Combined Laparoscopically Harvested Omental Flap With Meshed Skin Grafts and Vacuum-Assisted Closure for Reconstruction of Complex Chest Wall Defects

Laparoscopically harvested omental flap for immediate breast reconstruction: a retrospective single-center study of 300 cases

BACKGROUND

The laparoscopically harvested omental flap (LHOF) has been used in partial or total breast reconstruction, but most studies on LHOF were case reports or small case series. However, the clinical feasibility and oncological safety of LHOF in oncoplastic breast surgery remains controversial. This study reported our experience applying LHOF for immediate breast reconstruction.

METHODS

Between June 2018 and March 2022, 300 patients underwent oncoplastic breast surgery using LHOF at our institution. Their clinicopathological data, complications, cosmetic outcomes, and oncologic outcomes were evaluated.

RESULTS

All patients underwent total breast reconstruction using LHOF after nipple-sparing mastectomy. The median operation time was 230 min (ranging from 155 to 375 min). The median operation time for harvesting the omental flap was 55 min (ranging from 40 to 105 min). The success rate of the laparoscopically harvested pedicled omental flap was over 99.0%. Median blood loss was 70 ml, ranging from 40 to 150 ml. The volume of the flap was insufficient in 102 patients (34.0%). The overall complication rate was 12.3%. Subcutaneous fluid in the breast area (7%) was the most common reconstruction-associated complication, but most cases were relieved spontaneously. The incidence rate of omental flap necrosis was 3.3%. LHOF-associated complications occurred in two cases, including one case of incisional hernia and one case of vascular injury. Cosmetic outcomes were satisfactory in 95.1% of patients on a four-point scale by three-panel assessment and 97.2% using the BCCT.core software. Two local and one systemic recurrence were observed during a median follow-up period of 32 months.

CONCLUSIONS

The LHOF for immediate breast reconstruction is a safe and feasible method that involves minimal donor-site morbidity, satisfactory cosmetic outcomes, and promising oncologic safety.

Chest wall reconstruction for deep radiation necrosis: case report and overview of surgical options

INTRODUCTION

To report a case of radiation necrosis after reirradiation for breast cancer and the difficulties encountered when treating these complex cases.

PATIENTS AND METHODS

We present an 86-year-old woman with a history of right-sided intraductal breast cancer treated with a right mastectomy followed by local adjuvant radiotherapy (50 Gray). Twelve years later, she was diagnosed with a local recurrence in the mastectomy scar which was treated with local resection (including resection of rib four) and adjuvant radiotherapy up to 32 Gray. In July 2020 she presents at the Department of Plastic and Reconstructive Surgery with a chronic ulcer on the right-sided hemithorax.

RESULTS

A multi-staged, multidisciplinary approach was necessary to secure lasting coverage of the extensive defect.

CONCLUSION

Thoracic radiation necrosis should be subject to a multidisciplinary approach (plastic and thoracic surgeons) pre-, per-, and post-operatively. Each case may require a different surgical approach depending on the size and depth of the defect, patients' age, comorbidities, and previous medical treatment.

[Laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for deep sternal wound infection]

AIM

To present an experience of laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for deep sternal wound infection.

MATERIAL AND METHODS

It was made a prospective analysis of 14 patients aged 39-85 years after laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for the period December 2014 - November 2016. Men/women ratio was 10/4. All patients had deep sternal wound infection grade IV (Oakley-Wright classification).

RESULTS

Postoperative complications were observed in 2 (14.3%) of 14 (95% CI: 4.0-39.9%) cases that did not require re-operation. There were no 30-day postoperative mortality and significant complications as acute intestinal obstruction, postoperative ventral herniation and transplant rejection. Mean postoperative hospital-stay was 10.5 (9; 13) days.

CONCLUSION

Laparoscopic-assisted harvesting of omental flap is safe method for chest wall reconstruction in patients with severe sternal wound infection associated with soft tissue deficiency and high risk of local complications (bleeding, etc.). Laparoscopy significantly reduces incidence of postoperative complications after omental flap transposition and is feasible in majority of patients.

Breast necrosis secondary to vasopressor extravasation: management using indocyanine green angiography and omental flap closure

Extravasation is a rare but serious complication of vasopressor administration. A 60-year-old female who underwent ascending and hemiarch repair of the aorta along with aortic valve replacement developed extensive right breast and chest wall necrosis after vasopressor extravasation from an internal jugular vein central line. The patient underwent a total mastectomy due to deep tissue necrosis detected by laser-assisted indocyanine green dye angiography, and eventually required omental flap reconstruction to obtain adequate sternal coverage. This case represents a previously unreported complication of internal jugular central line extravasation of vasopressors with resultant breast and chest wall necrosis, and highlights the utility of the omentum in chest wall reconstruction.

