Search

The elderly population in the United States is expanding rapidly, and with advancements in modern medicine, the number of elderly patients undergoing surgery has risen in parallel. The aim of this study was to evaluate the effect of age and frailty on postoperative outcomes following pedicled flap reconstruction. The 2005-2016 ACS-NSQIP databases were queried to identify cases involving pedicled flaps based on CPT codes. Demographic data and postoperative complications were assessed using Chi-square and t -tests for analysis of categorical and continuous variables, respectively. A multivariable regression analysis was conducted to control for confounders. A total of 44,986 cases were included in our analysis. Patients in the 70-79year age group had the highest rates of all-cause (31.2%), mild systemic (25.3%) and severe systemic (7.4%) complications. Multivariable regression identified age as an independent risk factor for all-cause, severe systemic and wound complications. A score of 3+ on the 5-factor modified frailty index (mFI-5) was associated with all-cause, severe systemic and wound complications. When stratified by flap location, age was predictive of all-cause complications for breast, trunk, upper extremity and lower extremity flaps. Finally, mFI-5 score of 3+ was identified as an independent risk factor for all-cause complications in flaps of the head and neck, trunk and lower extremity. Although, increased age does contribute to risk of postoperative complications, the frailty index appears to hold much stronger predictive capacity. These findings stress the importance of optimizing preoperative comorbidities to reduce the risk of poor postoperative outcomes.

Sepsis is a serious and potentially life-threatening condition. Risk factors that are associated with the development of sepsis may differ as it relates to reconstructive flap surgery. The purpose of this study is to identify the incidence and predictors for sepsis in patients undergoing reconstructive flap surgery. The ACS-NSQIP database was queried from 2005 to 2016 for factors related to sepsis in patients undergoing reconstructive flap surgery. CPT codes were used to identify patient cohorts. A sepsis group was compared to a control group that underwent the same procedures without the postoperative manifestations of sepsis. Statistical analyses were performed to ascertain risk factors associated with the development of sepsis. 24,257 patients who underwent flap reconstruction were included in this study. Of these, 511 developed sepsis postoperatively (2.1%). Multivariate analysis showed that male gender ( p  < .001), African-American race ( p  < .001), hypertension requiring medication ( p  < .001), smoking ( p  < .001), a higher Charlson comorbidity Index score ( p  < .001), evidence of preoperative wound infection ( p  < .001), chronic steroid use ( p  < .001), and prolonged operative time ( p  < .001) all significantly were associated with the development of sepsis. Sepsis resulted in a higher chance of 30-day mortality ( p  < .001) and increased the risk of developing septic shock (OR: 2.578, CI: 1.241-5.354) This study shows that postoperative sepsis is a serious complication of reconstructive flap surgery. Risk reduction and prevention of potentially life-threatening complications is always a priority. Awareness of the risk factors contributing to the development of sepsis is crucial for early intervention and treatment.

Facial defects following Mohs surgery can cause significant functional, cosmetic, and psychologic sequelae. Various techniques for nasal reconstruction after Mohs surgery have been analyzed in the medical literature, yet there has been less attention given to procedures for other crucial facial aesthetic regions. A literature search using PubMed, EMBASE, and ISI Web of Science for studies assessing reconstructive techniques of the forehead, cheek, and perioral regions after Mohs surgery was performed. No limitations on date or language were imposed. Studies meeting inclusion criteria consisted of an entirely post-Mohs population, specified technique for aesthetic unit reconstruction, and detailed complications. The initial search yielded 2177 citations. Application of the author's inclusion and exclusion criteria resulted in 21 relevant studies. Linear closure was highlighted as the predominant technique when possible in all 3 aesthetic zones. Local flaps remained the workhorse option for cheek and forehead defects. Cheek and perioral reconstruction were associated with higher complication rates. Eighty-one percent of studies did not include patient-reported outcomes or standardized outcome measurement assessments. Mohs surgery has become a valuable approach for treatment of skin malignancies of the face. This review has identified significant study heterogeneity in methodology, design, and outcome assessment. Currently, there is no evidence-based literature to support an algorithm to guide surgeon choice of treatment in these 3 central areas. Recommendations are provided to improve the quality of future studies to better inform appropriate surgical technique for each facial unit analyzed.

