Internal mammary recipient site breast cancer recurrence following delayed microvascular breast reconstruction

OBJECTIVE

The internal mammary vessels are a popular recipient site for microsurgical anastomoses of free flap breast reconstructions. We, however, observed 3 patients undergoing internal mammary vessel delayed free flap breast reconstruction that subsequently developed tumor recurrence at this site. We reviewed their characteristics to determine whether there was a correlation between delayed microsurgical reconstruction and local recurrence.

METHODS

A retrospective review of a single surgeon's delayed free flap breast reconstructions using the internal mammary vessels was conducted over a 7-year period to identify the time intervals between mastectomy and delayed breast reconstruction and between delayed breast reconstruction and recurrence.

RESULTS

Three patients developed local recurrence at the site of the microvascular anastomoses following delayed breast reconstruction. All patients had been disease-free following mastectomy. The median time interval between mastectomy and delayed breast reconstruction was 28 months (range = 20-120 months) while that between delayed breast reconstruction and local recurrence was 7 months (range = 4-10 months). Two patients died from metastatic disease, 36 and 72 months following their local recurrence. One patient remains alive 44 months after reconstruction.

CONCLUSIONS

Local tumor recurrence at the internal mammary vessel dissection site following delayed breast reconstruction raises the question whether these 2 events may be related. Specifically, could internal mammary vessel dissection undertaken for delayed microsurgical reconstruction predispose to recurrence in the internal mammary lymph nodes? Further research is needed to ascertain whether delayed breast reconstruction increases the risk of local recurrence in this patient group.

Reverse abdominoplasty: a practical option for oncological trunk reconstruction

OBJECTIVES

Following radical oncological resection, full-thickness upper central trunk defects present a significant challenge. Common reconstructive options include pedicled flaps, such as pectoralis major, rectus abdominis, and latissimus dorsi. In complex cases, free tissue transfer may be required. Reverse abdominoplasty, although initially described for cosmetic body contouring, can be used to reconstruct upper central trunk defects following radical tumour ablation. We present 4 such applications in the management of advanced or recurrent malignancies and review the relative indications for this approach.

METHODS

Four consecutive cases (2004-2010) were reviewed with respect to indication, operative procedure, and complications.

RESULTS

There were no cases of complete flap loss. One patient underwent revision for marginal flap necrosis while another developed local recurrence, requiring re-excision and reconstruction with flap advancement.

CONCLUSIONS

Where pedicled flaps are unavailable or insufficient, adjacent abdominal tissue can be recruited into chest wall defects, avoiding microsurgical free tissue transfer. The authors feel that the reverse abdominoplasty is currently underused in this context and offers an excellent alternative in complex cases where other reconstructive options are unavailable, or where comorbidities preclude free-tissue transfer. The technique is versatile, simple to perform and affords an acceptable cosmetic outcome, yet is not widely reported in the literature. It has particular merit in cases with a high chance of disease recurrence, in the management of recurrent breast cancer, and in patients with multiple comorbidities. The reverse abdominoplasty should therefore be considered when evaluating patients for oncological trunk reconstruction.

A Simple Algorithm for Immediate Postmastectomy Reconstruction of the Small Breast-A Single Surgeon's 10-Year Experience

INTRODUCTION

Immediate small breast reconstruction poses challenges including limited potential donor site tissues, a thinner skin envelope, and limited implant choice. Few patients are suitable for autologous reconstruction while contralateral symmetrization surgery that often offsets the problem of obvious asymmetry in thin and small-breasted patients is often unavailable, too expensive, or declined by the patient.

METHODS

We reviewed 42 consecutive patients with mastectomy weights of 350 g or less (the lowest quartile of all reconstructions). Indications for the mastectomy, body mass index, bra cup size, comorbidity, reconstruction type, and complications were recorded.

RESULTS

A total of 59 immediate reconstructions, including 25 latissimus dorsi flaps, 23 implant-only reconstructions, 9 abdominal flaps, and 2 gluteal flaps, were performed in 42 patients. Of the 42 mastectomies, 4 were prophylactic. Forty-three percent of patients had immediate contralateral balancing surgery. The average mastectomy weight was 231 g (range, 74-350 g). Seven percent of implant-based reconstructions developed capsular contracture requiring further surgery. One free transverse rectus abdominus myocutaneous flap failed because of fulminant methicillin resistant staphylococcus aureus septicaemia.

