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Background: Reconstruction is an important adjunct to breast cancer management. This study evaluated the frequency of major and minor complications in the largest reported series of consecutive mastectomy patients treated with free tissue transfer for breast reconstruction., Methods: All patients treated with microvascular breast reconstruction at the University of California, Los Angeles, Medical Center over an 11-year period were identified using a retrospective analysis. Frequency of complications was assessed., Results: A total of 1195 breast reconstructions were performed in 952 patients. Transverse rectus abdominis musculocutaneous flaps were used in most cases (81.8 percent), whereas the superior gluteal musculocutaneous flap (10.1 percent) and other free flaps were used in the remaining patients. The overall complication rate was 27.9 percent and consisted primarily of minor complications (21.7 percent). Major complications were noted in 7.7 percent, including six total flap losses (0.5 percent). Obesity was a major predictor of complications. Smoking was not associated with increased rates of overall or microsurgical complications. Neoadjuvant chemotherapy was also an independent predictor of complications and was associated with wound-healing problems and fat necrosis. Prior abdominal surgery in transverse rectus abdominis musculocutaneous flap patients increased the risk of partial flap loss, fat necrosis, and donor-site complications., Conclusions: Microsurgical breast reconstruction is a safe and highly effective technique. Complications tend to be minor and do not affect postreconstruction adjuvant therapy. Obesity is a major predictor of flap and donor-site complications, and these patients should be appropriately counseled. Similarly, neoadjuvant preoperative chemotherapy and prior abdominal surgery increase the rates of minor complications.

The lack of adequate recipient vessels often complicates microvascular breast reconstruction in patients who have previously undergone mastectomy and irradiation. In addition, significant size mismatch, particularly in the outflow veins, is an important contributor to vessel thrombosis and flap failure. The purpose of this study was to review the authors' experience with alternative venous outflow vessels for microvascular breast reconstruction. In a retrospective analysis of 1278 microvascular breast reconstructions performed over a 10-year period, the authors identified all patients in whom the external jugular or cephalic veins were used as the outflow vessels. Patient demographics, flap choice, the reasons for the use of alternative venous drainage vessels, and the incidence of microsurgical complications were analyzed. The external jugular was used in 23 flaps performed in procedures with 22 patients. The superior gluteal and transverse rectus abdominis musculocutaneous (TRAM) flaps were used in the majority of the cases in which the external jugular vein was used (72 percent gluteal, 20 percent TRAM flap). The need for alternative venous outflow vessels was usually due to a significant vessel size mismatch between the superior gluteal and internal mammary veins (74 percent). For three of the external jugular vein flaps (13 percent), the vein was used for salvage after the primary draining vein thrombosed, and two of three flaps in these cases were eventually salvaged. In three patients, the external jugular vein thrombosed, resulting in two flap losses, while the third was salvaged using the cephalic vein. A total of two flaps were lost in the external jugular vein group. The cephalic vein was used in 11 flaps (TRAM, 64.3 percent; superior gluteal, 35.7 percent) performed in 11 patients. In five patients (54.5 percent), the cephalic vein was used to salvage a flap after the primary draining vein thrombosed; the procedure was successful in four cases. In three patients, the cephalic vein thrombosed, resulting in two flap losses. One patient suffered a thrombosis after the cephalic vein was used to salvage a flap in which the external jugular vein was initially used, leading to flap loss, while a second patient experienced cephalic vein thrombosis on postoperative day 7 while carrying a heavy package. There was only one minor complication attributable to the harvest of the external jugular or cephalic vein (small neck hematoma that was aspirated), and the resultant scars were excellent. The external jugular and cephalic veins are important ancillary veins available for microvascular breast reconstruction. The dissection of these vessels is straightforward, and their use is well tolerated and highly successful.

The incidence of breast cancer is increasing each year. Concomitantly, cosmetic breast augmentation has become the second most often performed cosmetic surgical procedure. As the augmented patient population ages, an increasing number of breast cancer cases among previously augmented women can be anticipated. The surgical treatment of these patients is controversial, with several questions remaining unanswered. Is breast conservation therapy feasible in this patient population and can these patients retain their implants? A retrospective review of all breast cancer patients with a history of previous augmentation mammaplasty who were treated at the Revlon/UCLA Breast Center between 1991 and 2001 was performed. During the study period, 58 patients were treated. Thirty patients (52 percent) were treated with a modified radical mastectomy with implant removal. Twenty-eight patients (48 percent) underwent breast conservation therapy, which consisted of lumpectomy, axillary lymph node dissection, and radiotherapy. Twenty-two of the patients who underwent breast conservation therapy initially retained their implants. Eleven of those 22 patients (50 percent) ultimately required completion mastectomies with implant removal because of implant complications (two patients), local recurrences (five patients), or the inability to obtain negative margins (four patients). Nine additional patients experienced complications resulting from their implants, including contracture, erosion, pain, and rupture. The data illustrate that breast conservation therapy with maintenance of the implant is not ideal for the majority of augmented patients. Breast conservation therapy with explantation and mastopexy might be appropriate for rare patients with large volumes of native breast tissue. Mastectomy with immediate reconstruction might be a more suitable choice for these patients.