Background: Indocyanine green angiography has gained popularity in breast reconstruction for its ability to assess mastectomy skin and tissue flap viability. The authors aim to analyze trends and outcomes associated with indocyanine green angiography use in breast reconstruction., Methods: Using 2012 to 2014 data from the Healthcare Cost and Utilization Project National Inpatient Sample, Agency for Healthcare Research and Quality, the authors identified breast reconstructions performed with or without indocyanine green angiography use. Trends over time were assessed using the Cochran-Armitage test. Outcomes were assessed using logistic regression and generalized linear modeling., Results: Over the study period, 110,320 patients underwent breast reconstruction: 107,005 (97.0 percent) without and 3315 (3.0 percent) with indocyanine green angiography use. Usage increased over time: 750 patients (1.9 percent) in 2012, increasing to 1275 patients (3.7 percent) in 2013 (p < 0.001). Smokers (p = 0.018), hypertensive patients (p = 0.046), obese patients (p < 0.001), and those with a higher comorbidity index (p < 0.001) were more likely to undergo indocyanine green angiography. Autologous reconstruction was more frequently combined with its use compared with tissue expander reconstruction (4.5 percent versus 2.1 percent; p < 0.001). There was a significant increase in the odds of débridement associated with its use (OR, 1.404; p < 0.001; 95 percent CI, 1.201 to 1.640)., Conclusions: Indocyanine green angiography use in breast reconstruction has increased in recent years and is associated with higher débridement rates. These rates may indicate changing trends for clinicians when deciding whether to débride tissue during breast reconstruction., Clinical Question/level of Evidence: Therapeutic, III.

Background: Implant-based reconstruction is the predominant form of breast reconstruction, with the two-stage tissue expander/implant approach being the most popular. Recently, the direct-to-implant, one-stage breast reconstruction procedure has gained momentum. In this study, national and regional trends across the United States for the two different types of implant-based reconstructions were evaluated., Methods: The Nationwide Inpatient Sample database was used to extrapolate data on type of mastectomy, implant-based reconstructive technique (one-stage or two-stage), and sociodemographic and hospital variables. Differences were assessed using the chi-square test, impact of variables on reconstructive method was analyzed using logistic regression, and trends were analyzed using the Cochrane-Armitage test., Results: Between 1998 and 2012, a total of 1,444,587 patients treated for breast cancer or at increased risk of breast cancer met the defined selection criteria. Of these, 194,377 patients underwent implant-based breast reconstruction (13.6 percent one-stage and 86.4 percent two-stage). In both, there was a significant increase in procedures performed over time (p < 0.001). The highest increase in both was seen in the Northeast region of the United States, and the lowest increase was seen in the South. When stratified into regions, analysis showed differences in socioeconomic and hospital characteristics within the different regions., Conclusions: There is an observed increase in the number of one-stage and two-stage breast reconstructions being performed. Sociodemographic and hospital factors of influence vary in the different regions of the United States. This study provides important information for clinicians and policy makers who seek to ensure equitable and appropriate access for patient to the different types of implant-based procedures.

