Revisiting Anastomosis to the Retrograde Internal Mammary System in Stacked Free Flap Breast Reconstruction: An Algorithmic Approach to Recipient-Site Selection.

BACKGROUND: The authors present their stacked flap breast reconstruction experience to facilitate selection of either caudal internal mammary vessels or intraflap vessels for the second recipient anastomosis. METHODS: A retrospective review was conducted of multiflap breast reconstructions (double-pedicled deep inferior epigastric perforator, stacked profunda artery perforator, and stacked profunda artery perforator/deep inferior epigastric perforator) performed at the authors' institution from 2011 to 2018. Data collected included demographics, recipient vessels used, and intraoperative/postoperative flap complications. Complications were compared between cranial, caudal, and intraflap anastomoses. RESULTS: Four hundred stacked flaps were performed in 153 patients. Of 400 arterial anastomoses, 200 (50 percent) were to cranial internal mammary vessels, 141 (35.3 percent) were to caudal internal mammary vessels, and 59 (14.8 percent) were to intraflap vessels. Of 435 venous anastomoses, 145 (33.3 percent) were to caudal internal mammary vessels, 201 (46.2 percent) were to cranial internal mammary vessels, and 89 (20.5 percent) were to intraflap vessels. Intraoperative revision for thrombosis occurred in 12 of 141 caudal (8.5 percent), 14 of 20 cranial (7 percent), and seven of 59 intraflap (11.9 percent) arterial anastomoses (p = 0.373), and in none of caudal, three of 201 cranial (1.5 percent), and two of 89 intraflap (2.2 percent) venous anastomoses (p = 0.559). Postoperative anastomotic complications occurred in 12 of 400 flaps (3 percent) and were exclusively attributable to venous compromise; seven of 12 (58.3 percent) were salvaged, and five of 12 (41.7 percent) were lost. More lost flaps were caused by caudal [four of five (80 percent)] versus cranial [one of five (20 percent)] or intraflap (zero of five) thrombosis (p = 0.020). CONCLUSION: If vessel features are equivalent between the caudal internal mammary vessels and intraflap vessels, intraflap vessels should be used for second site anastomosis in stacked flap reconstructions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Simplifying Lip Reconstruction: An Algorithmic Approach.

The authors provide an overview of lip reconstruction after Mohs surgery based on the senior author's practice. Lip reconstruction offers unique challenges to preserve not only lip function but also aesthetics. Lip reconstruction must take into consideration the three anatomical layers that comprise the lip and defects that involve the mucosa, the muscle, the skin or more than one layer will help determine the modality of repair. The authors offer an algorithm based on defect location, tissue involvement, and severity of defect to simplify an often complex decision-making process.

Immediate versus Delayed Sarcoma Reconstruction: Impact on Outcomes.

Background. Sarcoma is a rare malignancy, and more recent management algorithms emphasize a multidisciplinary approach and limb salvage, which has resulted in an increase in overall survival and limb preservation. However, limb salvage has resulted in a higher rate of wound complications. Objective. To compare the complications between immediate and delayed (>three weeks) reconstruction in the multidisciplinary limb salvage sarcoma patient population. Methods. A ten-year retrospective review of patients who underwent sarcoma resection was performed. The outcome of interest was wound complication in the postoperative period based on timing of reconstruction. We defined infection as any infection requiring intravenous antibiotics, partial flap failure as any flap requiring a debridement or revision, hematoma/seroma as any hematoma/seroma requiring drainage, and wound dehiscence as a wound that was not completely intact by three weeks postoperatively. Results. 70 (17 delayed, 53 immediate) patients who underwent sarcoma resection and reconstruction met the inclusion criteria. Delayed reconstruction significantly increased the incidence of postoperative wound infection and wound dehiscence. There was no difference in partial or total flap loss, hematoma, or seroma between the two groups. Discussion and Conclusion. Immediate reconstruction results in decreased wound complications may reduce the morbidity associated with multidisciplinary treatment in the limb salvage sarcoma patient.

Predictive factors of wound complications after sarcoma resection requiring plastic surgeon involvement.

INTRODUCTION: The most effective management of a patient with sarcoma is surgical resection. Often the resection is performed, the wound is irradiated, adjuvant chemotherapy is administered, and the wound is closed without plastic surgery consultation. Wound complications, after these treatment protocols, often require plastic surgery involvement and the treatment may require more advanced reconstructive techniques with higher rates of complications than if involvement occurred earlier. METHODS: A retrospective review of all patients who underwent sarcoma excision from 2001 to 2011 was performed. Factors such as tumor size, radiation, chemotherapy, delayed reconstruction (>3 weeks), and immediate reconstruction (<3 weeks) were analyzed for their correlation with wound complications or flap loss. RESULTS: A total of 127 patients underwent sarcoma resection. Wound complications occurred in 49 (38%) patients. All 15 delayed reconstructions had a wound complication, whereas only 11 (37%) of immediate reconstructions had a wound complication. Wound complications with tissue excision less than 500 g occurred in 18 (26%) patients and occurred in 31 (54%) patients with excision greater than 500 g. Seventy-two patients underwent radiation with a wound complication rate of 46% compared with 29% for patients who were not radiated. Chemotherapy was used in 35 patients with a wound complication rate of 49%. CONCLUSIONS: The most predictive factor of sarcoma complication is whether the procedure was a delayed or immediate reconstruction. The second most predictive factor is the amount of tissue excised, greater than 500 g of tissue excised was associated with significantly higher complication rates. Other aspects of sarcoma treatment that may be correlated with higher incidence of wound complications are radiation and the use of adjuvant chemotherapy. Early plastic surgery involvement can help with preoperative planning and reduce the complication rates in patients with sarcoma resection.