Pedicled full-thickness abdominal flap combined with skin grafting for the reconstruction of anterior chest wall defect following major electrical burn

Successful reconstruction of extensive anterior chest wall defect following major electrical burn represents a very challenging surgery. Herein we report the first case using pedicled full-thickness abdominal flap combined with skin grafting to treat this injury with severe infection and exposure of pericardium and ribs in a Chinese patient. Following the performance of chest debridement to remove necrotic and infected tissues and the injection of broad-spectrum antibiotics to reduce infection, a pedicled full-thickness abdominal flap was used to cover the exposed pericardium and ribs, and skin grafting from the right leg of the patient was done to cover the exposed vital tissues. The patient was followed up for a total of 3·5 years, and satisfactory cosmetic and functional outcomes were obtained without complications. This report provides an effective method for the surgeons who encounter similar cases where reconstruction of extensive anterior chest wall is required.

Omentum for Mammary Disorders: A 30-Year Systematic Review

PURPOSE

Although the safety of applying omentum to the female breast for total breast reconstruction is controversial, it has recently been used to treat certain mammary disorders as well. A systematic review was therefore conducted to analyze and establish the suitability and safety of applying omentum to the breast.

METHODS

Covereing the interval from January 1984 to December 2013, we performed searches in MEDLINE, Embase, SciELO, and Google-Scholar for original articles describing the applicability of greater omentum to the breast and its clinical complications.

RESULTS

Sixty observational articles with 985 women were chosen. The main clinical indications were total breast reconstruction after mastectomy due to breast cancer (45 studies), radiation damage (23 studies), and congenital Poland syndrome (4 studies). Altogether, 273 complications were identified among the 985 women treated. The most frequent was flap necrosis (26.74 %). The most serious was injury to the digestive system (1.10 %). There was a 35.48 % incidence of local breast cancer recurrence in eight observational studies on oncological risk. Seven of the eight included only women with advanced cancer. One of these studies reported the incidence and relapse time predominantly according to the primary tumor size.

CONCLUSIONS

Although the oncological risk remains unclear, there was a high volume of complications that affected the digestive system. These findings suggest that omentum has well established applicability, but only for total breast reconstruction of huge defects, where muscular/myocutaneous or perforator flaps may be unsuitable.

Staging resection and reconstruction with temporary wound VAC coverage in a case of giant cystosarcoma phyllodes of the breast

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We report a rare case of malignant cystosarcoma phyllodes invading the chest wall.

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The patient presented with systemic toxicity and hematologic/electrolyte disarray.

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Surgical resection and reconstruction were staged with temporary wound VAC coverage.

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Definitive histopathologic tumor margins were assessed between procedures.

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Adjuvant medical/radiotherapy were administered resulting in long-term remission.

Introduction

Cystosarcoma phyllodes (CP) is a rare breast tumor occurring most often in females in their fifth decade. While usually benign, some CP tumors exhibit aggressive growth patterns and extensively invade chest wall structures; resecting these tumors to negative surgical margins can be challenging. We present a case of malignant CP involving the chest wall where using a negative pressure vacuum-assisted closure (VAC) system after resection enabled complete histopathologic margin assessment prior to reconstruction. This is the first known report of staged breast tumor resection and reconstruction with interim VAC coverage.

Case presentation

A 48 year-old woman presented with rapidly increasing left breast size, fevers, and fatigue. On examination, the left breast was massively enlarged with engorged vessels and skin necrosis. Lab analyses revealed unusual metabolic abnormalities requiring preoperative hospitalization. We performed a left modified radical mastectomy with partial resection of pectoralis major and minor muscles, temporarily sealing the wound with a VAC due to concern for deeper tumor extension that could require further resection. Pathology revealed malignant CP with a negative deep margin. The 38 cm defect was then repaired with latissimus myocutaneous flap plus skin graft. At three-year follow up the patient remains free of disease.

Conclusion

In cases of malignant CP involving the chest wall, minimizing the extent of chest wall resection is critical for reducing morbidity, while completely clearing tumor margins is essential for reducing recurrence risk. Using temporary wound VAC coverage enables cautious debulking followed by histopathologic margin assessment prior to definitively reconstructing the breast.

Giant basal cell carcinoma of the anterior chest wall with bone invasion

Giant basal cell carcinoma (BCC) of the chest wall is rare and poses challenges related to resection and reconstruction. A 69-year old man presented with giant BCC invading sternum. Wide resection and reconstruction with polymethylmethacrylate and mesh was performed. The soft tissue defect was covered with a pedicled omental flap and skin graft. He developed an infection requiring removal of the mesh construct; however, debridement and antibiotics cleared the infection. This case illustrates the locally aggressive nature of this disease and the need for tertiary-level care.

Use of the omental free flap for reconstruction of degloving hand and foot injuries: two case reports

Different techniques are used for reconstruction of degloving hand or foot injuries, however the best option has not been found yet. In this paper we present two clinical cases when degloving hand and foot injuries were successfully covered with the omental free flap.