Background: Mastectomy skin necrosis represents a significant clinical morbidity after immediate breast reconstruction. In addition to aesthetic deformity, necrosis of the native mastectomy skin may require debridement, additional reconstruction, or prolonged wound care and potentially delay oncologic treatment. This study aims to evaluate patient and procedural characteristics to identify predictors of mastectomy skin necrosis after microsurgical breast reconstruction., Methods: A retrospective review was performed of all immediate microsurgical breast reconstructions performed at a single academic center. Patient records were queried for age, diabetes, active smoking, previous breast surgery, preoperative radiation, preoperative chemotherapy, body mass index, mastectomy type, mastectomy weight, flap type, autologous flap type, and postoperative mastectomy skin flap necrosis., Results: There were 746 immediate autologous microsurgical flaps performed by three plastic surgeons at our institution during the study period. The incidence of mastectomy skin flap necrosis was 13.4%. Univariate analysis revealed a significantly higher incidence of mastectomy skin necrosis in patients with higher mastectomy weight (P < 0.001), higher autologous flap weight (P < 0.001), higher body mass index (0.002), and diabetes (P = 0.021). No significant association was found for age, smoking, prior breast surgery, preoperative chemotherapy or radiation, or mastectomy type. Multivariate analysis demonstrated statistically significant associations between mastectomy skin necrosis and both increasing mastectomy weight (odds ratio 1.348 per quartile increase, P = 0.009) and diabetes (odds ratio 2.356, P = 0.011)., Conclusions: Increasing mastectomy weight and coexisting diabetes are significantly associated with postoperative mastectomy skin necrosis after microsurgical reconstruction. These characteristics should be considered during patient counseling, procedure selection, operative planning, and intraoperative tissue viability assessment., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Administration of statins or other cardiovascular medications (CVMs) could potentially protect against the development of ischemia-reperfusion (I/R) injury in free flap reconstruction. The aim of this study was to examine whether the use of statins and other CVMs decreased the rate of I/R injury in autologous free flap breast reconstruction., Methods: Retrospective chart review was performed on women who had undergone mastectomy and autologous free flap breast reconstruction between 2004 and 2010. Patient characteristics, use of statin and/or CVMs, and I/R-related complications were ascertained. Multivariable logistic regression was used to identify associations between independent risk factors and specific complications., Results: There were 702 free flap breast reconstructions included in this study; 45 performed in patients on statins, 70 in patients on CVMs, and 38 in patients on both. Overall complication rate in patients on statins and patients on CVMs was significantly higher than those not on any medication (46.7% versus 31.5%, P=0.037 and 45.7% versus 31.5%, P=0.017, respectively). When I/R complications were pooled, there were no significant differences between patients not on any medications and those on statins (P=0.26), CVMs (P=0.18), and both (P=0.83.), Conclusions: Although there may be theoretical pharmacologic benefits of statins and/or CVMs to reduce the incidence of IR injury in autologous free flap breast reconstruction, the results of this study showed no clear advantages when these drugs were used., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The distally based sural fasciocutaneous flap is one of the few options available for local flap reconstruction of soft-tissue defects in the lower one-third of the leg. Few studies have assessed risk factors associated with poor outcomes in this flap. A literature search was performed of MEDLINE, EMBASE, CINAHL and the Cochrane Library for articles evaluating the use of sural artery fasciocutaneous flaps for soft-tissue reconstruction of the leg. Data were pooled and a univariate analysis was performed to identify characteristics associated with increased morbidity. A logistic regression model was created, and odds ratios and p values associated with the development of complications were calculated. Sixty-one papers were identified which included data on 907 patients. The majority of sural flaps were used to cover defects of the heel (28.2%), foot (14.4%) or ankle (25.8%). Trauma was the most common indication, followed by ulcers and open fractures. Flap complications were recorded in 26.4% of cases with a flap loss rate of 3.2%. With multivariate analysis, venous insufficiency and increasing age were independent risk factors for complications. Patients with venous insufficiency had nine times the risk of developing a complication compared to patients without venous insufficiency., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The superficial inferior epigastric artery (SIEA) flap is an excellent option for free tissue transfer breast reconstruction. Similar to the free transverse rectus myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps, the SIEA pedicle supplies the fasciocutaneous tissues of the lower abdomen. The SIEA flap does not involve removal of or potential damage to the rectus muscles. Nonetheless, the vascular pedicle may be a challenge to dissect and variable in its presence and caliber. This article presents a case report and an extended delay technique to augment the SIEA system in a patient with prior bilateral deep inferior epigastric artery ligation., (Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Since the inception of microvascular free tissue transfer, flap monitoring has been based on clinical signs. Color, capillary refill, and handheld Doppler have been used for monitoring in the postoperative period; however, subjective clinical examination may delay recognition of flap compromise. Tissue oximeter monitoring offers an objective method for detecting vascular compromise with the measurement of tissue oxygen saturation and real-time flap perfusion., Methods: The authors reviewed 614 consecutive microsurgical flaps for breast reconstruction from 2004 to 2010. The authors' first 380 patients underwent clinical flap postoperative monitoring. Starting in June of 2008, the authors used tissue oximetry as an adjunct on 234 consecutive patients. Flap reexploration, flap loss, salvage rate, fat necrosis, and characteristics of vascular compromise were analyzed., Results: There were 26 instances of flap reexploration (6.8 percent) and 11 flap losses (2.9 percent) before use of tissue oximetry. After tissue oximetry was used, there were 16 instances of flap reexploration (6.8 percent) and one flap loss. The rate of flap reexploration was not statistically significant between groups, but the difference between the flap failure rates is significant (p = 0.025). The flap salvage rate was previously 57.7 percent; after tissue oximetry monitoring, the flap salvage rate was 93.75 percent (p = 0.015)., Conclusions: The use of tissue oximetry has decreased the authors' flap loss rate and improved the flap salvage rate in microsurgical breast reconstruction. This device is a useful adjunct in flap monitoring during the postoperative period, as it may help decrease flap loss by detecting impending vascular compromise before it becomes clinically evident.

