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Psychological effects of mastectomy for women with breast cancer have driven treatments that optimize cosmesis while strictly adhering to oncologic principles. Although skin-sparing mastectomy is oncologically safe, questions remain regarding the use of nipple-areola complex (NAC)-sparing mastectomy (NSM). We prospectively evaluated NSM for patients undergoing mastectomy for early-stage breast cancer or risk reduction.We enrolled 33 early-stage breast cancer and high-risk patient; 54 NSMs were performed. NAC viability and surgical complications were evaluated. Intraoperative and postoperative pathologic assessments of the NAC base tissue were performed. NAC sensory, cosmetic and quality of life (QOL) outcomes were also assessed.Twenty-one bilateral and 12 unilateral NSMs were performed in 33 patients, 37 (68.5%) for prophylaxis and 17 (31.5%) for malignancy. Mean age was 45.4 years. Complications occurred in 16 NACs (29.6%) and 6 skin flaps (11.1%). Operative intervention for necrosis resulted in 4 NAC removals (7.4%). Two (11.8%) of the 17 breasts with cancer had ductal carcinoma-in-situ at the NAC margin, necessitating removal at mastectomy. All evaluable patients had nipple erection at 6 and 12 months postoperatively. Cosmetic outcome, evaluated by two plastic surgeons, was acceptable in 73.0% of breasts and 55.8% of NACs, but lateral displacement occurred in most cases. QOL assessment indicated patient satisfaction.NSM is technically feasible in select patients, with a low risk for NAC removal resulting from necrosis or intraoperative detection of cancer, and preserves sensation and QOL. Thorough pathologic assessment of the NAC base is critical to ensure disease eradication.

The purpose of this study was to determine the optimal timing of delayed abdominal free flap breast reconstruction following postmastectomy radiation therapy. The authors evaluated the association between timing of delayed abdominal free flap breast reconstruction following postmastectomy radiation therapy and postoperative complications.The authors reviewed a prospectively maintained database of delayed abdominal free flap breast reconstruction performed between July of 2005 and December of 2009. Data regarding demographics, operative variables, and clinical outcomes were collected. Patients were classified as having undergone reconstruction less than 12 months after postmastectomy radiation therapy (group I) or 12 months or more after postmastectomy radiation therapy (group II). Complications were compared between groups, including microvascular thrombosis, flap loss, reoperation, wound dehiscence, and fat necrosis.One hundred eighty-nine patients were identified, 82 (43.4 percent) in group I and 107 (56.6 percent) in group II. The total flap loss rate was 2.6 percent, with all flap losses occurring in group I (p = 0.014). The reoperation rate was higher in group I (14.6 percent versus 4.7 percent; p = 0.022). In addition, group I patients trended toward a higher incidence of microvascular thrombosis, infection, and wound dehiscence.Patients who underwent delayed abdominal free flap breast reconstruction after 12 months from the completion of postmastectomy radiation therapy developed fewer complications, including microvascular thrombosis and total flap loss, than those who underwent delayed abdominal free flap breast reconstruction within 12 months of completing postmastectomy radiation therapy. Allowing an interval of 12 months between the completion of postmastectomy radiation therapy and delayed abdominal free flap breast reconstruction will likely minimize complications and optimize outcomes in free flap breast reconstruction in patients receiving postmastectomy radiation.