Managed care organizations recently have attempted to add aesthetic surgery to their line of available services. To better understand the challenges posed by these actions, all members of the American Society for Aesthetic Plastic Surgery were surveyed about managed care overtures to aesthetic plastic surgeons, their responses, and the likely responses of their patients. The goal was to examine both the supplier and consumer ends of the aesthetic surgery market to determine the likely effects of managed care's attempts to capture aesthetic surgery. A total of 632 plastic surgeons returned the surveys (response rate, 54.5 percent). Twenty-two percent reported being approached by managed care organizations about joining a panel of aesthetic surgeons. Approximately one-quarter of the plastic surgeons said they would participate in aesthetic surgery panels developed by managed care organizations. Characteristics significantly associated with willingness to participate were solo practice structure, a low percentage of practice revenues from aesthetic surgery, and a very competitive practice environment. Plastic surgeons believed that their colleagues would be even more willing to acquiesce to managed care aesthetic surgery; more than one-third said that 25 to 50 percent of their colleagues would join, and nearly one-third thought that more than half would participate. Plastic surgeons believed that many of their patients would also participate in managed care aesthetic surgery. Twenty-four percent thought that more than half of their patients would choose an aesthetic surgeon through their managed care organization if that organization developed a network for aesthetic surgery. This figure increased to almost 40 percent if the organization would deny coverage for complications resulting from nonpanel surgeons, and to 41 percent if the organization would offer price discounts. This survey shows that most plastic surgeons are against managed care aesthetic surgery. But it also shows that some plastic surgeons will participate, and that most plastic surgeons think many of their colleagues and patients will do likewise. This means that managed care organizations have the potential to make inroads in aesthetic surgery on both the supplier and consumer ends of the market. To prevent managed care from capturing aesthetic surgery, plastic surgeons must anticipate the likely business strategy of managed care. To this end, they must understand the steps involved in the creation of a new service business and offer organized countermeasures against each of them.

The advent of managed care has unleashed market forces on the health care system. One result of these new pressures is a shift from nonprofit to Wall Street-based financing. This report quantifies these trends by comparing health organizations' financial structures in the 1980s and now. The reasons behind this shift and the function of the stock market are examined. A review of Wall Street's key financial measures confirms that health care has shifted to the stock market as its principal means of financing. The stock market works by assigning a current price to a company's stock based on estimates for future earnings. Thus, companies desire predictability in their costs, revenues, and profits. Plastic surgeons can master this system by meeting the challenges imposed by Wall Street financing. Important steps include continuously measuring costs and outcomes of procedures, demanding cost data from hospitals and payers, using these data to improve costs and outcomes, and taking advantage of the system's openness to innovation and easier access to capital. As they seek to protect their role as medical decision makers under the new free-market system, plastic surgeons can benefit from understanding the mechanisms of the stock market.

Healthcare traditionally has been described as not conforming to the laws of economics. Consumers pay for aesthetic surgery directly, thus freeing it from the usual confounding factors and making it more likely to comply with the market forces explained by economics. Recent studies have demonstrated the ability of classic economics to analyze, predict, and optimize the financial environment of aesthetic surgery. This article describes economic principles and how they can be applied to aesthetic surgery. Some of the basic instruments of economics include the study of supply and demand, prices, and price elasticity; capital investments; communication and cooperation; and consumer cognitive limitations. Each of these tools offers plastic surgeons the opportunity to gain improved control of their financial environment.

Many plastic surgeons develop technologies that are manufactured by Wall Street-financed companies. Others participate in the stock market as investors. This study examines the bioengineered skin industry to determine whether it integrates clinical and financial information as Wall Street tenets would predict, and to see whether the financial performance of these companies provides any lessons for practicing plastic surgeons. In efficient markets, the assumptions on which independent financial analysts base their company sales and earnings projections are clinically reasonable, the volatility of a company's stock price does not irrationally differ from that of its industry sector, and the buy/sell recommendations of analysts are roughly congruent. For the companies in this study, these key financial parameters were compared with a benchmark index of 69 biotech companies of similar age and annual revenues (Student's t test). Five bioengineered skin companies were included in the study. Analysts estimated that each company would sell its product to between 24 and 45 percent of its target clinical population. The average stock price volatility was significantly higher for study companies than for those in the benchmark index (p < 0.05). Similarly, buy/sell recommendations of analysts for the study companies were significantly less congruent than those for the benchmark companies (p < 0.05). These results indicate clinically unrealistic projections for market penetration, significantly high price volatility, and significantly high discordance among professional analysts. In all cases, the market is inefficient-an unusual finding on Wall Street. A likely explanation for this market failure is a cycle of poor clinical correlation when assigning sales projections, which in turn leads to price volatility and discordance of buy/sell recommendations. This study's findings have implications for plastic surgeons who develop new technology or who participate in the equities markets as investors. Plastic surgeons who develop new medical devices or technology cannot universally depend on the market to drive clinically reasonable financial performance. Although inflated sales estimates have benefits in the short term, failure to meet projections exacts severe financial penalties. Plastic surgeons who invest in the stock market, because of their unique clinical experience, may sometimes be in the position to evaluate new technologies and companies better than Wall Street experts. Well-timed trades that use this expertise can result in opportunities for profit.

