Striving for Normalcy after Lower Extremity Reconstruction with Free Tissue: The Role of Secondary Esthetic Refinements.

BACKGROUND: Many patients with successful lower extremity salvage have postoperative functional and esthetic concerns. Such concerns range from contour irregularity preventing proper shoe-fitting to esthetic concerns involving color, contour, and texture match. The purpose of this study is to determine the overall incidence as well as factors associated with an increased likelihood of undergoing secondary, esthetic refinements of lower extremity free flaps and to review current revision techniques. METHODS: All patients undergoing lower extremity soft tissue coverage for limb salvage procedures between January 2007 and June 2013 at a single institution were included in the analysis. Patients who underwent secondary refinements for lower extremity free flaps were compared with patients not undergoing secondary procedures. RESULTS: During the study period, 152 patients underwent reconstruction and were eligible for inclusion. Of these, 32 (21.1%) patients underwent secondary, esthetic revisions. Few differences in patient or case characteristics were noted, although revision patients trended toward being younger, having lower body mass index, with defects secondary to acute trauma located below the ankle. The most common revision was complex soft tissue rearrangement or surgical flap debulking/direct excision (87.5% of patients), followed by scar revision (12.5%), suction-assisted lipectomy (3.1%), laser scar revision (3.1%), and tissue expansion with local tissue rearrangement (3.1%). CONCLUSION: A significant portion of patients desire secondary revisions following the initial procedure. This is especially true of younger patients with below ankle reconstruction. In many patients, an esthetic consideration should not be of secondary concern, but should be part of the ultimate reconstructive algorithm for lower extremity limb salvage.

A simplified approach to reconstruction of hemipelvectomy defects with lower extremity free fillet flaps to minimize ischemia time.

External hemipelvectomy associated with trauma or during the operative management of musculoskeletal sarcomas may yield a soft tissue defect that can only be sufficiently covered by free tissue transfers. The application of "spare-parts surgery," such as a fillet of leg or thigh flap, uses distal uninvolved parts that are otherwise viable tissues as donor tissues to cover defects. This concept has great utility to achieve soft tissue coverage in challenging cases, such as hemipelvectomy. However, during such complicated and time-consuming cases, prolonged ischemia time of the proposed donor tissues can be problematic. We describe a technique developed by the senior author (SJK) that minimizes the ischemia time of donor free tissues during external hemipelvectomy. This technique is applicable to other surgeries where filleted spare parts are the donor-site source for free tissue transfer.

Trends in immediate breast reconstruction across insurance groups after enactment of breast cancer legislation.

BACKGROUND: To improve access to breast reconstruction for mastectomy patients, the United States enacted the Women's Health and Cancer Rights Act in January of 1999. The objective of the current study was to evaluate the impact of this legislation on patients with different insurance plans. METHODS: Women aged ≥18 years who underwent mastectomy for cancer were identified in the Nationwide Inpatient Sample database (2000-2009) and were classified according to their immediate breast reconstruction (IBR) status. Trends in rates of IBR were described for each insurance category. Multivariable logistic regression analysis with adjustment for age, race, estimated household income, and Elixhauser comorbidity index was performed to evaluate the relation between insurance status and IBR. RESULTS: In total, 168,236 patients were identified who underwent a mastectomy during the study interval. Across the 10-year study period, rates of IBR increased 4.2-fold in Medicaid patients, 2.9-fold in Medicare patients, 2.6-fold in privately insured patients, and 2.1-fold in self-pay patients (P < .01). However, after adjustment for confounders, women without private insurance were less likely to undergo IBR compared with women who had private insurance (Medicaid: odds ratio [OR], 0.34; 95% confidence interval [CI], 0.32-0.37; Medicare: OR, 0.53; 95% CI, 0.49-0.58; self-pay: OR, 0.43; 95% CI, 0.37-0.50; other types of nonprivate insurance: OR, 0.64, 95% CI, 0.56-0.73). CONCLUSIONS: After the enactment of policy designed to improve access to IBR, Medicaid and Medicare patients experienced the greatest relative increase in rates of IBR. Although policy changes had the most impact on traditionally underserved populations, disparities still exist. Future studies should endeavor to understand why such disparities have persisted.

Racial disparities in immediate breast reconstruction after mastectomy: impact of state and federal health policy changes.

BACKGROUND: Federal and Pennsylvania state policies instituted in the late 1990s were designed to improve access to postmastectomy breast reconstruction. We sought to evaluate the impact of these policy changes on access to care among racial minorities. METHODS: Mastectomy patients ≥18 years old were identified in the Pennsylvania Health Care Cost Containment Council inpatient database (1994-2004) and classified by immediate breast reconstruction (IBR) status. Rates of IBR were calculated by patient characteristics and year. Patients were stratified by race before (1994-1997) and after (2001-2004) policy changes, and relative odds of IBR were estimated by univariate and multivariate logistic regression analyses with adjustment for known confounders. RESULTS: Overall rates of IBR were significantly higher in the time period after policy change compared to before policy change (18.5 vs. 32.7 %, p < 0.01). White, black, and Asian patients all saw a significant rise in rates of IBR. However, after adjustment for potential confounders, black patients, Asian patients, and those of mixed or other races all remained less likely to undergo IBR when compared to white patients after policy changes (odds ratio [OR] 0.66, 95 % confidence interval [CI] 0.55-0.80; OR 0.30, 95 % CI 0.18-0.49; OR 0.29, 95 % CI 0.16-0.51, respectively). CONCLUSIONS: Rates of IBR increased across all racial groups after policy changes. However, not all races were affected equally, and thus disparities remained. Future studies are needed to investigate the role of other factors, including cultural preferences in utilization of IBR that might explain residual disparities.