Supplemental Digital Content is available in the text., Background: Patients undergoing surgeries involving extensive posterior spine instrumentation and fusion often have multiple risk factors for wound healing complications. We performed a systematic review and meta-analysis of the available evidence on immediate (proactive/prophylactic) and delayed (reactive) spinal wound reconstruction. We hypothesized that immediate soft-tissue reconstruction of extensive spinal wounds would be associated with fewer postoperative surgicalsite complications than delayed reconstruction. Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a PubMed database search was performed to identify English-language, human-subject literature published between 2003 and 2018. Data were summarized, and the pooled prevalence of various wound complications was calculated, weighted by study size, using the generic inverse variance method. A subgroup analysis of all studies with a comparison group (Oxford Centre for Evidence-based Medicine level 3 or better) was performed, and Forest plots were created. Results: The database search yielded 16 articles including 828 patients; 428 (51.7%) received an immediate spinal wound reconstruction and 400 (48.3%) had a delayed reconstruction. Spinal neoplasm was the most common index diagnosis. Paraspinous muscle flap reconstruction was performed in the majority of cases. Pooled analysis of all studies revealed immediate reconstruction to be associated with decreased rates of overall wound complications (28.5% versus 18.8%), hardware loss (10.7% versus 1.8%), and wound infections (10.7% versus 7.6%) compared with delayed reconstruction. Conclusions: Immediate soft-tissue reconstruction of high-risk spinal wounds is associated with fewer wound healing complications and increased hardware retention.

Background. The purpose of this study was to evaluate outcomes of free flap reconstruction for advanced osteoradionecrosis (ORN) defects and develop an algorithm to guide surgical planning. Methods. All cases involving free flap reconstruction for ORN of the mandible between 1998 and 2008 were reviewed. A defect classification scheme was developed. Flap selection and outcomes were analyzed and evaluated by defect type. Results. Seventy-five free flaps and 13 pedicle flaps were performed in 63 patients. Total flap loss was 5%. Overall surgi- cal complication was 32%. Complication rates were higher with bone flaps than with soft tissue flaps (p ¼ .018). A full oral diet was tolerated in 57% of patients, whereas 26% required partial tube feeding, and 16% were tube-feeding dependent. Conclusion. Free flap reconstruction of advanced ORN defects can be safely performed in a variety of flap configura- tions with good outcomes. The classification scheme may assist in flap selection. V

The vertical rectus abdominis musculocutaneous (VRAM) flap has numerous uses in pelvic reconstruction; however, flap harvest can result in abdominal wall morbidity. The authors hypothesized that combining component separation with fascial advancement closure would result in acceptable surgical donor-site outcomes.Patients were evaluated who underwent VRAM flap reconstruction for contaminated pelvic defects and component separation with fascial advancement closure or tension-bearing primary fascial closure for VRAM flap donor-site defects between 2006 and 2009. The indication for component separation was the inability to approximate fascial edges (1) at all or (2) without excessive fascial tension, creating a high risk of postoperative failure. Primary outcome indicators included wound complications, myofascial laxity, and incisional hernia.Seventy-four patients were included in the study: 15 who underwent component separation and 59 who underwent primary fascial closure. The mean follow-up was 16 months (range, 6 to 39 months). The incidences of seroma, infection, and skin and fascial dehiscence were higher in the primary fascial closure group (39 percent) than in the component separation group (13 percent) (p0.053). There was a fourfold greater incidence of incisional hernia in the primary fascial closure group (24 percent) than in the component separation group (6 percent). There was also a trend toward a higher incidence of myofascial laxity in the primary fascial closure group (14 percent) than in the component separation group (6 percent).Component separation was effective in allowing closure of VRAM donor sites that were otherwise impossible to reapproximate without excessive fascial tension. Component separation closures resulted in fewer postoperative wound complications, hernias, and bulges, despite a more difficult closure, and should be considered when fascial closure tension would be excessive.