DISCUSSION AND CONCLUSION

Balancing contralateral surgery is key in achieving excellent symmetry in reconstruction small-breasted patients. However, many patients wish to avoid contralateral surgery, thus restricting a surgeon's reconstructive options. Autologous flaps, traditionally, had not been considered in thinner women because of inadequacy of donor site tissue, but in fact, often, as with larger-breasted patients, produce superior cosmetic results. We propose a simple algorithm for the reconstruction of small-breasted women (without resorting to super-complex microsurgery), which is designed to tailor the choice of reconstructive technique to the requirements of the individual patient.

Central breast excision with immediate autologous reconstruction for recurrent periductal sepsis: an application of oncoplastic surgical techniques

OBJECTIVE

The aim of this procedure was to definitively treat periductal mastitis and periareolar sepsis which was previously resistant to multiple surgical procedures and nonoperative treatment of chronic nipple sepsis.

METHODS

We employed a multidisciplinary approach to the treatment of end-stage periductal mastitis using a combination of central breast excision and immediate autologous latissimus dorsi flap reconstruction.

RESULTS

Clearance of periductal mastitis and infection has been achieved with no recurrence at 3 years. Good symmetry of breast shape and volume has been achieved using this technique.

CONCLUSIONS

This method of partial breast reconstruction, commonly used for reconstruction of breast cancer ablative defects, may also provide good outcomes in nonmalignant disease.

Previous multiple abdominal surgeries: a valid contraindication to abdominal free flap breast reconstruction?

PRESENTED IN PART AT THE FOLLOWING ACADEMIC MEETINGS: 57th Meeting of the Italian Society of Plastic, Reconstructive and Aesthetic Surgery, September 24-27, 2008, Naples, Italy.45th Congress of the European Society for Surgical Research (ESSR), June 9-12, 2010, Geneva, Switzerland.British Association of Plastic Reconstructive and Aesthetic Surgeons Summer Scientific Meeting, June 30-July 2, 2010, Sheffield Hallam University, Sheffield, UK.

BACKGROUND

Patients with previous multiple abdominal surgeries are often denied abdominal free flap breast reconstruction because of concerns about flap viability and abdominal wall integrity. We therefore studied their flap and donor site outcomes and compared them to patients with no previous abdominal surgery to find out whether this is a valid contraindication to the use of abdominal tissue.

PATIENTS AND METHODS

Twenty patients with multiple previous abdominal operations who underwent abdominal free flap breast reconstruction by a single surgeon (C.M.M., 2000-2009) were identified and retrospectively compared with a cohort of similar patients without previous abdominal surgery (sequential allocation control group, n = 20).

RESULTS

The index and control groups were comparable in age, body mass index, comorbidities, previous chemotherapy, and RT exposure. The index patients had a mean age of 54 years (r, 42-63) and an average body mass index of 27.5 kg/m(2) (r, 22-38). The main previous surgeries were Caesarean sections (19), hysterectomies (8), and cholecystectomies (6). They underwent immediate (n = 9) or delayed (n = 11) reconstructions either unilaterally (n = 18) or bilaterally (n = 2) and comprising 9 muscle-sparing free transverse rectus abdominis muscle and 13 deep inferior epigastric perforator flaps. All flaps were successful, and there were no significant differences in flap and donor site outcomes between the 2 groups after an average follow up of 26 months (r, 10-36).

CONCLUSION

Multiple previous abdominal surgeries did not predispose to increased flap or donor site morbidity. On the basis of our experience, we have proposed some recommendations for successful abdominal free flap breast reconstruction in patients with previous multiple scars. Careful preoperative planning and the use of some intraoperative adaptations can allow abdominal free flap breast reconstruction to be reliably undertaken in such patients.

Versatility of the anterolateral thigh free flap: the four seasons flap

Presented at the following academic meetings:○ 56th Meeting of the Italian Society of Plastic, Reconstructive and Aesthetic Surgery (SICPRE) Fasano (Brindisi), Italy, September 26-29, 2007○ 42nd Meeting of the European Society for Surgical Research (ESSR), Warsaw, Poland, May 21-24, 2008○ Winter Meeting, British Association of Plastic, Reconstructive and Aesthetic Surgeons, (BAPRAS) London, December 1-3, 2009BACKGROUND: The anterolateral free flap has become increasingly popular at our institution year on year. We decided to review our experience with this flap and study the reasons for this trend.

