[BREAST CANCER-RELATED LYMPHEDEMA: INCIDENCE AND RISK FACTORS, PREVENTIVE MEASURES AND TREATMENTS].

INTRODUCTION: Lymphedema is a pathological condition in which intercellular protein-rich fluid accumulates and leads over time to inflammation, adipose tissue hypertrophy and fibrosis. Secondary lymphedema is caused by injury or blockage of the lymphatic system and the main cause in the Western world is the treatment of a variety of cancers, the main one being breast cancer. Chronic arm edema after breast cancer surgery is a common problem with an estimated incidence of 1 in 5 patients after breast cancer treatment. In this article we review the main risk factors, approaches to reducing the risk of developing lymphedema after treatment for breast cancer and existing treatment protocols for lymphedema including the surgical innovations in this field and our experience in these innovative surgical approaches. To date, 26 physiological surgeries have been performed at the Tel Aviv Medical Center using the microsurgical approach for treating lymphedema. These surgeries had no significant complications and the improvement was observed to be greater in the group of patients with secondary lymphedema. Lymphovenous anastomosis and vascularized lymph node transfer offer promising solutions for the treatment of breast cancer related lymphedema. The introduction of additional techniques and the refinement of these procedures will probably continue to improve the results in the future.

Superiomedial Pedicle Breast Reduction for Gigantic Breast Hypertrophy: Experience in 341 Breasts and Suggested Safety Modifications.

BACKGROUND: Reduction mammoplasty in patients with gigantic breast hypertrophy runs a high risk of complication. Traditionally, inferior pedicle reductions or free nipple grafting techniques have been recommended for gigantic breasts on the basis of measurements and expected resection weights. The superiomedial pedicle (SMP) technique has been less commonly used, due to concerns of vascular inadequacy. This study examines the outcomes of SMP in large reductions and outlines suggested modifications for enhanced safety. METHODS: This is a retrospective review of all patients who underwent SMP breast reduction in our institution between 2005 and 2016. Included are cases with resection weights greater than 800 g. RESULTS: A total of 173 patients with 341 breasts were included. Mean sternal notch to nipple (SNN) distance was mean 35.0 ± 6.6 cm (range 23-44.5) on the left and 34.9 ± 6.6 cm (range 18-46) on the right. Mean resection weight was 1152.2 ± 368.6 g (range 810-2926) on the left and 1159.4 ± 326.6 g (range 800-2528) on the right. The total complication rate was 22.7%. Minor complications occurred in 63 (18.6%) breasts. Major complications occurred in 12 (4.1%) breasts. NAC congestion and partial necrosis occurred in 1.8% and total NAC necrosis in 0.9%. CONCLUSION: The SMP reduction technique is a safe option for gigantic breast reduction with comparable complication rates to other techniques. Preoperative measurements or resection weights are not reliable risk factors alone. High tissue density may be a significant risk factor. High-risk breasts mandate surgical planning and should be tailored to include technical modifications as described. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Latissimus Dorsi Flap: A Winning Hand for Breast Reconstruction Salvage.

BACKGROUND: There are several methods for primary breast reconstruction following oncologic resection, including alloplastic and autologous-based reconstruction. Major complications that can lead to re-operation and reconstruction failure occur in up to 25% of the patients and necessitate salvage procedures. OBJECTIVES: To present the authors' experience using a pedicled latissimus dorsi (LD) flap for the salvage of complicated and impending failed breast reconstruction. METHODS: A retrospective cohort study was conducted of all patients who underwent breast reconstruction salvage by means of an LD flap in our institution during a 5-year period. Demographic, oncologic, surgical, and postoperative data were collected and analyzed. RESULTS: Seventeen patients underwent breast reconstruction salvage with the LD flap. Fourteen patients had alloplastic reconstruction and three patients had autologous reconstruction. Postoperative complications included wound infection in three patients, minor wound dehiscence in two, and donor site seroma in two. One case of postoperative infection required re-operation with exchange of the implant with a tissue expander. All breast reconstructions were salvaged using the LD flap. Only one patient complained of functional limitations in using the arm of the harvested LD. CONCLUSIONS: The LD flap is a valuable and reliable flap for alloplastic or autologous breast reconstruction salvage and has a high rate of salvage success despite the challenging surgical environment. This flap offers a good cosmetic reconstruction outcome with relatively low donor-site morbidity and high patient satisfaction.

