The no-vertical scar technique for oncoplastic breast reconstruction.

INTRODUCTION: Oncoplastic reconstruction can optimize breast conserving therapy. Nipple loss is a concern in patients with significant ptosis and breast hypertrophy particularly with pedicle undermining during tumor resection. The modified Robertson technique (No-Vertical Scar reduction) has been previously described for breast reduction in large, ptotic patients using a wide, bell-shaped inferior pedicle with only inframammary fold and peri­areolar incisions. The purpose of this study was to evaluate the No-Vertical Scar (NVS) technique applied to oncoplastic reconstruction. METHODS: Women undergoing oncoplastic breast reduction using a NVS, Wise, or Vertical method were assessed. Predictive variables included patient demographics, comorbidities, and sternal notch to nipple (SNN) distance. Outcome variables were delayed wound healing, surgical site infection, seroma, fat necrosis, nipple necrosis, use of a free nipple graft, and time between surgery and adjuvant radiation. RESULTS: Fifty patients met inclusion criteria using NVS (N = 15), Wise (N = 16), and Vertical (N = 19) methods. The NVS group had a significantly higher BMI (p=.009), greater sternal notch to nipple distance (p=<0.001) and increased resection volume (p=<0.001) as compared to Wise and Vertical groups. There was no significant difference in complications (p=.25). No nipple necrosis occurred, and no free nipple grafts were required. CONCLUSION: The NVS approach is a useful technique for oncoplastic reconstruction in select patients with macromastia and severe Grade II or Grade III ptosis. The wide, bell-shaped pedicle is versatile for obliterating a lumpectomy cavity and optimizing nipple perfusion if pedicle undermining occurs during resection.

Advantages of the Delayed-Immediate Microsurgical Breast Reconstruction: Extending the Choice.

BACKGROUND: Deep inferior epigastric perforator (DIEP) reconstruction can be performed in an immediate (at time of mastectomy), delayed-immediate (immediate tissue expander followed by staged DIEP), or delayed timing following mastectomy. Avoiding flap radiation is a known benefit of the delayed-immediate approach. The purpose of this study is to evaluate patients who chose DIEP flap as the reconstructive method during initial consultation and compared characteristics of surgery in relation to their final reconstructive choice. METHODS: Consecutive patients having breast reconstruction from 2017 to 2019 were divided into three groups: immediate DIEP after mastectomy (Group I); delayed-immediate DIEP with tissue expander first followed by DIEP (Group II); and patients who initially chose delayed-immediate DIEP but later decided on implants for the second stage of reconstruction (Group III). Exclusion criteria were patients that had delayed DIEP (no immediate reconstruction) or had initially chose implant-based reconstruction. RESULTS: The study included 59 patients. Unilateral free flaps in Group II had shorter operative times (318 minutes) compared with Group I unilateral free flaps (488 minutes) (p = 0.024). Eleven patients (30.6%) had prophylactic mastectomies in Group I compared with none in Group II (p = 0.004). Patients who had immediate tissue expansion frequently changed their mind from DIEP to implant for second stage reconstruction frequently (52.2%). CONCLUSION: Delayed-immediate DIEP reconstruction has several advantages over immediate DIEP flap including shorter free flap operative times. Patients commonly alter their preference for second stage reconstruction. A patient-centered advantage of delayed-immediate reconstruction is prolonging the time for patients to make their choice for the final reconstruction.

Evaluation of an Extended-duration Chemoprophylaxis Regimen for Venous Thromboembolism after Microsurgical Breast Reconstruction.

Patients undergoing free flap breast reconstruction are at a high risk for venous thromboembolism based upon Caprini scores. Guidelines for venous thromboembolism prophylaxis recommend high-risk groups receive extended chemoprophylaxis for several weeks after gynecological, orthopedic, and surgical oncology cases. Extended prophylaxis has not been studied in free flap breast reconstruction. The purpose of this study was to compare outcomes of free flap breast reconstruction patients who received extended venous thromboembolism (VTE) prophylaxis with those who received standard inpatient-only prophylaxis. METHODS: Patients undergoing microsurgical breast reconstruction were divided into two groups: standard VTE prophylaxis (Group I) and extended prophylaxis (Group II). Both groups received prophylactic subcutaneous heparin or enoxaparin preoperatively and enoxaparin 40 mg daily postoperatively while inpatient. Group II was discharged with a home regimen of enoxaparin 40 mg daily for an additional 14 days. RESULTS: In total, 103 patients met inclusion criteria (36 patients in Group I, 67 patients in Group II). The incidence of VTE was 1.5% in Group II compared with 2.8% in Group I (P = 0.6). There was no difference in reoperative hematoma between Group I (n = 0) and Group II (n = 1) (P = 0.7). Total flap loss was 2.2%. CONCLUSIONS: Although this retrospective pilot study did not show statistical significance in VTE between those receiving extended home chemoprophylaxis (1.5% incidence) compared with inpatient-only chemoprophylaxis (2.8%), the risk of bleeding complications was similar. These results indicate that a larger, higher powered study is justified to assess if an extended home chemoprophylaxis protocol should be standard of care post free flap breast reconstruction.

Immediate Lymphatic Reconstruction after Axillary Lymphadenectomy: A Single-Institution Early Experience.