METHODS

A retrospective review of all anterolateral thigh free flaps performed at Addenbrooke's University Hospital from the available charts was carried out. This chart review included patients' demographics, indications, flap size, recipient vessels used, ischemia time, flap, and donor site outcomes. All flap perforator vessels were located preoperatively using a handheld Doppler ultrasound probe.

RESULTS

From October 1999 to December 2008, 55 anterolateral thigh flaps were performed in 55 patients to reconstruct a variety of soft-tissue defects (upper and lower limbs, chest wall, skull base, head and neck). Flap size ranged 12 to 35 cm in length and 4 to 11 cm in width. During flap elevation, the main supply to the flap was found to be a direct septocutaneous perforator in 41% (n = 23) of the cases as opposed to a musculocutaneous perforator, which was found in 59% (n = 32). The mean ischemia time was 82 minutes (range, 62-103). The overall flap success rate was 100%. Two flaps were successfully salvaged after reexploration for venous congestion. The donor site morbidity was minimal. The mean follow-up time was 18 months (range, 2-48).

DISCUSSION AND CONCLUSION

The anterolateral thigh free flap was found to be a very reliable flap (100% success) across a wide range of clinical indications. It facilitates microvascular anastomoses as evidenced by the short ischemia time. It provided ample skin with volume that could be tailored to the defect. These advantages have led to its widespread use by different consultants and trainees in our department.

Accidental latissimus dorsi flap pedicle avulsion during immediate breast reconstruction: salvage by conversion to free flap

Pedicle damage is a rare complication of latissimus dorsi (LD) flap breast reconstruction. We report a case of accidental avulsion of the vascular pedicle of a totally autologous (extended) LD flap during immediate breast reconstruction in a patient who had previously undergone contralateral breast reconstruction with a pedicled TRAM flap based on the opposite superior epigastric vessels. The intra-operative strategy to salvage the avulsed LD flap by conversion to a free flap while not compromising the contralateral breast reconstruction is discussed.

A very late infection of an abdominal mesh following a pedicled TRAM flap harvest

Pedicled transverse rectus abdominis myocutaneous (TRAM) flap is still a common procedure for breast reconstruction. To lessen the incidence of abdominal-wall abnormalities, the donor-site defect in the transverse rectus abdominis muscle is generally repaired with a prosthetic mesh. This carries the well-known risks of foreign-body implantation, the most serious of which is infection. We report here a case of a 46-year-old patient who presented with an infected mesh 6.5 years after pedicled transverse rectus abdominis myocutaneous (TRAM)-flap breast reconstruction, requiring subsequent removal of the mesh. This is the latest recorded presentation of an abdominal prosthetic mesh infection in the English literature. The onset of late mesh infection could be related to a transient systemic infection and bacteraemia.

The unwritten price of cosmetic tourism: an observational study and cost analysis

INTRODUCTION AND AIMS

Cosmetic tourism, driven by the promise of inexpensive operations abroad, is increasingly popular despite warnings from professional bodies regarding associated risks. Increasing numbers of individuals have presented to our department requesting NHS treatment of complications from such surgery. We set out to characterize these patients and evaluate costs incurred through their assessment and management.

MATERIAL AND METHODS

An observational study was conducted from 2007 to 2009 on patients presenting to a tertiary referral Plastic Surgery practice with complications of cosmetic tourism surgery. Demographic characteristics, as well as those related to the operation, were recorded. Hospital patient flow pathways were constructed, cost analysis performed using Patient Level Costing, and expenditure and profitability calculated.

KEY RESULTS

Nineteen patients presented within the study period. Most operations were performed in Europe or Asia, and were primarily breast augmentation procedures (n=13). The principal complications were wound infection or dehiscence, and poor cosmetic results. Eleven patients received NHS treatment, at a cost of £120,841. The mean cost for all patients' management was £6360 (range: £114-£57,968), rising to £10,878 for those accepted for treatment. For 8 of the 9 patients (89%) for whom full patient level costing was available, the hospital incurred a financial loss.