Wound extracellular matrix is a key regulator of cell adhesion, migration, proliferation, and differentiation during cutaneous repair. The amount and organization of normal wound extracellular matrix are determined by a dynamic balance among overall matrix synthesis, deposition, and degradation. Matrix metalloproteinases (MMPs) are one family of structurally related enzymes that have the collective ability to degrade nearly all extracellular matrix components. The MMPs are broadly categorized into collagenases, gelatinases, stromelysins, and membrane-type MMPs by their substrate specificity. The aim of this study was to characterize the temporal changes in mRNA profiles for rat collagenase [matrix metalloproteinase-1 (MMP-1)], gelatinase A (MMP-2), matrilysin (MMP-7), gelatinase B (MMP-9), and membrane type 1-MMP (MT1-MMP), as well as tissue inhibitor of metalloproteinases-1 (TIMP-1), TIMP-2, and TIMP-3 during the inflammatory, granulation, and early remodeling phases of excisional skin repair. Eight full-thickness skin wounds were made on the backs of each rat (7-mm2 wounds; 16 rats; n = 128 wounds). Two animals at a time were reanesthetized, and all eight wounds on each animal were excised at 12 and 24 hours and at 2, 3, 5, 7, 10, and 14 days after injury. Six wounds from each animal were excised for RNA isolation, whereas two wounds were excised for histology. Controls consisted of nonwounded skin from identical locations in four animals. Total RNA from each time point was isolated and relative mRNA quantitation performed by using reduced-cycle reverse transcription-polymerase chain reaction. Correct polymerase chain reaction product amplification was confirmed by probing the blotted polymerase chain reaction product with a 32P-labeled oligonucleotide specific for a given MMP or TIMP. We demonstrated that the majority of MMP and TIMP mRNA induction and peak expression coincided temporally with the well-characterized inflammatory and granulation stages of repair. In conclusion, there is a distinct pattern of MMP and TIMP expression during normal excisional wound repair.

To gather information about aesthetic surgery's current practice structures, competitive environment, patient price sensitivity, and marketing and practice development requirements, a two-page survey was developed and mailed to all 1180 members of the American Society for Aesthetic Plastic Surgery. A total of 632 surveys were returned (response rate of 54.5 percent). Most aesthetic plastic surgeons said they were in solo practice (63.3 percent). More than two-thirds described the marketplace as "very competitive," with 59 percent reporting 25 or more surgeons offering aesthetic surgery in their area. They estimated their patients' average income at $62,800. Nearly all plastic surgeons labeled their patients as "moderately price sensitive" (62.3 percent) or "very price sensitive" (30.6 percent). Similarly, 23.2 percent estimated that they had lost 20 or more patients within the last year for reasons of price. Practice development and marketing efforts represented an average of 7.3 percent of plastic surgeons' working time. Parameters associated with a high percentage of time devoted to these activities were solo practice, percentage of revenue from aesthetic surgery greater than 50 percent, a practice environment designation of moderately or very competitive, and ten or more area surgeons offering aesthetic surgery (p < 0.05). High patient income led to only slight decreases in price sensitivity and did not significantly reduce the amount of time spent on marketing and practice development. Although the rest of the healthcare industry has undergone a period of consolidation, aesthetic surgeons have been able to resist these changes. The results of this survey suggest that the fragmented nature of the aesthetic surgery industry is associated with additional burdens on plastic surgeons. As the aesthetic surgery market becomes more competitive, plastic surgeons may benefit from consolidation to reduce costs and maximize efficiency.

Economic theory dictates that changes in consumer demand have predictable effects on prices. Demographics represents an important component of demand for aesthetic surgery. Between the years of 1997 and 2010, the U.S. population is projected to increase by 12 percent. The population increase will be skewed such that those groups undergoing the most aesthetic surgery will see the largest increase. Accounting for the age-specific frequencies of aesthetic surgery and the population increase yields an estimate that the overall market for aesthetic surgery will increase by 19 percent. Barring unforeseen changes in general economic conditions or consumer tastes, demand should increase by an analogous amount. An economic demonstration shows the effects of increasing demand for aesthetic surgery on its fees. Between the years of 1992 and 1997, there was an increase in demand for breast augmentation as fears of associated autoimmune disorders subsided. Similarly, there was increased male acceptance of aesthetic surgery. The number of breast augmentations and procedures to treat male pattern baldness, plastic surgeons, and fees for the procedures were tracked. During the study period, the supply of surgeons and consumer demand increased for both of these procedures. Volume of breast augmentation increased by 275 percent, whereas real fees remained stable. Volume of treatment for male pattern baldness increased by 107 percent, and the fees increased by 29 percent. Ordinarily, an increase in supply leads to a decrease in prices. This did not occur during the study period. Economic analysis demonstrates that the increased supply of surgeons performing breast augmentation was offset by increased consumer demand for the procedure. For this reason, fees were not lowered. Similarly, increased demand for treatment of male pattern baldness more than offset the increased supply of surgeons performing it. The result was higher fees. Emphasis should be placed on using these economic relationships to expand the demand for aesthetic surgery.

Large, complex bony defects can be a vexing problem for the reconstructive surgeon, especially when standard donor sites are not available or do not provide sufficient tissue. Using the concept of flap prefabrication, we demonstrated in a single patient that (1) iliac crest bone chips and bone morphogenic protein in an alloplastic mandibular tray can ossify in a heterotopic location and (2) neovascularization sufficient to support a large, custom-designed bone graft occurs within a convenient "carrier" flap. Ultimately, the fields of angiogenesis and osteogenesis research could significantly contribute to the ability of the plastic surgeon to construct the "ideal" composite prefabricated flap for complicated reconstruction.