Oncoplastic partial breast reconstruction improves patient satisfaction and aesthetic outcome for central breast tumours.

BACKGROUND: Patients with centrally located tumours involving the nipple-areolar complex (NAC) who undergo breast-conserving treatment (BCT) are at high risk for breast deformity and asymmetry. Immediate oncoplastic breast reconstruction (OBR) can have a favourable impact on surgical outcome. METHODS: We retrospectively compared aesthetic outcomes and patient satisfaction among women treated with NAC lumpectomy and immediate OBR with patients treated with BCT alone. Aesthetic outcome was evaluated by independent observers, and patient satisfaction was assessed by the BREAST-Q questionnaire. RESULTS: A total of 24 patients were studied, 12 in each group. Demographics and oncological staging were similar in both groups, apart from mean age, hypertension and tumour size/lumpectomy weight. Patients in the OBR group had higher scores for aesthetic outcome and a higher degree of patient satisfaction from the surgical outcome compared to the patients in the BCT-alone group. CONCLUSIONS: The immediate OBR approach in the treatment of centrally located tumours with NAC resection has clear advantages over BCT alone. This approach should be considered for and offered to suitable patients.

Breast Reduction and Mastopexy for Repair of Asymmetry After Breast Conservation Therapy: Lessons Learned.

BACKGROUND: Breast conservation therapy (BCT) can cause breast distortion and asymmetry. Repair of this asymmetry by means of breast reduction or mastopexy procedures can be challenging and harbor considerably high rates of complications. METHODS: In this retrospective study, we describe our experience in repairing post-BCT breast asymmetry by performing breast reduction or mastopexy. The surgical protocol we followed consisted of stringent patient selection, thorough surgical planning, basic surgical refinements, and patient education for enhancing the likelihood of achieving a good outcome with minimal surgical complications. RESULTS: Our search of the departmental database identified 25 patients with breast asymmetry who had undergone breast reduction or mastopexy between 2009 and 2017. Corrective surgery was performed 4 years on average after the completion of radiotherapy, and those patients included eleven who had undergone breast reduction and fourteen who had undergone mastopexy on the radiated side. Two patients (8%) had major complications that required further surgery (major fat necrosis, wound infection, and breast deformation), and five patients (20%) had minor complications (infection, minor fat necrosis, wound dehiscence, and nipple congestion). All complications developed on the radiated breast. There was no correlation between the occurrence of complications and patients' demographics, tumor type, tumor location, and breast tissue resection (p > 0.05). CONCLUSION: Only two of our 25 patients had major complications following breast reduction and mastopexy for the repair of asymmetry post-BCT. Following our four-step protocol was instrumental in leading to the successful performance of these procedures. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Modified Kunlin's Technique for Microsurgical End-to-End Anastomoses: A Series of 100 Flaps.

BACKGROUND: In 1949, a French vascular surgeon, Jean Kunlin, first described a venous end-to-side anastomotic technique to address large vessel size mismatches. It was later modified by Dr. Robert Linton for end-to-end (ETE) anastomoses on the "macrovascular" scale. While multiple procedures exist for addressing moderate caliber discrepancies, few safely and reliably compensate for marked diameter differences at the microvascular level. In this study, we present the first large series adapting a modified geometric Kunlin's technique for arterial and venous ETE anastomoses in reconstructive microsurgery. METHODS: We reviewed 100 consecutive cases of free flap reconstructions from 2006 to 2015 utilizing a modified geometric Kunlin's technique for arterial and venous ETE anastomoses. Patient demographics and flap outcomes were analyzed. Overall flap survival rates and postoperative complications were analyzed and compared with standard values in the microsurgical literature. RESULTS: A total of 146 ETE anastomoses from 100 free flaps were analyzed. The average patient age was 51 ± 3.1 years (range: 10-84 years). Free flaps in this study were used for gender confirmation phalloplasties (20%) and reconstructing defects of the head and neck (63%), extremities (16%), and trunk (1%). There was a total of 17 takebacks including 5 for hematoma, 8 for anastomotic thromboses (6 venous), and 4 without any identifiable complication. Of these takebacks, two partial and two complete flap losses occurred. There was an 88% salvage rate for flaps requiring takebacks during the postoperative period. Overall, flap survival rate was 98% including those with complications or takebacks. CONCLUSION: The modified Kunlin's technique is a reliable, facile, and versatile method of performing ETE anastomoses for arterial and venous vessels, especially with vessel diameter mismatches of 3:1 or greater, as well as for challenging orientations. Notably, it provides equivalent flap survival and complication rates as compared with other techniques in the microsurgical literature.