CONCLUSION

The costs to the NHS of managing complications of cosmetic tourism are substantial, and underestimated by central funding agencies.

Epigastric hernia following DIEP flap breast reconstruction: complication or coincidence?

OBJECTIVE

Donor site hernias are a rare but well recognised complication of deep inferior epigastric perforator (DIEP) flap breast reconstruction but there are no reported cases of epigastric hernias after such surgery. We report three patients who developed symptomatic epigastric hernias within 2-8 months after discharge from follow-up.

PATIENTS AND METHODS

Patients who were referred to the Breast Plastic Surgery Clinic with symptomatic epigastric hernias following DIEP flap breast reconstruction were retrospectively reviewed.

RESULTS

The three patients were aged between 50 and 70 years. Their mean BMI was 29 and none were smokers or diabetic. The incidences of other predisposing factors were: previous abdominal surgery (1/3), heavy lifting (2/3) and multiparity (2/3). They were successfully treated laparoscopically (2) or by open technique (1) confirming the CT scan findings.

DISCUSSION AND CONCLUSION

The aetiology of epigastric hernias is obscure in general. The association with DIEP flap harvest may be purely coincidental. However, it appears that abdominal flap harvest predisposed these patients to epigastric hernias. One or more of the following factors may have caused either weakness of the anterior abdominal wall or increased intraabdominal pressure: * Short-term partial denervation of the rectus abdominis muscle; * Heavy lifting; * Previous surgery; obesity; multiple pregnancies; * Tight plication of the infraumbilical rectus sheath and muscle. This series of 3 symptomatic epigastric hernias following DIEP flap breast reconstruction is interesting as it documents donor site morbidity at a site distant from the exact site of flap harvest; this subject merits further detailed investigation.

Aesthetic and functional abdominal wall reconstruction after multiple bowel perforations secondary to liposuction

This report describes a case of aesthetic and functional abdominal wall reconstruction performed to salvage a deformed, scarred, and herniated anterior abdomen after severe peritonitis and partial rectus muscle necrosis secondary to multiple bowel perforations sustained during liposuction performed in a cosmetic clinic. The diagnosis of intestinal perforation was missed intraoperatively and in the immediate postoperative period. The patient was admitted 4 days after the surgery to the intensive therapy unit in septicemic shock. After resuscitation and stabilization, she was treated by debridement of the abdominal wall, bowel resection, and temporary jejunostomy and colostomy (reversed 10 months later). She was referred 18 months after liposuction to the Plastic Surgery Service with a large central midline abdominal incisional hernia presenting with thinned out skin (14 × 11 cm) overlying adherent bowel. A components separation technique was successfully used to reconstruct the abdominal wall, with no recurrent herniation 2 years later. Survivors of bowel perforations sustained during abdominal liposuction may later present with challenging aesthetic and functional problems, as described in this report. These long-term sequelae have not been addressed hitherto in the literature.

Reconstruction of a chronic late post-nephrectomy wound with an extended free latissimus dorsi flap

This report describes the case of a 74-year-old man who spontaneously developed a chronic loin and posterior thoracic wound 28 years after a nephrectomy and adjuvant radiotherapy for renal cell carcinoma. His wound was successfully managed surgically, with an ipsilateral free latissimus dorsi myocutaneous flap, the vascular pedicle of which was extended using 15cm saphenous vein grafts.

Surgical correction of the expanded earlobe after ear gauging

Expansion of the earlobe by ear gauging or plugging is an increasingly fashionable practice. As patients get older, some seek to have their ears restored to normal. This report presents a simple local flap technique that has been successful in achieving uneventful healing with acceptable cosmetic results.

Cowden syndrome and reconstructive breast surgery: case reports and review of the literature

Cowden syndrome (CS) is a rare, autosomal dominant inherited disorder associated with multiple benign and malignant neoplasms, including breast cancer. Prophylactic resection of susceptible organs remains controversial. We briefly describe the syndrome and review management of the risk of CS-associated malignancies. Three cases of bilateral risk-reducing mastectomy and immediate breast reconstruction are described.