The size of the plastic surgery workforce has important effects on the financial environment of the specialty. Economic theory predicts that increasing the area supply of surgeons performing aesthetic surgery will result in lower fees for their services. This study tested that theory in the actual aesthetic surgery marketplace. The study examined the ratio of plastic surgeons to the general population of several states. It then traced the aesthetic surgery fees resulting from different densities of area plastic surgeons. This information was economically analyzed to project the fee effects of possible future changes in the number of practicing plastic surgeons. For the states of New York, California, and Texas, there is a proportional decrease in fees as the density of plastic surgeons increases. For example, New York has 34 percent more plastic surgeons proportionally than Texas, and its fees are 30 percent lower in real dollars. Economic analysis can project the fee effects of changing the supply of surgeons performing aesthetic surgery. The analysis reveals that a 30 percent national increase in the supply of plastic surgeons would lower fees by approximately 32 percent. Similarly, if the number of plastic surgeons increases by 50 percent, fees will decrease by approximately 53 percent. However, these fee effects can be mitigated by expanding the demand for aesthetic surgery. In conclusion, the size of the plastic surgery workforce has profound effects on the fees paid for aesthetic surgery, and the magnitude of these effects can be understood, predicted, and optimized using the tools of economics.

The laws of microeconomics explain how prices affect consumer purchasing decisions and thus overall revenues and profits. These principles can easily be applied to the behavior aesthetic plastic surgery patients. The UCLA Division of Plastic Surgery resident aesthetics clinic recently offered a radical price change for its services. The effects of this change on demand for services and revenue were tracked. Economic analysis was applied to see if this price change resulted in the maximization of total revenues, or if additional price changes could further optimize them. Economic analysis of pricing involves several steps. The first step is to assess demand. The number of procedures performed by a given practice at different price levels can be plotted to create a demand curve. From this curve, price sensitivities of consumers can be calculated (price elasticity of demand). This information can then be used to determine the pricing level that creates demand for the exact number of procedures that yield optimal revenues. In economic parlance, revenues are maximized by pricing services such that elasticity is equal to 1 (the point of unit elasticity). At the UCLA resident clinic, average total fees per procedure were reduced by 40 percent. This resulted in a 250-percent increase in procedures performed for representative 4-month periods before and after the price change. Net revenues increased by 52 percent. Economic analysis showed that the price elasticity of demand before the price change was 6.2. After the price change it was 1. We conclude that the magnitude of the price change resulted in a fee schedule that yielded the highest possible revenues from the resident clinic. These results show that changes in price do affect total revenue and that the nature of these effects can be understood, predicted, and maximized using the tools of microeconomics.

Objective: The purpose of the study was to assess the results and morbidity associated with simultaneous bilateral TRAM free flap breast reconstruction and describe refinements in its surgical technique., Summary Background Data: Bilateral prophylactic total mastectomies might be an agreeable option for those patients at highest risk for breast cancer if autogenous tissue breast reconstruction could be performed with reasonable technical ease and acceptable morbidity. However, some surgeons harbor reservations regarding the extensiveness of the surgery, the associated morbidity, and the aesthetic quality of the resulting outcome., Methods: A multicenter retrospective review of clinical experience with 120 consecutive patients who underwent 240 simultaneous bilateral TRAM free flap breast reconstructions was developed., Results: The average operating time, including the time required for the breast ablative portion of the procedures, was 8.6 hours. The average length of hospitalization was 7.6 days. However, for the last 40 patients, these figures were reduced to 7.1 hours and 6.1 days, respectively. Nonautologous blood transfusions were needed in 33 cases (28%), but only 1 was required in the last 40 patients. Thromboses developed in six of 240 flaps (2.5%): 4 were arterial and 2 were venous. Re-exploration allowed us to restore circulation in five flaps, whereas one flap was unsalvageable and was replaced successfully with an alternate flap. An uncomplicated deep vein thromboses developed in one patient with a history of recurrent deep vein thromboses that had no adverse effect on her outcome. Minor complications developed in 18 patients (15%) (e.g., hematoma, partial wound necrosis, wound infection, or prolonged postoperative ileus) that did not affect the long-term outcome. Fourteen patients (11.6%) had abdominal wall weakness or hernias. Follow-up time averaged 37.2 months (range, 14-62 months). On last follow-up, patients' self-reported overall satisfaction with the procedure was 56% excellent, 40% good, and 4% fair., Conclusions: Simultaneous bilateral free flap reconstruction is technically feasible with a high rate of success and an acceptable morbidity. When performed by experienced surgeons, bilateral prophylactic total mastectomies combined with simultaneous bilateral TRAM free flap reconstruction may provide an adequate surgical option with aesthetically acceptable results for patients at high risk for breast cancer.

Of 114 patients who had TRAM flap breast reconstruction, 46 (40 percent) had preexisting abdominal surgical scars. Sixty-six free TRAM flaps and 9 pedicled TRAM flaps were performed in the 46 patients. The records were analyzed to determine what impact, if any, abdominal scars had on postoperative complications. There were no reconstructive failures or significant (>25 percent) flap losses. Eight minor complications occurred in 7 patients (15 percent). The incidences of abdominal-wall weakness (4.3 percent), partial flap loss (4.3 percent), minor fat necrosis (4.3 percent), and donor-site wound problems (4.3 percent) were acceptable. Subcostal scars and multiple abdominal scars were found to predispose to skin complications. Right lower paramedian scars precluded free TRAM flaps because of damage to the inferior epigastric vessels in three of three patients. Both obesity (p = 0.003) and smoking (p = 0.05) were associated with a greater risk of wound-healing complications. We conclude that with certain technical modifications, TRAM flap reconstruction is a safe and effective procedure in patients with abdominal scars.