Cryopreservation of Stromal Vascular Fraction Cells Reduces Their Counts but Not Their Stem Cell Potency.

Adipose-derived stem cells are derived from the nonfat component of adipose tissue termed the stromal vascular fraction (SVF). The use of freshly isolated autologous SVF cells as an alternative to adult stem cells is becoming more common. Repeated SVF administration for improved clinical outcomes is complicated by the need for repeated liposuction. This can be overcome by cryopreservation of SVF cells. The current study aimed to assess whether SVF cells retain their stem cell potency during cryopreservation. METHODS: SVF cells isolated from lipoaspirates (donor age: 46.1 ± 11.7 y; body mass index: 29.3 ± 4.8 kg/m2) were analyzed either immediately after isolation or following cryopreservation at -196°C. Analyses included assessment of nucleated cell counts by methylene blue staining, colony-forming unit fibroblast counts, surface marker expression using a flow cytometric panel (CD45, CD34, CD31, CD73, CD29, and CD105), expansion in culture, and differentiation to fat and bone. RESULTS: While cryopreservation reduced the number of viable SVF cells, stem cell potency was preserved, as demonstrated by no significant difference in the proliferation, surface marker expression in culture, bone and fat differentiation capacity, and the number of colony-forming unit fibroblasts in culture, in cryopreserved versus fresh SVF cells. Importantly, reduced cell counts of cryopreserved cells were due, mainly, to a reduction in hematopoietic CD45+ cells, which was accompanied by increased proportions of CD45-CD34+CD31- stem cell progenitor cells compared to fresh SVF cells. CONCLUSIONS: Cryopreservation of SVF cells did not affect their in vitro stem cell potency and may therefore enable repeated SVF cell administrations, without the need for repeated liposuction.

Immediate breast reconstruction in high-risk cases using an anatomically shaped permanent expandable implant.

BACKGROUND: Anatomically shaped permanent expandable implants are dual-chambered devices, which allow their postoperative expansion for the adjustment of volume. Their use is optional when 1-stage immediate breast reconstruction (IBR) direct to permanent implant is not feasible. The aim of this study is to present one center's long-term experience with the anatomical Becker expandable implant in a large series of patients who underwent either IBR or a salvage procedure for IBR with the device. METHODS: The records of 141 patients (a total of 161 breasts) who underwent IBR with the Becker implant were retrospectively reviewed. Patient demographics and surgical outcomes were analyzed. Indications for this procedure included reduced skin envelopes, compromised skin flaps, salvage procedures, and single-stage procedures in patients with major comorbidities. RESULTS: One hundred twenty-three devices (76%) involved IBR and 38 devices (24%) were salvage cases after direct-to-implant IBR. The device was used in a previously radiated breast in 36 cases (22%). Long-term follow-up demonstrated that 99 devices (61.5%) had been exchanged or removed and that only 62 devices (38.5%) remained as permanent implants. Removal of the device was associated with prior breast radiation and advanced age. CONCLUSIONS: The use of the Becker device in high-risk IBR cases had a low retention rate as a permanent implant. Favorable indications for the use of this device in IBR cases include contralateral breast augmentation and patients with major comorbidities, which demonstrated a higher retention rate. Other indications for high-risk IBR cases could probably benefit using a 2-stage tissue-expander and implant technique.

Bridging the Gap: A 20-Year Experience with Vein Grafts for Free Flap Reconstruction. The Odds for Success.