Background: Breast reconstruction using flaps from the lower abdomen can be compromised by fat necrosis. The muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps are techniques that have evolved in an effort to decrease abdominal donor-site morbidity. Each flap in this evolution, however, includes fewer perforating blood vessels. The authors hypothesized that flaps with fewer perforators are less well perfused and therefore more likely to suffer fat necrosis. Methods: The authors prospectively studied the incidence of fat necrosis and number of perforators in 228 consecutive abdominal free flap breast reconstructions. Results: The incidence of fat necrosis was 14, 25, 5, and 19 percent for SIEA flaps and flaps with one to two, three to five, and more than five perforators, respectively. The incidence of fat necrosis was significantly associated with the number of perforators (p = 0.007), smoking (p = 0.02), and inclusion of zone 3 of flaps (p = 0.05). The lowest risk of fat necrosis occurs in flaps with three to five perforators, which are predominantly muscle-sparing TRAM flaps. The risk of fat necrosis is highest in flaps with one or two perforators, which are predominantly DIEP flaps. SIEA flaps, and flaps with poor perforators in which greater than five perforators were included, had an intermediate risk of fat necrosis. Conclusions: The risk of fat necrosis in breasts reconstructed with free muscle-sparing TRAM, DIEP, and SIEA flaps increases as the number of perforators supplying the flap decreases. Breast reconstruction using DIEP and SIEA flaps may decrease abdominal donor-site morbidity compared with muscle-sparing TRAM flap techniques, but these flaps also carry a higher risk of fat necrosis that can compromise the breast reconstruction.

The authors hypothesized that obese patients would experience fewer complications after oncoplastic breast reconstruction following partial mastectomy than after immediate breast reconstruction following total mastectomy.Complication rates were compared for oncoplastic breast reconstruction versus immediate breast reconstruction (with either implants or autologous tissue) in consecutive obese patients (body mass index ≥ 30 kg/m(2)) treated at a single center between January of 2005 and April of 2013. Logistic regression was used to analyze the associations between patient and surgical characteristics and postoperative outcomes.The study included 408 patients: 131 oncoplastic breast reconstruction and 277 immediate breast reconstruction patients. Presenting breast cancer stage was similar between the two groups. Oncoplastic breast reconstruction patients were older (55 years versus 53 years; p = 0.029), more obese (average body mass index, 37 kg/m(2) versus 35 kg/m(2); p0.001), and had more comorbidities. Nevertheless, the oncoplastic breast reconstruction group experienced fewer major complications requiring operative management (3.8 percent versus 28.5 percent; p0.001), fewer complications delaying adjuvant therapy (0.8 percent versus 14.4 percent; p0.001), and fewer incidences of hematoma/seroma formation (3.1 percent versus 11.6 percent; p0.004) than the immediate total breast reconstruction group. Univariate analysis found oncoplastic breast reconstruction to be an independent protector against major complications (OR, 0.1; p0.001) and complications that delayed adjuvant therapy (OR, 0.05; p = 0.002).Oncoplastic breast reconstruction likely represents a safer option than immediate total breast reconstruction following mastectomy for obese patients, particularly for patients who are superobese or present with preexisting medical comorbidities.Therapeutic, III.

Background: Infectious complications in tissue expander (TE) breast reconstruction can be devastating and costly. Therefore, to optimize care, we examined patient’s demographics, microbiology of TE infections, and the efficacy of empiric antimicrobial regimens and thereafter generated an algorithm for the treatment of these complex infections. Methods: We retrospectively reviewed all patients who underwent TE breast reconstruction between 2003 and 2012 and analyzed those patients who developed a “definite” device-related infection leading to TE explantation and had a positive intraoperative culture. Results: A total of 3,082 patients underwent immediate breast reconstruction with TE. Of these, 378 patients (12.3%) developed an infection, 189 (6.1%) eventually proceed with explantation, and 118 (3.8%) had a positive intraoperative culture. Gram-positive organisms caused 73% of infections, and Gram-negative organisms caused 27% of infections. Narrow-spectrum empiric antimicrobials with predominantly Gram-positive coverage were deemed appropriate in only 62% of cases, and those with Gram-negative coverage were appropriate in 46%. Broad-spectrum antimicrobials were used in 47% of cases, mainly recommended by infectious disease specialists, and were considered appropriate in >90% of the occasions. Conclusions: Current empiric antibiotic regimens do not cover the vast spectrum of organisms causing TE infections. To increase the salvage rate of an infected TE, at the first sign of infection, in addition to benefiting with an infectious diseases consultation, empiric coverage with broad-spectrum antibiotics active against biofilm-embedded organisms should be administered.

