: RT to the neo-breast compared with no RT following immediate autologous free flap reconstruction for breast cancer is well tolerated at 1 year following surgery despite patients undergoing RT also having a higher cancer stage and more intensive surgical and systemic treatment. Neo-breast symptoms are more common in patients receiving RT by the EORTC Breast Cancer-Specific Quality of Life Questionnaire but not by the BREAST-Q. Patient-reported results at 1 year after surgery suggest RT following immediate autologous free flap breast reconstruction is well tolerated.

Goal-directed fluid therapy for microvascular free flap reconstruction following mastectomy: A pilot study.

BACKGROUND: Fluid management of the surgical patient has undergone a paradigm shift over the past decade. A change from 'wet' to 'dry' to a 'goal-directed' approach has been witnessed. The fluid management of patients undergoing free flap reconstruction is particularly challenging. This is typically a long operation with minimal surgical stimulation, and hypotension often ensues. The use of vasopressors in these cases is contraindicated to maintain adequate flow to the flap. Hypotension is often treated with intravenous fluid boluses. However, aggressive fluid administration to maintain adequate blood pressure can result in flap edema, venous engorgement and, ultimately, flap loss. OBJECTIVE: The primary objective of the present study was to determine whether goal-directed fluid therapy, titrated to maintain stroke volume variation ≤13%, with the use of an arterial pulse contour device results in improved postoperative cardiac index (CI) and stroke volume index (SVI) with reduced amounts of intravenous fluid. The primary end points studied were CI, SVI and cumulative crystalloid/colloid administration. METHODS: Twenty female patients undergoing simultaneous microvascular free flap reconstruction immediately following mastectomy were studied. Preoperative and intraoperative care were standardized. Each patient received intra-arterial blood pressure monitoring. In all patients, cardiac output measurement occurred throughout the intraoperative period using the arterial pulse contour device. Control patients had their fluid administered at the discretion of the anesthesiologist (blinded to results from the cardiac output device). Patients in the intervention group had a baseline crystalloid infusion of 5 mL/kg/h, with intravenous colloid boluses to maintain a stroke volume variation ≤13%. RESULTS: There was no difference in heart rate or mean arterial pressure between groups at the end of the operation. However, at the end of the operation, the intervention group had significantly higher mean (± SD) CI (3.8±0.8 L/min/m(2) versus 3.0±0.5 L/min/m(2); P=0.02) and SVI (51.4±2.4 mL/m(2) versus 43.3±2.3 mL/m(2); P=0.03). This improved CI and SVI was achieved with similar amounts of administered intraoperative fluid (5.8±0.5 mL/kg/h versus 5.0±0.7 mL/kg/h, control versus intervention). The intervention group required less postoperative fluid resuscitation during the early postoperative period (total fluid administered from end of operation to midnight of the operative day, 6.4±1.9 mL/kg/h versus 10.2±3.3 mL/kg/h, intervention versus control, respectively, P<0.01). DISCUSSION: Goal-directed fluid therapy using minimally invasive cardiac output monitoring resulted in improved end-operative hemodynamics, with less 'rescue' fluid administration during the perioperative period.