BACKGROUND: Successful free tissue transfer requires tension-free microvascular anastomosis. Vein grafts are used when this cannot be obtained, which increases microsurgical complexity and the chance of vessel thrombosis. Previous studies on vein grafts are limited to low numbers and selected techniques, making it difficult to draw conclusions. METHODS: A retrospective chart review was performed for all patients who underwent vein grafts in free flap reconstruction from 1995 to 2015. Information on patient and flap characteristics, returns to the operating room, and flap loss was analyzed. RESULTS: Seventy-two free flap reconstructions requiring 122 vein grafts were performed in the genitourinary/perineal (49 percent) and head and neck (38 percent) regions. The majority were performed in the initial operation (82 percent) and, of those, the majority were planned (71 percent). The most common vein graft types used were transposition arteriovenous loops (57 percent) and interpositions (26 percent). Of the initial cases, 22 percent returned to the operating room, resulting in a 7 percent total flap loss rate and a 7 percent partial flap loss rate. On univariate analysis, graft timing/planning, gap type, vein graft type, and reconstruction location were significantly associated with take-backs and flap loss. However, gap type and location seem to be strongly associated with graft timing/planning and vein graft type. Graft type and planning/timing do not have as strong a relationship and seem to independently relate to flap loss. CONCLUSIONS: Vein grafts are more successful when planned and when performing transpositions and arteriovenous loops over interpositions. These graft types should be considered over interpositions when possible. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

DIEP Flap Breast Reconstruction Complication Rate in Previously Irradiated Internal Mammary Nodes.

BACKGROUND: Postmastectomy radiation therapy (PMRT) is a widely accepted treatment for locally advanced breast cancer. Some patients require additional boost radiation to the internal mammary nodes as the part of regional nodal irradiation (RNI). Delayed breast reconstruction with an autologous free flap using the internal mammary vessels for microvascular flap anastomosis is a common practice for these patients. The aim of our study was to evaluate the effect of RNI on autologous microvascular breast reconstruction. PATIENTS AND METHODS: A retrospective study was performed on 57 patients (69 flaps) undergoing deep inferior epigastric perforator (DIEP) flap for delayed breast reconstruction after radiation therapy. The study group included 37 patients (65%) who received PMRT and RNI to the internal mammary nodes. The control group included 20 patients (35%) who received PMRT alone. Early and delayed surgical complications, including wound complications, fat necrosis, and flap loss, were compared between the groups. RESULTS: The patient demographics in both groups were similar. Complication rate showed a higher trend in the study group for flap loss (8.3% versus 0%) and vascular anastomosis failure (5.6% versus 0%), but with no statistical difference (p = 0.54, 0.53, respectively). The control group showed a higher trend in fat necrosis (25% versus 8.3%, p = 0.11). CONCLUSIONS: DIEP flap breast reconstructions with internal mammary vessels anastomosis should be performed with cautious in patients who had received RNI to internal mammary nodes because of potential added risk for surgical complications.

Association Between Postoperative Complications After Immediate Alloplastic Breast Reconstruction and Oncologic Outcome.

INTRODUCTION: Mastectomy with immediate reconstruction is associated with increased complications when compared with mastectomy without reconstruction. Postoperative complications have been associated with worse oncologic outcome in other cancers. We examined the association between postoperative complications after immediate reconstruction and oncologic outcome. METHODS: This retrospective study included all women undergoing mastectomy and immediate alloplastic reconstruction for breast cancer between the years 2009 and 2016. Data collected included demographics, cancer and treatment characteristics, type of surgery, postoperative complications, and outcome. Association between postoperative complications and oncologic outcome was examined using Cox regression analysis. RESULTS: Between January 2009 and December 2016, 227 women underwent mastectomy with immediate alloplastic reconstruction. One hundred eighty-six (82%) were done for breast cancer. Most (148; 80%) had infiltrating carcinoma. The mean age was 48.8 years (range, 21-77 years). Forty-seven (25%) had a previous history of radiation. Fifty-four (29%) had neoadjuvant treatment. Complications occurred in 83 (45%) of the women. Fifty-five (30%) needed revisional surgery (closure of wound, debridement, exchange or removal of implant, and evacuation of hematoma). Complications were associated with older age and previous radiation history (57% vs. 40% in women with no previous radiation; P = .04). The mean follow-up was 1138 days. Twenty-five (12%) women developed recurrence during follow-up. There was no association between presence of postoperative complications and recurrence of cancer. CONCLUSIONS: Postoperative complications were not associated with worse oncologic outcome in this study. The study may be limited by the relatively short follow-up.