Background: The ability to determine flap perfusion in reconstructive surgery is still primarily based on clinical examination. In this study, the authors demonstrate the use of an intraoperative, near-infrared fluorescence imaging system for evaluation of perforator location and flap perfusion., Methods: Indocyanine green was injected intravenously in six breast cancer patients undergoing a deep inferior epigastric perforator flap breast reconstruction after mastectomy. Three dose levels of indocyanine green were assessed using the fluorescence-assisted resection and exploration (FLARE) imaging system. This system uses light-emitting diodes for fluorescence excitation, which is different from current commercially available systems. In this pilot study, the operating surgeons were blinded to the imaging results., Results: Use of the FLARE system was successful in all six study subjects, with no complications or sequelae. Among the three dose levels, 4 mg per injection resulted in the highest observed contrast-to-background ratio, signal-to-background ratio, and signal-to-noise ratio. However, because of small sample size, the authors did not have sufficient power to detect statistical significance for these pairwise comparisons at the multiple-comparison adjusted type I error of 0.017. Six milligrams per injection provided a similar contrast-to-background ratio but also a higher residual background signal., Conclusion: Based on this pilot study, the authors conclude that near-infrared assessment of perforator flap breast reconstruction is feasible with a light-emitting diode-based system, and that a dose of 4 mg of indocyanine green per injection yields the best observed contrast-to-background ratio compared with a dose of 2 or 6 mg for assessment of flap perfusion.

The use of vasopressors during microsurgery is still debated. General anesthesia often induces hypotension, but microsurgeons are reluctant to use intraoperative vasopressors with the potential risks of vasoconstriction. A retrospective review was performed on 187 consecutive patients undergoing 258 deep inferior epigastric perforator flaps, free transverse rectus abdominis myocutaneous flap, and muscle-sparing free transverse rectus abdominis myocutaneous flap operations. A total of 102 patients (140 flaps) received intraoperative ephedrine and/or phenylephrine and 85 patients (118 flaps) did not. The administration of vasopressors did not affect the rates of reoperation, complete flap loss, partial flap loss, or fat necrosis. Patients receiving vasopressors had no differences in operative time, number of perforators, or number of rows of perforators harvested. There was no statistically significant association between dosage, timing, and complications. Although we do not recommend routine vasopressor use during microsurgery, administration does not seem to increase complications in microsurgical breast reconstruction.

Background: Transposition of well-vascularized flap tissue with or without implantable mesh is often required to repair full-thickness, composite abdominal wall defects. The authors hypothesized that the combination of an inlay of bioprosthetic mesh and a subtotal thigh flap would enable a reliable reconstruction for large, composite abdominal wall defects., Methods: The authors retrospectively reviewed data on patients who underwent repair of large, composite abdominal wall defects with bioprosthetic mesh and free or pedicled subtotal thigh flaps at a major cancer center from 2004 to 2007. Patient, defect, surgical technique, and outcome data were obtained from a prospectively maintained database and medical charts., Results: Seven patients who received eight subtotal thigh flaps (five pedicled and three free flaps with vein grafts to the femoral vessels) met the study criteria. Indications for reconstruction were tumor resection, enterocutaneous fistula, and abdominal wall osteoradionecrosis. All but one patient received preoperative radiotherapy (mean dose, 54.8 Gy). The musculofascial defect was repaired with a mean of 536.4 cm2 of bioprosthetic mesh. The mean subtotal thigh flap skin paddle size was 514 cm2. Complications included partial flap necrosis in one patient, a cerebrospinal fluid leak in one patient, partial split-thickness skin graft loss in two patients, a focal asymptomatic musculofascial repair-site bulge in one patient, and a hernia (not requiring surgery) in one patient. No bioprosthetic mesh infections, wound dehiscences, bowel obstructions, or seromas occurred (mean follow-up, 27.7 months)., Conclusion: Massive, composite abdominal wall defects can be repaired successfully with relatively minor complications using a combination of bioprosthetic mesh and subtotal thigh flaps.