Some spontaneous return of sensibility following autologous tissue breast reconstruction is often suspected but not well documented. In the present study, objective touch-pressure, pain, temperature, and vibratory sensibilities were recorded in 33 autologous breast reconstructions at an average of 25.2 months postoperatively. Correlation of the sensory return with patients' satisfaction toward reconstruction was done by a detailed questionnaire. All except one patient regained a variety of sensibilities touch pressure in 97 percent of patients (averaging 81.05 gm/mm2 versus control of 7.98 gm/mm2), pain in 88 percent of patients, heat in 64 percent of patients (45 percent of quadrants), cold in 82 percent of patients (67 percent of quadrants), and high- and low-frequency vibration in 100 percent of patients (high in 90 percent of quadrants, low in 96 percent). Subjectively, 94 percent considered their chest comfortable to touch following reconstruction compared with 34 percent following mastectomy. On a scale from 1 to 10, patients rated their reconstructions an average of 9.3. Our findings confirm the spontaneous return of sensibility following a variety of autologous tissue breast reconstructions. The value of the sensory return is suggested by the high degree of satisfaction in nearly all patients. Further attempts to correlate the degree of sensory return with the degree of satisfaction were inconclusive because of the uniformly high satisfaction reported by the patients. The mechanism of reinnervation appears to come both from the skin margins and from the deep surface of the flap. Future developments in breast reconstruction should take into consideration the eventual quality of sensory return.

Unlabelled: Numerous reports of flap prefabrication have demonstrated good survival. The durability of these flaps compared with that of other flap types or normal tissue, however, remains unknown. The purpose of this study was to determine how prefabricated flaps respond to a bacterial challenge compared with identically sized normal random-pattern flaps. Rat abdominal cutaneous-panniculus carnosus flaps were prefabricated with a standard-sized groin fasciovascular tissue carrier and then inoculated with Staphylococcus aureus. The prefabricated flaps were divided into two groups. Group one (standard prefabricated flap, n = 24) received no growth factor. Group two (n = 24) received an angiogenic growth factor between the carrier and flap tissue. A random-pattern flap served as a nonprefabricated control (n = 12). Grading of the prefabricated flaps with growth factor versus the standard prefabricated flaps versus controls showed dehiscence (41 versus 37 versus 4 percent), ulceration (21 versus 29 versus 18 percent), erythema/cellulitis (40 versus 44 versus 8 percent), and necrosis (9 versus 29 versus 0 percent). The control flaps had significantly less dehiscence, erythema/ cellulitis, and necrosis than the standard prefabricated flaps. Similarly, the prefabricated flaps with angiogenic growth factor had significantly less necrosis than the standard prefabricated flaps., Conclusions: (1) prefabricated flaps were demonstrated to be less durable than random-pattern flaps against a bacterial challenge, (2) angiogenic growth factor may help to improve the durability of prefabricated flaps against bacterial infection, and (3) the biologic behavior of prefabricated flaps is not the same as that of normal tissue and deserves further investigation.

Possible adverse effects of microbial organisms have been implicated in symptomatic silicone implant patients. In the literature, numerous authors have investigated the possible role of infection with respect to implant problems. To date, various bacterial species have been reported, including Staphylococcus aureus, Staphylococcus epidermidis, peptostreptococci, and Clostridium perfringens. Infections in polyurethane-coated prostheses also have been shown to prolong morbidity. Antibiotic use has been relatively empirical in this regard. The purpose of this study was, first, to determine the frequency, type, and clinical relevance of microbial colonization on implant surfaces removed from symptomatic patients and, second, to determine possible effects of microbial colonization on implant integrity (gel bleed, rupture). A total of 139 implants from 72 symptomatic patients were entered into the prospective clinical study between February of 1993 and July of 1994 at the UCLA Medical Center. The implant shell types included smooth (79 percent), polyurethane (8 percent), textured (7 percent), and smooth and Dacron (6 percent). The implant locations were subglandular (71 percent), submuscular (28 percent), and subcutaneous (1 percent). Of the 139 implants removed, 69 percent were intact and 31 percent were ruptured. Forty-seven percent of 139 implants were culture-positive. Propionibacterium acnes was isolated most frequently (57.5 percent), followed by Staphylococcus epidermidis (41 percent), and then Escherichia coli (1.5 percent). No fungal infections were identified. Culture positivity was not significantly associated with systemic symptoms. Sixty-seven percent of the positive culture implants were intact; 33 percent were ruptured. The frequency (47 percent) and types (P. acnes and S. epidermidis) of microbial colonization are determined in symptomatic silicone implant patients.

Recent reports suggested that the presence of synovial metaplasia in the capsular tissues of breast implants is greater with textured-shelled implants compared with smooth. Textured implants, however, have become popular only in the last few years. Therefore, the studies do not address the possibility that synovial metaplasia may be a dynamic process related to time (e.g., implant age) rather than implant shell surface. In the current study, 159 implant capsules (85 patients) removed between February of 1992 and July of 1993 at UCLA Medical Center were evaluated histologically and correlated with clinical data, including the age of implants. Synovial metaplasia was identified in 40 percent (64 of 159) of the capsule specimens. A logistic regression analysis that removed the effect of implant age demonstrated no correlation of implant shell type (textured versus smooth) with the presence of synovial metaplasia. Gel bleed, implant location, pericapsular fluid, implant rupture, and capsular contracture also did not have any significant association with synovial metaplasia in the current study. The incidence of synovial metaplasia appears to decrease with age (77 percent at < 5 years; 22 percent at > 15 years). Our findings suggest that synovial metaplasia is not rare and in fact may be a fairly common transitional histologic finding. It may be part of the common progression that occurs at the implant-capsule interface. The clinical significance remains unknown.