Uncommon flaps for chest wall reconstruction

The omentum, external oblique musculocutaneous, and thoracoepigastric flaps are uncommonly used for chest wall reconstruction. Nevertheless, awareness and knowledge of these flaps is essential for reconstructive surgeons because they fill specific niche indications or serve as lifeboats when workhorse flaps are unavailable. The current report describes the anatomic basis, technical aspects of flap elevation, and indications for these unusual flaps.

Evidence-based recommendations for the use of Negative Pressure Wound Therapy in traumatic wounds and reconstructive surgery: steps towards an international consensus

Negative pressure wound therapy (NPWT) has become widely adopted over the last 15 years and over 1000 peer reviewed publications are available describing its use. Despite this, there remains uncertainty regarding several aspects of usage. In order to respond to this gap a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In this paper the results of the study of evidence in traumatic wounds (including soft tissue defects, open fractures and burns) and reconstructive procedures (including flaps and grafts) are reported. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence, drafting of the recommendations by a global expert panel, followed by a formal consultative consensus development program in which 422 independent healthcare professionals were able to agree or disagree with the recommendations. The criteria for agreement were set at 80% approval. Evidence and recommendations were graded according to the SIGN (Scottish Intercollegiate Guidelines Network) classification system. Twelve recommendations were developed in total; 4 for soft tissue trauma and open fracture injuries, 1 for burn injuries, 3 for flaps and 4 for skin grafts. The present evidence base is strongest for the use of NPWT on skin grafts and weakest as a primary treatment for burns. In the consultative process, 11/12 of the proposed recommendations reached the 80% agreement threshold. The development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone.

Aesthetic improvements in Poland's syndrome treatment with omentum flap

BACKGROUND

There are many techniques that can be used to reconstruct anomalous breast volume in Poland's syndrome, but repair of the stigmatizing deformities such as the transverse skin fold in the anterior axillary pillar, infraclavicular depression, and anomalous breast contours continues to be a challenge. This study aimed to demonstrate the superior results of laparoscopically harvested omentum flap to achieve these aesthetic improvements.

METHODS

Patients with Poland's syndrome from a clinical database were identified and their outcomes were studied.

RESULTS

In 15 consecutive patients with Poland's syndrome, the breast contour, the anterior axillary pillar, and the infraclavicular depression were treated with omentum flap and evaluated. Silicone implants were used beneath the flap in 80% of cases to improve symmetry. Flap consistency was similar to that of the natural breast and only a small incision in the breast fold was needed. The flap is extremely malleable, adapts to irregular surfaces, and has a long vascular pedicle. It does not leave a scar at the donor site as muscular flaps do. The omentum can repair small irregularities in breast contour, achieving a natural result different from all other flaps. Due to its malleability, it is possible to reconstruct even the extension to the axillary pillar, which is impossible with all other techniques.

CONCLUSIONS

The omentum flap technique is a means of repairing the deformities caused by Poland's syndrome and improves the aesthetic result with outcomes that seem superior to any other reconstructive option.

Enhancing clinical islet transplantation through tissue engineering strategies

Clinical islet transplantation (CIT), the infusion of allogeneic islets within the liver, has the potential to provide precise and sustainable control of blood glucose levels for the treatment of type 1 diabetes. The success and long-term outcomes of CIT, however, are limited by obstacles such as a nonoptimal transplantation site and severe inflammatory and immunological responses to the transplant. Tissue engineering strategies are poised to combat these challenges. In this review, emerging methods for engineering an optimal islet transplantation site, as well as novel approaches for improving islet cell encapsulation, are discussed.

Laparoscopic treatment of Poland's syndrome using the omentum flap technique

OBJECTIVE

For patients with Poland's syndrome, a transverse skin fold in the anterior axillary pillar, infra-clavicular depression and an anomalous breast contour are the most uncomfortable disfigurements. This study aims to demonstrate that superior aesthetic results can be achieved by using a laparoscopically harvested omentum flap to treat this condition.

METHODS

From a prospectively maintained clinical database of patients undergoing a laparoscopic omentum flap procedure for breast reconstruction, all of the patients with Poland's syndrome were identified and their outcomes were studied.

RESULTS

Thirteen consecutive patients with Poland's syndrome were treated and evaluated regarding breast contour, reconstruction of the anterior axillary pillar and filling of the infra-clavicular depression. Implants were employed beneath the flap in 76% of cases to improve symmetry. In 23% of cases, a contra-lateral mastopexy was performed, and in 15% of cases, a breast implant was used. The consistency of the flap is similar to natural breast tissue and only a small incision in the breast fold is needed. The majority of patients (85%) were female, with a mean age of 26 (18-53). The flap is extremely malleable, adapts to irregular surfaces, and has a long vascular pedicle. Additionally, its removal does not leave a scar at the donor site as the removal of muscular flaps does. For example, the removal of the latissimus dorsi flap causes a deformity in the dorsal contour. The mean operative time was 201 minutes (80-350) and the mean hospital stay was 2.3 days (1-5).

CONCLUSIONS

The outcomes of these patients revealed that the omentum flap technique provided superior amelioration of the deformities caused by Poland's syndrome when compared with other reconstructive options.