Background: Abdominoplasty has continued to become more frequently performed in the post-bariatric surgery and aesthetic patient populations. With the increase in these procedures, there is a need to decrease the length of drains for patient comfort and postoperative recovery. The authors' hypothesis was that a more superficial plane of abdominal flap elevation during abdominoplasty would decrease the postoperative need for drains., Methods: The authors reviewed 202 consecutive abdominoplasties with 99 procedures performed using a standard suprafascial dissection (group I) and 103 procedures using a modified plane of flap elevation that preserves the thin areolar tissue along the abdominal wall (group II). Patient demographics, perioperative complications, and drain data were recorded., Results: Patient characteristics did not differ significantly, with the mean age of group I and group II (44 +/- 8.9 years and 44 +/- 9.6 years, respectively) and body mass index of group I and group II (24 +/- 3.8 and 24 +/- 3.8, respectively) being similar. Perioperative complications included seven seromas in group I and two seromas in group II. There were two minor hematomas in group I and two minor hematomas in group II. The drains for patients in group II met criteria for removal 3 days earlier than those for group I (p < 0.0001). On average, patients in group II had drains removed at postoperative days 4 to 5., Conclusions: Flap elevation in a plane superficial to the standard suprafascial approach during abdominoplasty may decrease the length of time required for drains in the postoperative period in the abdominoplasty patient. Decreasing the length of time for postoperative drains may improve patient comfort and expedite recovery.

The main advantage of deep inferior epigastric perforator (DIEP) flap breast reconstruction is muscle preservation. Perforating vessels, however, display anatomic variability and intraoperative decisions must balance flap perfusion with muscle or nerve sacrifice. Studies that aggregate DIEP flap reconstruction may not accurately reflect the degree of rectus preservation. At Beth Israel Deaconess Medical Center from 2004-2009, 446 DIEP flaps were performed for breast reconstruction. Flaps were divided into three categories: DIEP-1, no muscle or nerve sacrifice (126 flaps); DIEP-2, segmental nerve sacrifice and minimal muscle sacrifice (244 flaps); DIEP-3, perforator harvest from both the medial and lateral row, segmental nerve sacrifice and central muscle sacrifice (76 flaps). Although the rate of abdominal bulge was similar among groups, fat necrosis was significantly higher in DIEP-1 when compared with DIEP-3 flaps (19.8% vs. 9.2%, P = 0.049). We describe a DIEP flap classification system and operative techniques to minimize muscle and nerve sacrifice., (Copyright 2010 Wiley-Liss, Inc. Microsurgery, 2010.)

Despite recent advances in perforator flap reconstruction, there can be significant variability in vessel size and location. Although preoperative evaluation may provide valuable information, real-time intraoperative methods have the potential to provide the greatest benefit. Our laboratory has developed the Fluorescence-Assisted Resection and Exploration (FLARE) near-infrared (NIR) fluorescence imaging system for intraoperative visualization of details of the underlying vasculature. The FLARE system uses indocyanine green, a safe and reliable NIR fluorophore already FDA-approved for other indications. The system has been optimized in large-animal models for the identification of perforator size, location, and perfusion and has also been translated to the clinic for use during breast reconstruction after mastectomy. In this article, we review our preclinical and clinical data, as well as literature describing the use of similar NIR fluorescence imaging systems in plastic and reconstructive surgery.

Background: In the evolution of flap physiology and reconstruction, there has been a trend of decreased donor-site morbidity. In this article, the chronology of flap reconstruction is discussed, with particular emphasis on the current state of nonmicrosurgical perforator based flaps., Methods: A literature search was conducted to study the evolution of flap physiology and reconstruction. Using this database, the authors describe the evolution of pedicled perforator flap reconstruction. Various examples of perforator-based flaps are discussed in this article., Results: The literature review identified examples of scenarios where pedicled perforator flaps from various regions of the body are viable options. Several clinical cases are presented with respect to each region., Conclusion: Pedicled perforator flaps are a new concept in nonmicrosurgical perforator flap reconstruction.