Owing to favorable economic factors, improvements in implant design, and the widespread successful use of acellular dermal matrix, breast reconstruction with tissue expanders (TEs) and implants is becoming increasingly popular among breast cancer patients who have undergone mastectomy.1,2 The rate of breast reconstruction has increased steadily during the past several years; the American Society of Plastic Surgeons reported that more than 90,000 patients in the United States underwent breast reconstruction in 2013 alone.3 Of these patients, approximately 70,000 underwent breast reconstruction with a TE, whereas the remaining patients had autologous reconstructions. The advantages of TE-based breast reconstitutions include the potential for enhanced aesthetic outcomes and rapid postoperative recovery with minimal morbidity and functional limitation.4 Unfortunately, the rate of infection after breast TE reconstruction remains unacceptably high, ranging from 2.5% to 24%.5–9 During the past 10 years, our infection rate was approximately 12%. These infections are complex and severe, and patients whose TE infections do not respond to antibiotic treatment alone usually require further surgery and explantation of the device. We have estimated that at our institution, patients who developed an implant-based reconstructive breast infection required explanation of the TE in 50% of the occasions. The eventual loss of the TE is a significant complication that can delay further adjuvant radiation and chemotherapy and require a more complicated reconstruction in the future.10,11 The estimated medical and surgical costs of treating a patient who has an infected TE can surpass tens of thousands of dollars.12 In addition, rather than being cared for in an outpatient setting, to expedite care, patients with skin soft tissue inflammatory (SSTI) processes are commonly hospitalized, which further increases the costs. Therefore, to reduce the rate of TE removal, hospitalization, and overall costs at our institution, we created a standardized same-day multidisciplinary protocol for diagnosing and treating patients with early signs of TE infection. Herein, we describe the implementation of this protocol and our initial investigation of patient factors potentially associated with TE explantation.

The widespread use of bioprosthetic mesh in breast reconstruction has revealed an increased risk of seroma and infection, and a high financial cost. This study introduces a technique that mitigates these shortcomings using an autologous dermal graft (Autoderm). Indications, operative technique, and 1-year outcomes are reviewed. Thirty-six breasts in 21 patients underwent six unilateral and 15 bilateral, implant-based breast reconstructions with Autoderm. Mean follow-up was 365 days (range, 273 to 575 days). The overall complication rate was 13.9 percent. No patients developed breast cellulitis, hyperemia, periprosthetic infection, or seroma. There was one implant exposure following expansion. Autoderm provides the advantages of lower pole support and breast shaping, without the disadvantages of increased infection, seroma, and the high cost associated with allograft and xenograft meshes.

Reconstruction of complex defects of the central abdomen is both challenging and technically demanding for plastic surgeons. Advancements in the use of pedicle and free tissue transfer along with the use of bioprosthetic and synthetic meshes have provided for novel approaches to these complex defects. Accordingly, detailed knowledge of abdominal wall and lower extremity anatomy in combination with insight into the design, implementation, and limitations of various flaps is essential to solve these complex clinical problems. Although these defects can be attributed to a myriad of etiologic factors, the objectives in abdominal wall reconstruction are consistent and include the restoration of abdominal wall integrity, protection of intraabdominal viscera, and the prevention of herniation. In this article, it is our goal to review pertinent anatomy, pre- and postoperative care regimens, and the various local, regional, and distant flaps that can be utilized in the reconstruction of these complex clinical cases of the central abdomen.