Superomedial Pedicle Vertical Scar Breast Reduction: Objective and Subjective Assessment of Breast Symmetry and Aesthetics.

BACKGROUND: The superomedial vertical scar breast reduction (SVBR) described by Hall-Findlay is gaining popularity among surgeons worldwide. The aim of this study was to evaluate its long-term aesthetic outcome, the extent of quality of life improvement and the factors that influence patient satisfaction and reviewers' evaluation of aesthetic/surgical outcome. METHODS: In this historical prospective study, we included women who underwent SVBR at least one year prior to enrollment and responded to a quality of life questionnaire. Their breasts were photographed, measured and evaluated by the plastic surgery staff. RESULTS: A total of 40 patients responded to the questionnaire, and the breasts of 31 of them were measured and photographed. All 31 patients had good breast symmetry according to objective breast measurements. There was a clear correlation between the patients' and the reviewers' scores of breast symmetry, scar appearance and breast shape (r = 0.4-0.65, r = 0.432-0.495 and r = 0.335-0.403, respectively). The factor that most influenced reviewers' and patients' satisfaction with the overall aesthetic outcome was the breast-to-body proportion. CONCLUSIONS: The proportions between the breast size and the patient's body habitus are pivotal to patient satisfaction and should be taken into consideration when planning a reduction mammaplasty. The SVBR technique for breast reduction provided good cosmetic outcome and symmetry over a long-term follow-up. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Tissue Expansion Using Hyaluronic Acid Filler for Single-Stage Ear Reconstruction: A Novel Concept for Difficult Areas.

BACKGROUND: Auricular reconstruction is one of the most challenging procedures in plastic surgery. An adequate skin envelope is essential for cartilage framework coverage, yet few good options exist without additional surgery. We propose a novel method for minimally invasive tissue expansion, using hyaluronic acid (HA) filler to allow for single-stage ear reconstruction. OBJECTIVES: To introduce the novel concept of HA filler for tissue expansion in ear reconstruction, and as an alternative to traditional expansion techniques. METHODS: Macrolane is a large particle HA gel developed for large volume restoration. Expansion of the non-hair-bearing mastoid skin was performed in our clinic weekly or every other week. Final expansion was completed one week prior to reconstructive surgery. Tissue from one patient's expanded pocket was sent for histological analysis. RESULTS: Ten patients underwent single-stage auricular reconstruction with preoperative expansion. Injection sessions ranged from 7 to 13 (mean, 9.7). Mean injected volume per session was 2.03 mL per patient, for an average total of 19.8 mL (range, 14.5-30 mL). There were no major complications. One minor complication required removal of exposed wire from the antihelix in the office. Hematoxylin and eosin stain revealed similar histology to that seen with traditional expanders. CONCLUSIONS: This novel expansion technique using serial HA injections allowed for optimized skin coverage in single-stage ear reconstruction. The concept of tissue expansion using HA filler is a new frontier for research that may be applicable to other arenas of reconstruction. LEVEL OF EVIDENCE: 4.

Immunological and inflammatory mapping of vascularized composite allograft rejection processes in a rat model.