PURPOSE: Lymphedema is progressive arm swelling from lymphatic dysfunction which can occur in 30% patients undergoing axillary dissection/radiation for breast cancer. Immediate lymphatic reconstruction (ILR) is performed in an attempt decrease the risk of lymphedema in patients undergoing axillary lymph node dissection (ALND). The purpose of this study was to assess the efficacy of ILR in preventing lymphedema rates in ALND patients. METHODS: An institutional review board-approved retrospective review was performed of all patients who underwent ILR from 2017 to 2019. Patient demographics, comorbidities, operative and pathologic findings, number of LVAs, limb measurements, complications, and follow-up were recorded and analyzed. Student's sample t-test, Fisher's exact test, and ANOVA were used to analyze data; significance was set at p < 0.05. RESULTS: Thirty-three patients were included in this analysis. Three patients (9.1%) developed persistent lymphedema, and two patients (6.1%) developed transient arm edema that resolved with compression and massage therapy. A significant effect was found for body mass index and the number of lymph nodes taken on the development of lymphedema (p < 0.01). CONCLUSIONS: The rate of lymphedema in this series was 9.1%, which is an improvement from historical rates of lymphedema. Our findings support ILR as a technique that potentially decreases the incidence of lymphedema after axillary lymphadenectomy. Obesity and number of lymph nodes removed were significant predictive variables for the development of lymphedema following LVA.

The False Positive Rate of Transcutaneous Tissue Oximetry Alarms in Microvascular Breast Reconstruction Rises after 24 Hours.

BACKGROUND: Transcutaneous tissue oximetry is widely used as an adjunct for postoperative monitoring after microvascular breast reconstruction. Despite a high sensitivity at detecting vascular issues, alarms from probe malfunctions/errors can generate unnecessary nursing calls, concerns, and evaluations. The purpose of this study is to analyze the false positive rate of transcutaneous tissue oximetry monitoring over the postoperative period and assess changes in its utility over time. METHODS: Consecutive patients undergoing microvascular breast reconstruction at our institution with monitoring using transcutaneous tissue oximetry were assessed between 2017 and 2019. Variables of interest were transcutaneous tissue oximetry alarms, flap loss, re-exploration, and salvage rates. RESULTS: The study included 175 patients (286 flaps). The flap loss rate was 1.0% (3/286). Twelve patients (6.8%) required re-exploration, with 9 patients found to have actual flap compromise (all within 24 hours). The salvage rate was 67.0%. The 3 takebacks after 24 hours were for bleeding concerns rather than anastomotic problems. Within the initial 24-hour postoperative period, 43 tissue oximetry alarms triggered nursing calls; 7 alarms (16.2%) were confirmed to be for flap issues secondary to vascular compromise. After 24 hours, none of the 44 alarms were associated with flap compromise. The false positive rate within 24 hours was 83.7% (36/43) compared with 100% (44/44) after 24 hours (p = 0.01). CONCLUSION: The transcutaneous tissue oximetry false positive rate significantly rises after 24 hours. The benefit may not outweigh the concerns, labor, and effort that results from alarms after postoperative day 1. We recommend considering discontinuing this monitoring after 24 hours.

Preoperatively Identified Sarcopenia Leads to Increased Postoperative Complications, Hospital and ICU Length of Stay in Autologous Microsurgical Breast Reconstruction.

BACKGROUND: Sarcopenia is a condition characterized by the loss of skeletal muscle mass and strength. Recently, there has been a tremendous amount of research into the prognostic value of sarcopenia in surgical outcomes. The purpose of this study was to compare postoperative outcomes in free flap breast reconstruction in patients with and without sarcopenia. METHODS: One hundred three patients who underwent autologous breast reconstruction from 2013 to 2016 were studied. The cross-sectional area (CSA) of skeletal muscle was measured from preoperative computed tomography images at L3 using the National Institutes of Health ImageJ software. CSA was then normalized to patient stature by dividing CSA by height (cm2/m2). A previously published skeletal muscle index cutoff of 38.5 cm2/m2 was used to define sarcopenia. Intraoperative and postoperative surgical outcomes were recorded retrospectively. Outcomes were analyzed using multivariate, univariate, and regression statistics. RESULTS: Eight of the 103 (7.8%) patients were found to have sarcopenia. Sarcopenia was associated with a statistically significant increase in flap site delayed healing (37.5% vs. 20%, p = 0.046), take back to the operating room (25% vs. 11.6%, p = 0.05), intensive care unit length of stay (1.5 vs. 0.02 days, p < 0.0005), and hospital length of stay (8.38 vs. 5.49 days, p < 0.0005) when compared with patients without sarcopenia. There were no significant differences in flap loss, surgical site infection, hematoma, seroma, donor site delayed healing, intraoperative complications, and number of revision surgeries. CONCLUSION: Sarcopenia is significantly associated with increased complications in patients undergoing free flap breast reconstruction. Further investigation into the biochemical and physiologic changes associated with sarcopenia is needed.

Response to review article published titled 'Total ankle arthroplasty versus ankle arthrodesis - a comparison of outcomes over the last decade'.

We write in response to Lawton et al.'s (J Orthop Surg Res 12:76, 2017) important systematic review comparing the outcomes of total ankle replacement (TAR) and ankle arthrodesis (AA) after reviewing the existing literature. Traditionally, AA was the gold standard treatment for ankle osteoarthritis but there is renewed interest in TAR given modern design advantages of preserved ankle motion and gait. We outline some pertinent issues for surgeons to consider when interpreting results from review articles comparing treatment types given the limitations of primary studies. These include significant clinical heterogeneity from the indication for surgery, different treatment type subgroups and from poorly defined clinical outcomes.