HISTORIQUE: La prise en charge des liquides du patient opéré a connu un changement de paradigme depuis dix ans. On a constaté un passage de « mouillé ¼ à « sec ¼, puis à une démarche « axée sur des objectifs ¼. La prise en charge des liquides des patients qui subissent une reconstruction par lambeau libre est particulièrement difficile. C'est habituellement une longue opération associée à une stimulation chirurgicale minimale, qui entraîne souvent une hypotension. Le recours aux vasopresseurs est contre-indiqué dans ces situations, pour maintenir un débit suffisant dans le lambeau. L'hypotension est souvent traitée au moyen de bolus de liquide intraveineux. Cependant, l'administration énergique de liquides pour maintenir une tension artérielle suffisante peut provoquer un oedème du lambeau, un engorgement veineux et, au bout du compte, la perte du lambeau. OBJECTIF: L'objectif primaire de la présente étude visait à déterminer si la perfusion de liquides axée sur des objectifs, titrée pour maintenir la variation du volume de débit systolique à un maximum de 13 % au moyen d'un dispositif de contour de l'onde de pouls artériel, assure une amélioration de l'indice cardiaque postopératoire (IC) et de l'indice de débit systolique (IDS) et une moins grande utilisation de liquide intraveineux. Les paramètres primaires étudiés étaient l'IC, l'IDS et l'administration cumulative de crystalloïdes et de colloïdes. MÉTHODOLOGIE: Les chercheurs ont étudié 20 patientes subissant une reconstruction simultanée par lambeau libre microvasculaire suivant immédiatement une mastectomie. Les soins préopératoires et peropératoires ont été standardisés. Chaque patiente était soumise à une surveillance de la tension intra-artérielle. Le débit cardiaque de toutes les patientes a été mesuré pendant la période peropératoire au moyen du dispositif de contour de l'onde de pouls artériel. Les patientes témoins se sont fait administrer le liquide au moment déterminé par l'anesthésiste (non informé de résultats du dispositif de débit cardiaque). Les patientes du groupe d'intervention ont reçu une infusion crystalloïde initiale de 5 mL/kg/h, de même que des bolus de colloïde intraveineux pour maintenir une variation du débit systolique à un maximum de 13 %. RÉSULTATS: Il n'y avait pas de différence de fréquence cardiaque ou de tension artérielle moyenne entre les groupes à la fin de l'opération. Cependant, le groupe d'intervention présentait alors un IC moyen (± ÉT, 3,8±0,8 L/min/m2 par rapport à 3,0±0,5 L/min/m2; P=0,02) et un IDS (51,4±2,4 mL/m2 par rapport à 43,3±2,3 mL/m2; P=0,03) considérablement plus élevés. Cette amélioration de l'IC et de l'IDS se produisait au moyen de quantités similaires de liquide peropératoire (5,8±0,5 mL/kg/h par rapport à 5,0±0,7 mL/kg/h, groupe témoin par rapport au groupe d'intervention). Le groupe d'intervention avait besoin de moins de réanimation par liquide postopératoire au début de la période postopératoire (quantité totale de liquide administrée entre la fin de l'opération et minuit le jour de l'opération, 6,4±1,9 mL/kg/h par rapport à 10,2±3,3 mL/kg/h, groupe d'intervention par rapport au groupe témoin, respectivement, P<0,01). EXPOSÉ: La perfusion de liquides axée sur des objectifs faisant appel à une surveillance minimalement invasive du débit cardiaque assurait une amélioration de l'hémodynamique en fin d'opération, et l'administration d'un moins grand volume de liquide de « rattrapage ¼ pendant la période périopératoire.

A key to canthopexy: the tarsal strap. A fresh cadaveric study.

BACKGROUND: This article describes a poorly understood yet clinically significant eyelid structure the authors have labeled the tarsal strap. The tarsal strap anchors the tarsus to the periosteum of the inferolateral orbit. Releasing this tethering band is the cornerstone of achieving lasting, superior surgical results during lateral canthopexy and periorbital restoration in aesthetic and reconstructive surgery. METHODS: An 87-year-old, male, fresh cadaveric head of Caucasian origin was studied. The dissection was repeated on 15 cadaver heads, including both male and female cadavers, from various ethnic backgrounds, to confirm the anatomy of the tarsal strap described in this article. RESULTS: The tarsal strap was identified in all 16 cadaver dissections and appeared in a consistently similar location. CONCLUSIONS: Until now, the tarsal strap has been a poorly understood entity, despite being an anatomically and clinically significant eyelid structure. Knowledge of its significance is essential to restoring the lateral canthus and returning periorbital structures to their youthful state. It should be routinely sought out and properly released.