Supra-arcuate free fascial MS-TRAM, a modified technique to reduce donor site morbidity in obese population-comparative study.

BACKGROUND: Abdomen-based free flaps represent the gold standard option in the armamentarium of breast reconstruction. The natural evolution to more preservation with less invasive forms of these flaps has been driven by both patient and surgeon satisfaction. Nevertheless, obese patients are challenging due to the increased risk of compromised flap perfusion and donor site morbidity. This challenge is compounded by the prevalence of obesity worldwide, resulting in more free abdominal flaps being performed for breast reconstruction in obese patients. The authors present the outcomes of a modified supra-arcuate fascial muscle-sparing transverse rectus abdominus myocutaneous (FMS-TRAM) technique compared to standard muscle-sparing transverse rectus abdominus myocutaneous (MS-TRAM) technique to reduce the donor site morbidity while providing a well-vascularized large volume of autologous tissue. METHODS: A retrospective comparative data analysis was conducted at two centers: Cairo University Hospitals, Egypt, and University Hospitals Birmingham, United Kingdom. Standard MS-TRAM was performed in 65 patients between 2008 and 2011 (Group 1) versus 275 patients between 2011 and 2020 (Group 2) who underwent FMS-TRAM. The modified technique involved limiting the fascial incision to above or at the level of the arcuate line to preserve the integrity of the anterior rectus sheath caudally. All patients included were of the obese population (BMI≥30 kg/m2 ) and underwent unilateral post-mastectomy reconstruction. Patient demographics, comorbidities, operative details, and outcomes focusing on donor site morbidity and flap complications were recorded and compared between the two groups. RESULTS: The median age and BMI for Group 1 were 43 and 32, respectively. While for Group 2, they were 47 and 33, respectively. Flap weight ranged from 560 to 1470 g (Mean 705) for Group 1, while Group 2 ranged from 510 to 1560 (mean 715). The majority (280/340 [82%]) of the patients in both groups received radiotherapy. 7.7% of Group 1 were smokers, while in Group 2 it was 4.7%. The percentage of delayed versus immediate reconstruction in Group 1 was 60%/40%, while in Group 2, it was 43%/56%. The incidence of fat necrosis, partial necrosis, and total necrosis was 7.6%.1.5%, and 3%, respectively, for Group 1 and 8%, 1.4%, and 2.6%, respectively, for Group 2. The two-tailed p-value demonstrated a significant statistical difference (p < 0.00001) in donor site morbidity between both groups, with more bulge 20% (13/65) and hernia 1.5% (2/65) occurrence in Group 1 versus 1.9% (5/275) and 0.7% (2/275) in Group 2 respectively, over a follow-up period ranging from 24 to 60 months (mean 32). CONCLUSION: FMS-TRAM flaps are safe, robust, and reliable with less donor site morbidity while maintaining optimal flap perfusion for large volume flaps in obese patients with excellent, durable outcomes. It should be considered a valuable tool in the reconstructive armamentarium of breast reconstruction.

Acromiothoracic Venous Supercharge for Abdominal-Based Free Flaps in Breast and Chest Wall Reconstruction.

BACKGROUND: Supercharging the venous drainage of free abdominal flaps in breast reconstruction has been well described in the literature, with diverse options used to augment venous drainage. In this study, we present our experience in using the acromiothoracic vein (ATV)/thoracoacromial vein (TAV) as a secondary recipient vein for the superficial inferior epigastric vein (SIEV) of free, muscle-sparing transverse rectus abdominis myocutaneous flaps in breast and chest wall reconstruction. PATIENTS AND METHODS: We retrospectively reviewed 523 free, muscle-sparing transverse rectus abdominis myocutaneous flaps the senior author (H.H.K.) performed between 2009 and 2022 for breast and chest wall reconstruction; 46 cases required venous super drainage. Seventeen patients had ipsilateral SIEV anastomosed into the second internal mammary vein, 5 had ipsilateral SIEV anastomosed into flap second deep inferior epigastric vein, and 24 required the use of the (ATV)/(TAV), which will be the focus of this study. RESULTS: The study included 24 female (20 breast and 4 chest wall reconstruction) patients ranging in ages between 39 and 72 years. They had a median follow-up of 26 months. Combined muscle splitting and cutting techniques were used to expose the ATV/TAV. Increase in operative time ranged between 10 and 20 minutes (median, 12 minutes). Vein coupler sizes were 1.5 to 3 mm. The mean weight of the flap was 740 g (range, 460-1300 g). There was 1 flap failure (salvage with latissimus dorsi flap performed), whereas 23 flaps wholly survived. CONCLUSIONS: The ATV/TAV is a suitable recipient for venous supercharging free flaps used to reconstruct breast and chest wall defects.

