Staging computerized tomography before delayed breast reconstruction could alter the management plan.

BACKGROUND: Delayed breast reconstruction (DBR) comprises a significant proportion of breast reconstruction practice post completion of breast cancer treatment. The tumour's biology, staging, time constraints, ongoing treatment, and patient and surgeon's preference influence the decision to pursue DBR. There are no guidelines for assessing the oncological status before DBR in otherwise asymptomatic patients, particularly in those with a higher risk of recurrence. The purpose of this study was to identify the cohort of patients who could potentially benefit from staging CT scan before DBR regardless of the reconstructive modality and its impact on the overall management. MATERIAL AND METHODS: A retrospective review on 207 consecutive patients, who underwent staging CT scan before DBR in the period between 2009 and 2019 was performed. The CT scan findings were correlated with the breast prognostication scoring model (Nottingham Prognostic Index [NPI]) as an indicator factor for staging reasons. RESULTS: Incidental findings were reported in 34% (71/207) of the reviewed CT scans (incidentaloma group). There was no statistical significance in the NPI scores between non incidentaloma and incidentaloma groups. However, 5.7% (12/207) had their DBR procedure cancelled or the surgical plan altered. CONCLUSION: The patients with moderate to poor prognosis (NPI score 3.4 and above) could benefit from CT staging scan before DBR. This scan could detect adverse prognostic features precluding major surgery, which saves patients from unnecessary surgical risks and discomfort, and direct them towards the relevant management pathway.

Preoperative Long-term Therapeutic Subcutaneous Heparin Administration into Abdomen: Possible Cause for Nonobstructive Microvascular Flap Failure.

The anterioabdominal wall is the most common site for low molecular weight heparin administration for anticoagulation, either for prophylactic or for therapeutic indications. Occasionally, this could be associated with damage of the abdominal pannus microvasculature, which could possibly jeopardize the reliability of free abdominal flaps as deep inferior epigastric perforator and muscle sparing transverse rectus abdominis muscle, especially with therapeutic anticoagulation therapy. These flaps are reliant on a highly intricate complex vascular anatomy and perforasomes for their adequate perfusion and survival. The authors report a case of nonobstructive microvascular failure of a free muscle sparing transverse rectus abdominis muscle utilized for soft tissue coverage following resection of a chest wall breast cancer recurrence on a background of portacath-induced deep venous thrombosis of the axillary and subclavian vein whilst on chemotherapy. History of long-term therapeutic low molecular weight heparin administration in the abdomen resulted in microangiopathic densities evident on computerized tomography scan with subsequent flap failure due to possible jeopardization of the flap microvasculature and perfusion. Following exclusion of common local and systemic factors that can cause vascular compromise, a debridement and salvage re-reconstruction procedure utilizing a contralateral free latissimus dorsi flap was performed. Reconstructive surgeons should be cautious when planning to utilize free abdominal-based flaps on the background of long-term therapeutic low molecular weight heparin administration in the abdomen and may possibly explore other alternative options of using non-abdominal free flaps from the reconstructive armamentarium within this unique context.

Nipple-Sparing Mastectomy and Prepectoral Implant/Acellular Dermal Matrix Wrap Reconstruction in Large Ptotic Breasts.

Nipple-sparing mastectomy (NSM) with simultaneous prepectoral direct to implant reconstruction and acellular dermal matrix (ADM) is increasingly offered to patients opting for prophylactic or therapeutic mastectomies. The recent introduction of prepectoral implant/ADM in the armamentarium of breast reconstruction has proven to reduce pain and animation deformity. Despite this promising method, patients with macromastia and ptotic breasts remain a challenging group to treat. More often they would require secondary corrective procedures and can experience high failure rate and unsatisfactory outcomes. The authors present their experience in utilizing a bipedicled nipple-areola complex dermal flap through Wise pattern to achieve a successful NSM with prepectoral implant/ADM (Braxon) wrap (IBW) as a single stage in patients with large ptotic breasts. Patients seeking NSM with large ptotic breasts were included in the study in the period between 2016 and 2018. They were offered a single-stage Wise pattern NSM and immediate prepectoral IBW breast reconstruction. The technique and outcomes were recorded. Sixteen reconstructions were performed in 8 women with a median age of 32 years (range, 27-50 years) and a median body mass index of 32 kg/m2 (range, 29-39 kg/m2). The resected breasts weight ranged from 750 to 1,600 g (median, 890 g). All procedures were completed successfully with no nipple-areola complex necrosis or failure experienced during the follow-up period (range, 3-24 months) with all patients reported excellent satisfaction. The authors' results demonstrate that this technique could be safely planned for NSM in large ptotic breasts with excellent durable outcomes.