BACKGROUND: Hand and face vascularized composite allotransplantation (VCA) is an evolving and challenging field with great opportunities. During VCA, massive surgical damage is inflicted on both donor and recipient tissues, which may contribute to the high VCA rejection rates. To segregate between the damage-induced and rejection phase of post-VCA responses, we compared responses occurring up to 5 days following syngeneic versus allogeneic vascularized groin flap transplantations, culminating in transplant acceptance or rejection, respectively. METHODS: The immune response elicited upon transplantation of a syngeneic versus allogeneic vascularized groin flap was compared at Post-operative days 2 or 5 by histology, immunohistochemistry and by broad-scope gene and protein analyses using quantitative real-time PCR and Multiplex respectively. RESULTS: Immune cell infiltration began at the donor-recipient interface and paralleled expression of a large group of wound healing-associated genes in both allografts and syngrafts. By day 5 post-transplantation, cell infiltration spread over the entire allograft but remained confined to the wound site in the syngraft. This shift correlated with upregulation of IL-18, INFg, CXCL9, 10 and 11, CCL2, CCL5, CX3CL1 and IL-10 in the allograft only, suggesting their role in the induction of the anti-alloantigen adaptive immune response. CONCLUSIONS: High resemblance between the cues governing VCA and solid organ rejection was observed. Despite this high resemblance we describe also, for the first time, a damage induced inflammatory component in VCA rejection as immune cell infiltration into the graft initiated at the surgical damage site spreading to the entire allograft only at late stage rejection. We speculate that the highly inflammatory setting created by the unique surgical damage during VCA may enhance acute allograft rejection.

Optimizing Patient Selection for Direct-to-Implant Immediate Breast Reconstruction Using Wise-Pattern Skin-Reducing Mastectomy in Large and Ptotic Breasts.

BACKGROUND: Immediate breast reconstruction in large and ptotic breasts is challenging, often requiring skin-reducing procedures. The Wise-pattern skin-reducing mastectomy (WPSRM) technique provides reliable one-stage implant coverage using the pectoralis muscle and a de-epithelialized inferiorly based dermal flap. However, de-vascularization may result in mastectomy skin flap necrosis. We aimed to critically evaluate and isolate patients at high risk of complications using this procedure. METHODS: We retrospectively reviewed consecutive patients undergoing WPSRM by the senior author from January 2008 to December 2011. Data collected included patient demographics, breast cancer staging, smoking, preoperative radiation, chemotherapy, BMI, mastectomy weight, implant size and type. We analyzed their effect on complications, revisions and failure rate. RESULTS: Fifty-nine WPSRMs were performed in 39 patients with a minimum of 12-month follow-up. Complications occurred in 43.75% patients and 34.88% breasts. Multivariate statistical analysis revealed that age (p = 0.093) and BMI (p = 0.631) were not significant risk factors as opposed to previously published data. Mastectomy weight was significantly associated with major complications requiring secondary surgery (odds ratio per 100 g of breast tissue was 1.18; 95% CI 1.01-1.39; p = 0.036) as 90.5% of our complications occurred in those patients with mastectomy weight exceeding 700 g. Complications were reduced twofold when selecting a Becker adjustable implant over a silicone one for these higher mastectomy weights. CONCLUSION: WPSRM was found to be associated with an increased complication rate in patients with high mastectomy weights and immediate reconstruction with silicone implants. We propose an algorithm offering better patient selection for this technique in immediate breast reconstruction. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Implantable Doppler monitoring of buried free flaps during vascularized lymph node transfer.

BACKGROUND AND OBJECTIVES: Reliable flap monitoring is crucial to the success of free tissue transfer, including vascularized lymph node transfer (VLNT). However, no large-scale study has examined implantable Doppler monitoring in VLNT. We aimed to determine whether an implantable Doppler system can reliably monitor flap perfusion during VLNT and also to calculate the sensitivity and specificity of this system for detecting compromise in the monitored vessel. METHODS: An analysis of prospectively collected data of patients who underwent buried VLNT with implantable Doppler monitoring between 2014 and 2015 was performed. RESULTS: A consecutive series of 100 patients underwent VLNT with implantable Doppler monitoring. Five cases required return to the operating room for flap exploration due to a change in Doppler signal quality. All compromised flaps were salvaged. The sensitivity of the implantable Doppler system for flap monitoring was 100%, the specificity was 97.9%, the positive predictive value was 60%, and the negative predictive value was 100%. The false-positive rate was 2%. CONCLUSIONS: This is the largest reported series of implantable Doppler monitoring of free flap perfusion during VLNT. Our experience suggests that this is a safe and effective technique for postoperative monitoring of VLNT.