Background Studies of abdominal wall reconstruction with concurrent panniculectomy have reported contradictory results. The authors hypothesized that patients undergoing abdominal wall reconstruction with concurrent panniculectomy experience more wound healing complications but similar rates of hernia recurrence compared with abdominal wall reconstruction alone. Methods Of 548 consecutive patients, 305 patients (55.7 percent) underwent abdominal wall reconstruction alone and 243 (44.3 percent) underwent abdominal wall reconstruction with concurrent panniculectomy. Mean follow-up was 30 months. The authors compared these two groups' postoperative complications and outcomes before and after propensity score analysis. Results Abdominal wall reconstruction with concurrent panniculectomy patients had a significantly higher overall complication rate (38.3 percent versus 29.2 percent; p = 0.025) and a trend toward a higher surgical-site occurrence rate (27.6 percent versus 20.7 percent; p = 0.06) compared with abdominal wall reconstruction alone. There were significantly higher incidences of skin dehiscence (19.3 percent versus 12.5 percent; p = 0.032), fat necrosis (10.7 percent versus 3.6 percent; p = 0.002), and infection abscess (9.5 percent versus 4.3 percent; p = 0.023) but no significant difference in hernia recurrence (6.9 percent versus 11.5 percent; p = 0.27) at long-term follow-up. Propensity score analysis yielded 188 pairs of matched patients with no significant differences in overall complication and hernia recurrence rates. Significantly higher rates of fat necrosis (9.6 percent versus 4.3 percent; p = 0.041) and abscess (10.1 percent versus 3.2 percent; p = 0.007) were observed in the abdominal wall reconstruction with concurrent panniculectomy group. Conclusions Abdominal wall reconstruction with concurrent panniculectomy is associated with higher wound morbidity but similar surgical-site occurrence and hernia recurrence rates at long-term follow-up. The authors believe that panniculectomy can be safely performed when indicated.

BACKGROUND Obesity and higher body mass index may be associated with higher rates of wound healing complications and hernia recurrence rates following complex abdominal wall reconstruction. The authors hypothesized that higher body mass indexes result in higher rates of postoperative wound healing complications but similar rates of hernia recurrence in abdominal wall reconstruction patients. METHODS The authors included 511 consecutive patients who underwent abdominal wall reconstruction with underlay mesh. Patients were divided into three groups on the basis of preoperative body mass index: less than 30 kg/m (nonobese), 30 to 34.9 kg/m (class I obesity), and 35 kg/m or greater (class II/III obesity). The authors compared postoperative outcomes among these groups. RESULTS Class I and class II/III obesity patients had higher surgical-site occurrence rates than nonobese patients (26.4 percent versus 14.9 percent, p = 0.006; and 36.8 percent versus 14.9 percent, p < 0.001, respectively) and higher overall complication rates (37.9 percent versus 24.7 percent, p = 0.007; and 43.4 percent versus 24.7 percent, p < 0.001, respectively). Similarly, obese patients had significantly higher skin dehiscence (19.3 percent versus 7.2 percent, p < 0.001; and 26.5 percent versus 7.2 percent, p < 0.001, respectively) and fat necrosis rates (10.0 percent versus 2.1 percent, p = 0.001; and 11.8 percent versus 2.1 percent, p < 0.001, respectively) than nonobese patients. Obesity class II/III patients had higher infection and seroma rates than nonobese patients (9.6 percent versus 4.3 percent, p = 0.041; and 8.1 percent versus 2.1 percent, p = 0.006, respectively). However, class I and class II/III obesity patients experienced hernia recurrence rates (11.4 percent versus 7.7 percent, p = 0.204; and 10.3 percent versus 7.7 percent, p = 0.381, respectively) and freedom from hernia recurrence (overall log-rank, p = 0.41) similar to those of nonobese patients. CONCLUSION Hernia recurrence rates do not appear to be affected by obesity on long-term follow-up in abdominal wall reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.