Recent controversy encountered with silicone breast implants has increased the use of autogenous tissue for breast reconstruction following mastectomy. Surveillance of patients who have undergone autogenous tissue reconstruction is important in the evaluation of recurrent or new cancer. Magnetic resonance imaging (MRI) has proven to be a useful technique in the delineation of soft tissues and provides excellent resolution. Recently, MRI has been reported to be a valuable diagnostic imaging modality for the evaluation of augmented breast implant patients with regard to implant rupture detection, silicone granuloma identification, and silicone gel migration delineation. In this study, various autologous tissue donor sites currently available for breast reconstruction were imaged by MRI. The following donor flaps were included: fleur-de-lis, TRAM, gluteal, and tensor fasciae latae. A total of 10 clinical cases were investigated. The anatomic basis of each flap type is illustrated, and various tissue components of flap tissue (skin, fat, and muscle) are demonstrated on MRI scan. Anatomic knowledge of autogenous tissue types and MRI appearance of the flap-breast-chest-wall interface are critical in the surveillance and follow-up of breast cancer patients.

With the current controversy regarding the safety of silicone implants, the detection and evaluation of implant rupture are causing concern for both plastic surgeons and patients. Our study obtained comparative value analysis of mammography, sonography, and magnetic resonance imaging (MRI) in the detection of silicone implant rupture. Twenty-nine symptomatic patients (total of 59 silicone implants) were entered into the study. Intraoperative findings revealed 21 ruptured implants (36 percent). During physical examination, a positive "squeeze test" was highly suggestive of implant rupture. Mammograms were obtained of 51 implants (sensitivity 11 percent, specificity 89 percent). Sonography was performed on 57 implants (sensitivity 70 percent, specificity 92 percent). MRI was performed on 55 implants (sensitivity 81 percent, specificity 92 percent). Sonographically, implant rupture is demonstrated by the "stepladder sign." Double-lumen implants may appear as false-positive results for rupture on sonography. On MRI, the "linguine sign" represents disrupted fragments of a ruptured implant. The most reliable imaging modality for implant rupture detection is MRI, followed by sonogram. Mammogram is the least reliable. Our study supports the clinical indication and diagnostic value of sonogram and MRI in the evaluation of symptomatic breast implant patients.

The microvascular surgical anastomosis remains one of the most technically sensitive aspects of free-tissue transfers. To facilitate these often time-consuming, difficult anastomoses, various anastomotic coupling systems have been introduced. The 3M microvascular anastomotic coupling device, a polyethylene ring-pin device, was found to be highly successful in numerous animal studies. It has been available for use in human subjects for the last 4 years, but clinical experience remains sparse. Our clinical experience with the 3M coupler is reported in 100 free-tissue transfers. The average anastomotic time was 4 minutes. Mean follow-up was 8.6 months, and flap survival was 100 percent. The overall success rate for 3M (MACD) coupler use in microvascular anastomoses is 98.4 percent (121 of 123). Nine abandoned anastomoses were converted to sutured anastomoses intraoperatively. The over-all failure rate for 3M coupler anastomoses is 1.6 percent (2 of 123). We conclude that the 3M device is best suited for minimally discrepant, soft, pliable venous microvascular anastomoses and is unsuitable for end-to-side anastomoses in clinical situations. When carefully and selectively employed by a trained microvascular surgeon, the 3M coupler can be a safe, fast, and reliable adjunct for free-tissue transfers.

Breast implant rupture is an important complication of augmented and reconstructed breasts. Although several techniques such as mammography, xeromammography, ultrasound, thermography, and computed tomographic (CT) scanning have been proven to be useful to detect implant rupture, they have several disadvantages and lack specificity. In the current study, we have established magnetic resonance imaging (MRI) as a definitive, reliable, and reproducible technique to diagnose both intracapsular and extracapsular ruptures. The study was conducted in 100 symptomatic patients. Our imaging parameters were able to identify ruptures in implants with silicone shells. All the ruptures showed the presence of wavy lines, free-floating silicone shell within the gel ("free-floating loose-thread sign" or "linguine sign"). We had a 3.75 percent incidence of false-positive and false-negative results. The sensitivity for detection of silicone implant rupture was 76 percent, with a specificity of 97 percent. In addition, we also were able to identify the artifacts that may interfere with the definitive diagnosis of implant rupture.

Surface-temperature recording (STR) is one of the oldest and simplest methods of postoperative monitoring of free flaps. Its usefulness, however, remains poorly documented, and its problems, not well understood. To assess its value, we reviewed our series of 600 consecutive free flaps where surface-temperature recording was the main method of monitoring used and a detailed temperature record was kept. Seventy flaps suffered a postoperative microvascular compromise necessitating a surgical reexploration. Of these, 62 charts were satisfactory for review and were matched with 62 charts from similar but uncomplicated flaps. The derived value C delta T, which represents the change in temperature difference (delta T) between flap and control sites over a specified time period, was calculated at each time point. Of 10,000 derivations, only once did C delta T greater than 1.8 degrees C fail to identify a microvascular thrombosis, and 17 times a false alarm was given. Therefore, when properly applied and interpreted, the sensitivity of surface-temperature recording is 98 percent, and its predictive value is 75 percent, making it a simple, inexpensive, and highly reliable technique of free-flap monitoring. The thermodynamics behind surface-temperature recording is reviewed, pointing out the pitfalls that have to be avoided in order to improve the reliability of this technique.