Sacroperineal Reconstruction With Inferior Gluteal Artery Perforator Flaps After Resection of Locally Advanced Primary and Recurrent Anorectal Malignancy.

ABSTRACT: Modern interdisciplinary concepts with involvement of various surgical specialties can considerably reduce perioperative morbidity after sacroperineal resection of locally advanced primary or recurrent anorectal malignancies. Resultant defects can represent a major challenge for reconstruction particularly with chemoradiotherapy. The aim is to assess the long-term outcomes of sacroperineal reconstruction using inferior gluteal artery perforator flaps.We performed a retrospective data analysis on 31 patients who were treated with inferior gluteal artery perforator flaps (n = 61) over the period 2009-2021. The demographic data, comorbidities, operative details, and outcomes with special focus on wound infection and dehiscence were recorded.The median age was 42 year (range, 25-82 years) with preponderance of males (n = 21). The follow-up period ranged from 6 to 80 months. Early minor complications included superficial wound dehiscence (3), which was managed conservatively, whereas the major (2) included deep wound collection and infection (1), which required surgical drainage, and perineal hernia, which required repair. All flaps survived completely.Inferior gluteal artery perforator flaps are safe, robust, and reliable with less donor side morbidity and positive impact on quality of life. It should be considered as a valuable tool in the reconstructive armamentarium of sacroperineal defects within a multidisciplinary setting.

Salvage of Extensively Scarred Hands: Wide Awake Tenolysis and Interpositional Free Tissue Transfer.

BACKGROUND: This study introduced a dedicated technical approach to extensive hand adhesions, combined with failed primary nerve reconstruction. Wide awakelocal anesthesia no tourniquet (WALANT) tenolysis and interpositional free tissue transfer forge the main facets of the proposed reconstructive strategy. METHODS: A prospective study was conducted, including 22 patients diagnosed with extensive tendon adhesions in addition to failed primary nerve repair. After wide awake tenolysis, 20 adipofascial radial forearm flaps and two ALT flaps were used to wrap the tendons, whereas the nerves were grafted after complete separation from the tendons. Nerve recovery; final total range of motion of the fingers; and the disabilities of the arm, shoulder, and hand score were recorded in detail. RESULTS: All flaps healed uneventfully. Final assessment of the median nerve revealed M3 or more motor power and S3 sensory recovery in all patients except one patient who attained no muscle power at all and S1 as regards the sensory assessment. The ulnar nerve evaluation revealed that two of five patients did not recover motor power at all (M0), and the remaining three patients recovered M3 motor power with variable sensory outcomes. Final assessment of total range of motion of the fingers and the DASH score showed a statistically significant improvement except for one patient. CONCLUSION: WALANT tenolysis and interposition of well-vascularized fascial flaps along with simultaneous nerve grafts in extensively scarred hands provided goodfunctional outcomes.

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.

A constant harvest technique for chimeric anterolateral thigh flaps and patient outcomes following their use in reconstructive head and neck surgery.

BACKGROUND: Chimeric anterolateral thigh free flaps (ALT) have been commonly used for head and neck defects, which require two epithelial lined surfaces. However, because of unpredictable vascular anatomy, it is a challenge to consistently elevate large chimeric flaps with multiple perforators based on the Lateral Circumflex Femoral Artery (LCFA). Here, we present our method to reliably harvest a chimeric flap from the ALT territory and investigate its long-term outcomes when used in the reconstruction of extensive head and neck defects. METHODS: A prospective review of practice consisting of 27 patients, between January 2011 and April 2019, with extensive through-and-through head and neck defects, which require dual paddle flaps underwent reconstruction with chimeric ALT harvested with a portion of distal vastus lateralis. The age of the patients ranged from 32 to 68 years (mean 53.2 years). RESULTS: Flap length ranged from 17 to 30 cm (mean, 25.6 cm). The mean flap area was 261.6 cm2 (range, from 225 to 340 cm2). The mean ischemia time was 162.9 min (range, from 59 to 269 min). At a mean follow-up time of 33.4 months (range, from 4 to 91 months), four patients died of cancer recurrence. For the other 23 patients, 4 required revision to achieve better cosmetic lip competence. All flaps survived with two recorded returns to theater for pedicle exploration associated with partial flap loss only. CONCLUSION: Harvesting the chimeric ALT with a portion of vastus lateralis distally negates the need for tenuous intramuscular perforator dissection. It is a reliable option for head and neck surgery, which require composite reconstruction. Using this technique produces a good functional cosmetic outcome. It also allows large defects to be reconstructed in a single sitting with free tissue transfer.