The optimal type of mesh for complex abdominal wall reconstruction has not been elucidated. We hypothesized that AWRs using acellular dermal matrix (ADM) experience low rates of surgical site occurrence (SSO) and surgical site infection, despite increasing degrees of wound contamination.We retrospectively reviewed prospectively collected data from consecutive abdominal wall reconstructions with ADM over a 9-year period. Outcomes of abdominal wall reconstructions were compared between patients with different CDC wound classifications. Univariate and multivariate logistic regression and Cox proportional hazard regression analyses identified potential associations and predictive/protective factors.The 359 patients had a mean follow-up of 28.3 ± 19.0 months. Reconstruction of clean wounds (n = 171) required fewer reoperations than that of combined contaminated (n = 188) wounds (2.3% vs 11.2%; p = 0.001) and trended toward experiencing fewer SSOs (19.9% vs 28.7%, p = 0.052). There were no significant differences between clean and combined contaminated cases in 30-day SSI (8.8% vs 8.0%), hernia recurrence (9.9% vs 10.1%), and mesh removal (1.2% vs 1.1%) rates. Independent predictors of SSO included body mass index ≥30 kg/m(2) (odds ratio [OR] 3.6; p0.001), 1 or more comorbidities (OR 2.5; p = 0.008), and defect width ≥15 cm (OR 1.8; p = 0.02).Complex abdominal wall reconstructions using ADM demonstrated similar rates of complications between the different CDC wound classifications. This is in contradistinction to published outcomes for abdominal wall reconstruction using synthetic mesh that show progressively higher complication rates with increasing degrees of contamination. These data support the use of ADM rather than synthetic mesh for complex abdominal wall reconstruction in the setting of wound contamination.

Given that a woman can be a candidate for multiple medically appropriate methods of breast reconstruction, making a decision on which method to pursue can be a difficult one.1 Normative decision-making is a framework that could be used to help women make difficult decisions about breast reconstruction. Normative decision-making is an exhaustive, iterative process that involves identifying alternatives, obtaining information about the uncertainty of the outcomes, and clarifying preferences and values.2–4 For the case of breast reconstruction, the alternatives, that is, different reconstruction procedures, are very well understood.1,5,6 However, information about the uncertainties of the outcomes (eg, number of revisions needed, chances of experiencing a complication, or the final aesthetic result) is more difficult to obtain because large quantities of data may not exist for uncommon procedures or rare patient profiles. Clarifying preferences and values about breast reconstruction is also challenging7–9; however, the focus of this study is on the difficulty of estimating the probabilities of reconstruction outcomes. Such probabilities may be employed by future computational decision support systems to aid in patient decision-making and may make use of surgeon predictions obtained before system deployment. In the clinical decision-making literature, it is suggested that, in the absence of large quantities of data, probabilities of outcomes can be estimated by experts,10–12 that is, plastic surgeons in the case of breast reconstruction. Of course, estimating probabilities about breast reconstruction outcomes is difficult because there are numerous variables involved. Moreover, to provide the information needed for decision support, plastic surgeons must be able to estimate outcome probabilities in general, not simply for their own patients. However, we are unaware of any prior studies that address the validity of expert-elicited probabilities about breast reconstruction outcomes. The clinical impact of this study is in the context of a future computational decision support system for shared breast reconstruction decision-making. Such systems require patient-specific probability information that surgeons may provide. The goal of this study was to investigate to what extent plastic surgeons can predict breast reconstruction outcomes. The purpose of the system is to inform both the patient and the surgeon of risk and help them make better decisions regarding breast reconstruction.

Abdominal wall defects requiring soft tissue coverage can be either partial-thickness defects or full-thickness composite defects. Soft tissue flap reconstruction offers significant advantages in defects that cannot be closed primarily. Flap reconstruction is performed in a single-stage procedure obviating chronic wound management. If the defect size exceeds the availability of local soft tissue for coverage, regional pedicled flaps can be delivered into the abdominal wall while maintaining blood supply from their donor site. Microsurgical free tissue transfer increases the capacity to provide soft tissue coverage for abdominal wall defects that are not amenable to either local or regional flap coverage.