Twenty-two cases of traumatic below-knee amputation stumps with inadequate soft-tissue coverage salvaged with microvascular free flaps were reviewed retrospectively. All patients would have required an above-knee amputation for prosthesis fitting had microvascular free flaps not bee utilized. A total of 24 flaps were used in 22 patients; parascapular 11 (46%), foot filet six (25%), latissimus dorsi four (17%), lateral thigh, tensor fascia lata, and groin one (4%). Free flaps were performed immediately after injury in five (21%) cases, within the first week in two (8%), between 1 and 3 months in 12 (50%), and after 3 months in five (21%). Fifty per cent of the patients had significant other injuries. The patients had a total of 107 operations (mean, 4.9) related to their injury: 33 (mean, 1.5) of those operations were after the free flap, 27 (25%) of which were either performed because of a complication of the free flap or for revision of the free flap. Complications included partial necrosis in five (21%), neuroma in three (13%), hematoma in two (8%), donor site complication in two (8%), thrombosis requiring reoperation in one (4%), and flap failure in one (4%). Patient followup ranged from 12 to 116 months. All patients maintained a functional below-knee prosthetic level. The mean time to ambulation was 5.75 months, and was not significantly affected by flap complications. Most patients employed before their injury were employed after their injury. Despite a protracted course in these severe injured trauma patients, a functional below-knee amputation level was preserved in all cases utilizing microvascular free flaps.

The feasibility of prefabricating free flaps by inducing, through the process of staged reconstruction, an arteriovenous bundle and its surrounding fascia to perfuse a selected block of tissue was investigated experimentally and clinically. Sixteen rat knee joints were wrapped with their ipsilateral superficial inferior epigastric (SIE) fascia. In 8 joints, the composite flaps were resected en bloc and were immediately replaced orthotopically pedicled upon the superficial inferior epigastric vessels. In the remaining joints, the resection and orthotopic transfer were performed 2 weeks later. Only the joints in the latter group, which benefited from the staging period, were found to be perfused. The long finger proximal interphalangeal joint of a child was reconstructed by the staged microvascular transfer of his second toe proximal interphalangeal joint. At the first stage, a temporalis fascia flap was wrapped around the toe proximal interphalangeal joint and revascularized to the dorsalis pedis vessels. Six weeks later, the joint and its temporalis fascia envelope were dissected, and the "prefabricated" joint flap was transferred to the hand and revascularized to the wrist vessels. Bony union progressed uneventfully with excellent recovery of the range of motion. We conclude that regardless of the indigenous vascular anatomy, an unlimited array of composite free flaps can be constructed and transferred based on induced large vascular pedicles.

The impending no-reflow (NRF) state was studied in the rat hindlimb to identify possible biochemical mediators producing the no-reflow phenomenon. After 5 hours of ischemia, the venous effluents draining the ischemic limb and the contralateral nonischemic limb were collected for three 30-minute time periods. Thromboxane B2 (TxB2), prostaglandin E2 (PGE2), and 6-ketoprostaglandin F1 alpha, the stable metabolite of prostacyclin (PGI2), were measured by radioimmunoassay. Venous outflow rate, distal skin perfusion assessed by dermofluorometry, and histology of muscle and skin were examined in control limbs, ischemic limbs, and limbs with impending no reflow. The no-reflow state was characterized by a significantly decreased venous outflow (less than 0.01 ml per minute), decreased skin perfusion (index of fluorescence of 15 percent in no-reflow limbs versus 70 percent in reflow limbs), and absence of thrombosis of the vasculature. The no-reflow state also was associated with 2.4 times more thromboxane B2 and 1.5 times more 6-ketoprostaglandin F1 alpha than that observed in ischemic limbs with reflow. The biosynthesis of vasodilating prostaglandin E2 in the no-reflow state, however, was only 40 percent of the prostaglandin E2 measured in limbs with reflow. We propose that the impending no-reflow state may reflect a state of global microcirculatory "agonal" vasoconstriction, most probably due to an overabundant release of the vasoconstrictor thromboxane relative to the vasodilating prostaglandin E2 and prostacyclin. The likelihood of specific biochemical mechanisms producing the no-reflow state suggests that pharmacologic agents may be able to reverse the impending no-reflow state to improve tissue survival.