The anterolateral thigh (ALT) flap is now considered a workhorse for head and neck reconstruction in many centers. However, designing and raising the ALT flap has been traditionally recognized as being difficult, tedious, and technically demanding due to its variation in perforator anatomy. Designing the ALT flap on data gained solely using the handheld Doppler can be misleading, as its specificity and sensitivity varies greatly depending on amount of subcutaneous fat and the Doppler itself. Authors have investigated multiple imaging modalities in the search of the best way to predict and map the site and size of perforators before dissecting a flap. In this article, we describe a simplified technique for the ALT flap design and dissection without the use of preoperative imaging or vascular studies. Utilizing anatomic landmarks, the location of the three perforators (A, B, and C) can be anticipated and safely dissected. We conclude that accurate use of the ABC system is one approach in consistently dissecting the ALT flap.

Background: Patients seeking perforator flap breast reconstruction often face difficult choices if these procedures are not offered locally. To meet this demand, regional referral centers have been created to provide the latest procedures and to centralize cancer care. In 2004, the authors started the New England perforator flap program. The authors present a blueprint of their program and examine its impact on patient satisfaction and referral patterns., Methods: A retrospective chart review was performed on all women who underwent postmastectomy reconstruction at Beth Israel Deaconess Medical Center from 1999 to 2008. A total of 977 patients were identified. Demographics, complications, referring patterns, and state of residence were examined. A validated questionnaire (76.4 percent response rate) was administered determining satisfaction, quality of life, and referral patterns., Results: After program creation, there was an increase in the number of patients undergoing reconstruction from outside the state (10.6 percent versus 20.9 percent, p < 0.0001). There was also an increase in the number of outside referrals to the institution (53.8 percent versus 64.4 percent, p = 0.016). Perforator flap reconstruction had a higher referral rate from outside the referral base compared with nonperforator flap reconstruction (76.6 percent versus 52.0 percent, p < 0.0001). Finally, there was an increase in general patient satisfaction in perforator flap compared with nonperforator flap patients (82.7 percent versus 65.8 percent, p = 0.002)., Conclusions: The creation of a perforator flap program can increase referrals to an institution and increase general patient satisfaction. With the new National Accreditation Program for Breast Centers, more institutions may consider developing these programs. The authors offer their blueprint as a potential model for program design.

Wounds of the distal third of the leg with exposed bone traditionally require free flaps for coverage. Although this often provides good results, patients with multiple comorbidities cannot undergo the long operating times and multiple surgical sites required for these complex procedures. We reviewed the use of posterior tibial (PT) perforator flaps as an alternative to free flaps for distal leg wound coverage in ill patients. Six patients (mean age, 53 years) with multiple comorbidities that precluded free-flap closures were treated with PT perforator flaps to cover complex distal leg wounds. The most common comorbidity was cardiac disease. Five patients had Gustilo grade IIIB open tibial fractures and one had a chronic wound. Mean flap size was 8x5.5 cm with a mean of one perforator per flap. Mean operating room time was 103 minutes. Four flaps were done without general anesthesia. There were no perioperative cardiopulmonary events. With a mean follow-up of 15 months, all flaps survived and all patients were ambulatory. There were no cases of malunion, nonunion, infection, wound breakdown, or partial flap loss. The PT perforator flap is a reliable choice for patients with open leg wounds and comorbidities precluding free-flap closure.

Objective: Preoperative radiation therapy is considered a significant factor in head and neck reconstruction. STUDY AND DESIGN AND SETTING: In our consecutive series of 114 patients, 44 patients had prior head and neck irradiation. The 2 groups were compared on the basis of age, ischemic time, and flap size and were found not to be statistically different. The average ischemic time for the irradiated group was 94.1 minutes, and the average was 102.8 minutes for the nonirradiated group. The average flap size for the irradiated group was 69.5 cm 2 and was 72.0 cm 2 for the nonirradiated group., Results: Using a single-factor analysis of variance, the 2 groups did not differ statistically. The overall major flap complication rate for both irradiated and nonirradiated groups was approximately 10%., Conclusion: Microvascular reconstruction was accomplished in both irradiated and nonirradiated head and neck patients, with a 99% total flap survival rate and a 10% major flap complication rate.