Sciatic neuroma presenting forty years after above-knee amputation

We report a case of a sciatic neuroma presenting forty years after above knee amputation. Patients developing neuroma following a limb amputation can present with stump pain which is commonly resistant to medical intervention. The length of interval from the initial injury to presentation is widely variable. Diagnosis relies on clinical suspicion and accurate assessment, radiological imaging and, if indicated, surgical exploration. MRI provides a better soft tissue definition than CT and is more accurate in identifying small lesions than ultrasound. The aim of treatment for symptomatic neuroma is pain relief and improvement of function. This is often achieved by surgical excision.

Aesthetic and functional reduction of the labia minora using the Maas and Hage technique

INTRODUCTION

Enlarged labia minora can cause functional, aesthetic and psychosocial problems. There are many reported techniques for their surgical correction in both the gynaecological and surgical literature suggesting that no one method is superior to the others. The problem is compounded because an individual surgeon's experience is likely to be small given the infrequent request for surgery. For these reasons it is important that existing techniques are validated by independent surgeons rather than describing yet another variation.

METHODS

Patients who underwent surgical reduction of their labia minora from 2001-2008 were retrospectively reviewed. All cases were performed by the same surgeon using the Maas and Hage technique of a running interdigitating W-shaped excision.

RESULTS

12 patients aged from 15 to 52 years underwent reduction labioplasty for idiopathic hypertrophy. Postoperatively there were no wound dehiscences or infections. One patient developed a painful haematoma 2h after surgery necessitating surgical evacuation while another went into postoperative urinary retention relieved by overnight catheterisation. Both made uneventful recoveries. All patients were satisfied with their 'natural looking' cosmetic results and have returned to their normal activities without recurrence of their presenting symptoms. The mean follow up was 14 weeks but none have subsequently required or requested revisional surgery.

CONCLUSIONS

The running W-shaped resection was found to be an easy and effective method of reducing the labia minora by a single operator in a small series of cases. This independent review demonstrates the reproducibility of this technique and the favourable aesthetic and functional outcomes for the patient.

Continuous wound infusion of local anaesthetic agents following colorectal surgery: Systematic review and meta-analysis

AIM: To provide a specific review and meta-analysis of the available evidence for continuous wound infusion of local anaesthetic agents following midline laparotomy for major colorectal surgery.

METHODS: Medline, Embase, trial registries, conference proceedings and article reference lists were searched to identify randomised, controlled trials of continuous wound infusion of local anaesthetic agents following colorectal surgery. The primary outcomes were opioid consumption, pain visual analogue scores (VASs), return to bowel function and length of hospital stay. Weighted mean difference were calculated for continuous outcomes.

RESULTS: Five trials containing 542 laparotomy wounds were eligible for inclusion. There was a significant decrease in post-operative pain VAS at rest on day 3 (weighted mean difference: -0.43; 95% CI: -0.81 to -0.04; P = 0.03) but not on post-operative day 1 and 2. Local anaesthetic infusion was associated with a significant reduction in pain VAS on movement on all three post-operative days (day 1 weighted mean difference: -1.14; 95% CI: -2.24 to -0.041; P = 0.04, day 2 weighted mean difference: -0.97, 95% CI: -1.91 to -0.029; P = 0.04, day 3 weighted mean difference: -0.61; 95% CI: 1.01 to -0.20; P = 0.0038). Local anaesthetic wound infusion was associated with a significant decrease in total opioid consumption (weighted mean difference: -40.13; 95% CI: -76.74 to -3.53; P = 0.03). There was no significant decrease in length of stay (weighted mean difference: -20.87; 95% CI: -46.96 to 5.21; P = 0.12) or return of bowel function (weighted mean difference: -9.40; 95% CI: -33.98 to 15.17; P = 0.45).

CONCLUSION: The results of this systematic review and meta-analysis suggest that local anaesthetic wound infusion following laparotomy for major colorectal surgery is a promising technique but do not provide conclusive evidence of benefit. Further research is required including cost-effectiveness analysis.

Abdominoplasty as an adjunct to the management of peri-Caesarian section necrotising fasciitis

Necrotising fasciitis is a rare but potentially lethal condition, often requiring extensive soft tissue debridement and complex reconstructive surgery. The disease has been noted to complicate Caesarian section wounds, and our department has recently managed three such patients. They all required extensive abdominal wall debridements which would traditionally be closed initially by split skin grafting. We report on the clinical course of three patients, two of whom had their defects closed successfully by abdominoplasty without recourse to initial skin grafting.