The utility of the musculocutaneous anterolateral thigh flap in pharyngolaryngeal reconstruction in the high-risk patient.

BACKGROUND AND OBJECTIVES: Prior radiotherapy leads to increased wound complication rates for microsurgical reconstruction of pharyngolaryngeal (PL) defects. Incorporating vastus lateralis muscle together with anterolateral thigh flap (ALT) skin in defect reconstruction is useful in protecting vital structures and reinforcing irradiated neck skin and suture lines. This study shows the utility of the musculocutaneous ALT (MC ALT) in PL reconstruction in previously irradiated patients. METHODS: A single-surgeon, retrospective chart review of all patients with defects of the PL region where an MC ALT was used for reconstruction from February 2014 to May 2016. The harvest of the MC ALT is described. RESULTS: Thirteen consecutive patients underwent reconstruction with a MC ALT flap. All 13 patients had received previous radiotherapy. PL defects included five partial, five subtotal, and three total. There was a 100% flap survival rate with five early recipient site complications including three fistulas, one neck abscess, and one partial muscle necrosis. Three patients (23%) developed strictures requiring dilatation, two of whom had received post-reconstruction radiotherapy. CONCLUSIONS: The use of the MC ALT for reconstruction of PL defects should be considered to mitigate the negative effects of prior irradiation and provide a back-up plan in instances where complications occur.

An Oncoplastic Breast Augmentation Technique for Immediate Partial Breast Reconstruction following Breast Conservation.

BACKGROUND: Patients with a small breast volume and a relative large lumpectomy volume are at risk of developing severe breast deformity and asymmetry following breast conservation, presenting a unique surgical challenge. METHODS: A series of patients undergoing immediate reconstruction by means of an oncoplastic breast augmentation technique following breast conservation are described. The technique includes local tissue rearrangement and bilateral subpectoral breast augmentation with implants of different sizes and shapes, immediately after lumpectomy for a malignant tumor. RESULTS: Twenty-one consecutive patients underwent the oncoplastic breast augmentation technique (mean follow-up, 23 months; range, 12 to 48 months). Three patients (14.3 percent) had tumor-positive surgical margins. Postoperative complications included grade III/IV capsular contracture in five patients (23.8 percent) and breast infection in two patients (10 percent). All patients received postoperative radiation therapy. The cosmetic outcome was evaluated at least 6 months after radiation therapy, and it was favorable according to the reported high patient satisfaction (81 percent) and independent observers' evaluation scores (76 percent). CONCLUSIONS: The oncoplastic breast augmentation technique described in this article is an acceptable option in small-breasted patients with a relatively large lumpectomy volume who elect to undergo breast conservation. This technique allows conservation of the affected breast and minimizes potential breast deformation and asymmetry following radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Latissimus dorsi flap with vascularized lymph node transfer for lymphedema treatment: Technique, outcomes, indications and review of literature.

BACKGROUND AND OBJECTIVES: One of the surgical treatment options for lymphedema is vascularized lymph node transfer (VLNT). We present our experience with latissimus dorsi (LD) flap based VLNT for lymphedema treatment. METHODS: We reviewed 14 consecutive patients treated with pedicled or free LD VLNT between 2014 and 2016 for recalcitrant upper or lower extremity lymphedema. Seven patients underwent lymphovenous bypass in addition to LD VLNT. Limb volume and quality of life scores using the Lymphedema Life Impact Scale (LLIS) were analyzed for quantitative and qualitative assessment. RESULTS: Mean duration of lymphedema was 69 months (range 24-124 months). Follow-up ranged from 3 to 12 months (mean 6.7 month). Major complications included one free flap loss and one reoperation for thrombosis. Mean preoperative volume differential between normal and affected limb was 35% (range 3-87%). Volume differential reduction was 48%, 28%, and 46% at 3, 6, and 12 months, respectively. The LLIS score improved from mean of 46.8 before surgery to a mean of 38.6 at 12 month, demonstrating improvement in quality of life. CONCLUSIONS: The LD VLNT provides a viable option for treatment of UE and LE lymphedema in selected patients. J. Surg. Oncol. 2017;115:72-77. © 2016 Wiley Periodicals, Inc.