Oxygenation measurements are widely used in patient care. However, most clinically available instruments currently consist of contact probes that only provide global monitoring of the patient (e.g., pulse oximetry probes) or local monitoring of small areas (e.g., spectroscopy-based probes). Visualization of oxygenation over large areas of tissue, without a priori knowledge of the location of defects, has the potential to improve patient management in many surgical and critical care applications. In this study, we present a clinically compatible multispectral spatial frequency domain imaging (SFDI) system optimized for surgical oxygenation imaging. This system was used to image tissue oxygenation over a large area (16×12 cm) and was validated during preclinical studies by comparing results obtained with an FDA-approved clinical oxygenation probe. Skin flap, bowel, and liver vascular occlusion experiments were performed on Yorkshire pigs and demonstrated that over the course of the experiment, relative changes in oxygen saturation measured using SFDI had an accuracy within 10% of those made using the FDA-approved device. Finally, the new SFDI system was translated to the clinic in a first-in-human pilot study that imaged skin flap oxygenation during reconstructive breast surgery. Overall, this study lays the foundation for clinical translation of endogenous contrast imaging using SFDI.

Background  This study examines the effect of prior abdominal surgery on flap, donor-site, and overall complications in women undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction and assesses whether preoperative computed tomography angiography (CTA) affects outcomes. Methods  All DIEP flaps performed at our institution between 2004 and 2015 were identified retrospectively. Patients were stratified based on a history of prior abdominal surgery and whether or not they underwent a preoperative CTA. A subgroup analysis was performed to compare operative times and incidence of complications using adjusted odds ratios (ORs). Results  Over a 12-year period, 425 patients (640 flaps) had prior abdominal surgery, and 393 patients (547 flaps) had no prior abdominal surgery. Of the patients with previous abdominal surgery, 67 (15.7%) underwent preoperative CTA and 333 (78.4%) did not. Patients with prior abdominal surgery were more likely to have donor-site wound complications (OR: 1.82, 95% confidence interval [CI]: 1.15–2.87, p  = 0.01), fat necrosis ≥2cm of the transferred flap (OR: 1.39, 95% CI: 1.0–1.94, p  = 0.05), and were more likely to have bilateral DIEP flap reconstruction (OR: 1.61, 95% CI: 1.22–2.12, p  < 0.001). Preoperative CTA did not reduce the risk of complications and did not affect operative times. Conclusion  DIEP flap reconstruction can be safely performed in women with prior abdominal surgery. However, these patients should be counseled that they are at an increased risk for donor-site wound breakdown and fat necrosis of the reconstructed breast. Preoperative CTA does not reduce complication rate, overall operative time, or time needed to dissect perforators in women with abdominal scars. [ABSTRACT FROM AUTHOR]

Objective: Barbed sutures have recently been introduced for closure of surgical incisions. These self-anchoring sutures incorporate evenly spaced barbs in a circumferential distribution along their length, facilitating knotless wound closure and even distribution of tension along the suture line. In this study, we evaluated postoperative complications associated with the use of unidirectional barbed sutures compared with standard sutures for closure of the abdominal incision in deep inferior epigastric perforator flap breast reconstruction. Methods: A consecutive series of 142 patients undergoing deep inferior epigastric perforator flap breast reconstruction were identified at a single institution. The abdominal closure in the first 71 patients was performed using standard suture materials. In the subsequent 71 patients, closurewas performed using unidirectional barbed sutures. Patient demographics, complications, procedure time, and costs were compared between standard and barbed suture groups. Results: Demographic characteristics and comorbidity profileswere similar between the 2 groups.Overall, therewas a significantly higher incidence of complications in the standard suture group (17 vs 7 complications,P=.0423). Similar rates ofwound infection (P=.4412),wound dehiscence (P=.4934), and seroma (P = .1157) were recorded in both groups. Barbed sutures were $ 15.58 more expensive than standard sutures.No significant difference in total length of operationwas observed. Conclusion: In this study, the utility of unidirectional barbed sutures in deep inferior epigastric perforator flap breast reconstruction has been demonstrated. Barbed sutures may be useful in a broad range of plastic surgery procedures, not only because of their convenience but also based on favorable clinical outcomes. [ABSTRACT FROM AUTHOR]