Chest Wall Reconstruction with Porcine Acellular Dermal Matrix (Strattice) and Autologous Tissue Transfer for High Risk Patients with Chest Wall Tumors.

BACKGROUND: Tenets of chest wall reconstruction for malignancy are well known; however, the insertion of synthetic prosthetic material to achieve rigid and nonrigid skeletal reconstruction could be associated with more complications including infection and extrusion especially in high risk patients. This includes fungating, infected tumors, previous radiotherapy, scars, smoking, diabetes, and morbid obesity. Bioprosthesis Acelluar Dermal Matrix Strattice would be a substitute to resist infection and provide stable coverage. METHODS: A retrospective data analysis study on 8 high-risk patients who underwent chest wall resection and reconstruction with bioprosthesis (Strattice) with/without titanium plates in the period between 2012 and 2017 was performed. Patient's demographics, risk factors, clinico-pathological, radiological, operative details, adjuvant therapy, postoperative morbidity, and follow-up data were recorded. RESULTS: Sarcoma was the pathology in 7 and recurrent breast cancer in 1 with age range from 21 to 71 years (mean, 50) and preponderance of female patients (n = 5). Defects were located anterior/anterolateral with size ranging from 270 to 1,050 cm2 (mean, 511). Reconstruction was performed using Strattice only in 4 patients, whereas in 4 it was combined with titanium plates. All patients required flap reconstruction (3 pedicled and 5 free). The follow-up ranged from 9 to 52 months (mean, 24.8). Minor complications occurred in 2 patients; however, good functional outcome was achieved in all. CONCLUSION: Strattice would act as a safe alternative modality for chest wall reconstruction to resist infection in high-risk patients with extensive defects. It should be considered as a valuable tool in the armamentarium of chest wall reconstruction.

Internal Pudendal Artery Perforator Island Flap for Management of Recurrent Benign Rectovaginal Fistula.

The management of recurrent rectovaginal fistula after obstetric injury and cryptoglandular sepsis is considered a major surgical challenge. The fistula poses a significant negative psychosocial and sexual morbidity. In addition, the poor quality of local tissues due to previous attempts at surgical repair adds to this challenge. There are few data regarding the management of persistent or recurrent fistula in the literature; however, several studies reported high failure rates after 2 or more procedures. We present 4 cases managed successfully in a multidisciplinary approach involving fistulectomy and immediate reconstruction with an internal pudendal artery perforator island flap.

Multidisciplinary Oncoplastic Approach Reduces Infection in Chest Wall Resection and Reconstruction for Malignant Chest Wall Tumors.

BACKGROUND: Management of complex thoracic defects post tumor extipiration is challenging because of the nature of pathology, the radical approach, and the insertion of prosthetic material required for biomechanical stability. Wound complications pose a significant problem that can have detrimental effect on patient outcome. The authors outline an institutional experience of a multidisciplinary thoracic oncoplastic approach to improve outcomes. METHODS: Prospectively collected data from 71 consecutive patients treated with chest wall resection and reconstruction were analyzed (2009-2015). The demographic data, comorbidities, operative details, and outcomes with special focus on wound infection were recorded. All patients were managed in a multidisciplinary approach to optimize perioperative surgical planning. RESULTS: Pathology included sarcoma (78%), locally advanced breast cancer (15%), and desmoids (6%), with age ranging from 17 to 82 years (median, 42 years) and preponderance of female patients (n = 44). Chest wall defects were located anterior and anterolateral (77.5%), posterior (8.4%), and apical axillary (10%) with skeletal defect size ranging from 56 to 600 cm(2) (mean, 154 cm(2)). Bony reconstruction was performed using polyprolene mesh, methyl methacrylate prosthesis, and titanium plates. Soft tissue reconstructions depended on size, location, and flap availability and were achieved using regional, distant, and free tissue flaps. The postoperative follow-up ranged from 5 to 70 months (median, 32 months). All flaps survived with good functional and aesthetic outcome, whereas 2 patients experienced surgical site infection (2.8%). CONCLUSIONS: Multidisciplinary thoracic oncoplastic maximizes outcome for patients with large resection of chest wall tumors with reduction in surgical site infection and wound complications particularly in association with rigid skeletal chest wall reconstruction.