A retrospective review of 304 consecutive microvascular free flaps to the lower extremity was done to identify the patterns of usage, results, and problems. The most common indication (91%) was for the replacement of extensive tissue loss caused by motor-vehicle injuries. Most of the defects were below the mid-tibia (73%). The associated compound fractures were predominantly gradable as Gustilo type IIIb&c. The latissimus dorsi, the rectus abdominus, and the scapular skin were the flaps used most commonly for coverage (77%). The overall flap failure rate was 8%, compared with 3% for our series of non-lower extremity cases, and 0% for the non-traumatic lower extremity cases. The magnitude of the traumatic insult was the most significant factor associated with anastomotic failure. The rate of anastomotic thrombosis doubled in the presence of vascular trauma, increased threefold in the presence of larger bony defects, and increased fivefold when vein grafts were needed. Experience was important in reducing the complications and improving the results. Fourteen patients (6%) underwent an amputation within the first 3 months, ten of them because of flap failure. Of 85 patients followed up for over one year, 91% had recovered good to excellent leg function. The ability to add healthy and well vascularized tissue to the traumatized limb is critical for the achievement of: 1) early definitive wound healing and restoration of function; 2) salvage of many impending amputations; 3) better prosthetic stump reconstructions; 4) better esthetic results.

The author's experience with 10 gluteus maximus myodermal free flap breast reconstructions is reviewed against the current methods of reconstruction using silicone implants, latissimus dorsi flaps, regional skin flaps, and rectus abdominis myodermal flaps. The superior gluteal free flap can achieve a reliable, permanent, and aesthetic reconstruction of the breast without silicone implants. The softness, projection, natural appearance, and patient satisfaction are excellent compared with other methods. It is particularly useful in patients who object to the use of artificial implants, are not suitable for regional flaps, or have disappointing results from previous reconstructions. Technical modifications of the flap design and selection of the recipient vessels are important.

Safe planes exist for plantar incisions that minimize the possibility of subcutaneous nerve injury and are therefore useful in flap design. Nerve branch orientation in the plantar subcutaneous tissue is specific and guides dissection so as to avoid producing anesthesia in weight-bearing areas. An extensive proximal plantar subcutaneous plexus exists that permits elevation of plantar flaps in a superficial plane. This is due to the major contribution that the dorsal circulation makes to the skin of the plantar surface. The blood supply to the non-weight-bearing midsole area is not from the medial plantar artery exclusively. This is a watershed area with important lateral plantar artery and dorsalis pedis artery contributions as well. It is not necessary or desirable to base plantar flaps on a myocutaneous or fasciocutaneous supply with its required deep dissection. Local plantar flaps can be designed to include sensation and abundant blood supply without the need for "subfascial" dissection. Subcutaneous sensory plantar flaps designed in accordance with these principles promise a more ideal solution for the treatment of plantar defects.

Donor-site morbidity in 300 consecutive free flaps was reviewed to identify their etiologies and potentially prevent their recurrence in future cases. An overall morbidity rate of 20 percent was seen in this series. Secondary surgical procedures specific for donor-site problems were required in 7.7 percent of patients. Major complications occurred in 2.3 percent of the donor sites. From this review it is apparent that major donor-site morbidity is uncommon and most donor-site problems could probably have been avoided. Our recommendations are as follows: closure of the donor site to avoid excessive tension must be carefully planned preoperatively, donor-site anatomy and flap elevation techniques must be precisely understood, surgical retractors must be carefully placed to avoid injury to nearby structures, the donor site should be closed immediately following pedicle division, thus minimizing wound exposures, and complete surgical hemostasis is mandatory.

The potential hazards of using proximal segments of leg arteries for end-to-end anastomosis to vessels in free flaps are examined, and alternatives are proposed. The convservation of the major tibial arteries seems highly desirable, to minimize any subsequent development of ischemic complications. Turning a free flap upside down moves the anastomosis to the distal part of the extremity, thus conserving most of the muscular branches of the recipient artery. Cutting the recipient artery distally and bending it back in recurrent fashion also allows for easy end-to-end anastomosis, with many technical advantages.

The temporoparietal fascia is an ideal tissue source for free transfer to distant sites where ultrathin coverage is either desirable or mandatory. The fascia's dependable vascular anatomy facilitates the technical aspects of microvascular transfer by means of its large vessels, ample pedicle, and ability to be grafted on either side. Furthermore, this highly vascular tissue is available in surprisingly large quantities, and its donor scar is hidden in the hair. The authors have found this flap useful (1) in covering exposed bone and tendon without adding unwanted bulk, (2) in providing thin flap coverage or lining in major facial reconstruction, (3) in covering vital structures such as exposed nerves and vessels, (4) in providing neovascularity both as a recipient graft bed and for control of chronic infection, and (5) in reestablishing gliding-tendon mechanisms. The authors have successfully employed this free flap in 15 cases which involved deformities of the ankle, foot, Achilles tendon, forearm, hand, nose, and contralateral ear and scalp. Seven cases are utilized to illustrate the broad application of this unique and versatile free flap.

Closure of plantar defects with local rotation flaps was studied in 10 patients with 11 plantar defects. Ages ranged from 15 to 66 years, and the average defect was 3.0 X 3.6 cm. Two patients were diabetics. Etiology was variable and included trauma, tumors, and breakdown in patients with anesthetic plantar surfaces. Plantar flaps were designed superficial to the plantar fascia based on the proximal plantar subcutaneous plexus blood supply. Sensation was provided by including the medial calcaneal nerve territory within the flap and by performing a limited intraneural dissection of the medial and lateral plantar nerves. Flaps were medially based, although laterally based designs are also possible when sensation is absent. The follow-up period averaged 20.8 months. Patients with normal sensation preoperatively had full sensation postoperatively and were able to bear weight on the flap without limitation. There was minor breakdown in one patient with incomplete sensation. One patient developed a hematoma. Sensate plantar flaps can be designed superficial to the plantar fascia. These flaps are durable and allow normal weight-bearing on the reconstructed surface.