Learning Objectives Describe the significant locoregional clinical interaction that may result from ixabepilone chemotherapy following radiation. Explain the importance of awareness, detection, and management of radiation recall by both the medical and the radiation oncologist. Describe the spectrum of toxicity represented by radiation recall that can range from erythema to chest wall necrosis requiring reconstructive surgery. Background. Radiation recall is an acute inflammatory reaction within a previously irradiated field triggered by chemotherapy administration. We observed a series of patients with unexpectedly severe reactions that included radiation recall and delayed healing when patients received the microtubule stabilizer ixabepilone (Ixempra; Bristol-Myers Squibb, Princeton, NJ) after radiation. We therefore decided to evaluate our experience in patients receiving ixabepilone following radiotherapy. Methods. We performed a retrospective chart review of all patients treated with curative intent in the Department of Radiation Oncology at the MD Anderson Cancer Center from 2008–2011 who received any ixabepilone after completion of external-beam radiation therapy. These patients received adjuvant ixabepilone on one of two protocols, either for locally advanced breast cancer or for metastatic breast cancer. In total, 19 patients were identified and their charts were subsequently reviewed for evidence of ixabepilone-related toxicity. Results. Of the 19 patients identified who received ixabepilone following radiation therapy, three (15.8%) had unexpectedly serious reactions in the months following radiation therapy. Complications included delayed wound closure and drain placement into the seroma, intense erythema, and delayed wound closure and grade 4 chest wall necrosis requiring latissimus flap and skin grafting. The average number of days between the end of radiation therapy and documentation of reaction was 99. Conclusions. Ixabepilone chemotherapy may induce radiation recall and delayed wound healing when used shortly after the completion of external-beam radiotherapy. Significant clinical interactions have not been previously reported and merit further evaluation.

Abdominal wall reconstruction (AWR) requires a coordinated effort between general surgeons and plastic surgeons to re-establish and restore the boundaries of the abdominal cavity. Given the nature of the patient population and disease states that require AWR there is an inherent deficiency of healthy and robust tissue to support the abdominal viscera without herniation. As a result, mesh materials are often sought to enhance the structural integrity of the abdominal wall. The type of mesh material and plane of mesh placement are at the discretion of the surgeon. Surgical techniques have evolved to enable improved outcomes in AWR. Component separation through open or minimally invasive techniques provides the ability to re-approximate the rectus muscles bundles in the midline allowing a second layer of dynamic reconstruction to the underlying mesh construct. These techniques avoid bridging mesh repairs which have a greater risk of hernia recurrence. By optimizing patient selection criteria, mesh selection, and surgical technique as outlined in this chapter, superior outcomes can be achieved in even the most challenging abdominal wall reconstructions.

Introduction: Reconstruction with flaps requiring delayed division remains common, even with increasing use of free tissue transfer. Patient quality of life and function are significantly decreased during the delay period. Delay could be minimized by developing methods to reliably determine when the flap has developed sufficient vascular supply to undergo successful division. We report the use of laser angiography to determine the appropriate time for division of a forehead flap pedicle. Methods: The patient who had risk factors for microvascular disease underwent near-infrared laser angiography using indocyanine green on postoperative day 21 to assess vascular perfusion of the flap. Although traditional clinical examination indicated the flap was not adequately perfused, laser angiography revealed perfusion to all areas of the flap, so the pedicle was divided. Results: Pedicle division was successful, with no epidermolysis or necrosis. Conclusion: Near-infrared laser angiography with indocyanine green can assess perfusion status of the entire flap and inform the decision to divide the flap in an objective manner.

Background Abdominal wall reconstruction with bioprosthetic mesh is associated with lower rates of mesh infection, fistula formation, and mesh explantation than reconstruction with synthetic mesh. The authors directly compared commonly used bioprosthetic meshes in terms of clinical outcomes and complications. Methods A database of consecutive patients who underwent abdominal wall reconstruction with porcine or bovine acellular dermal matrix and midline musculofascial closure at their institution between January of 2008 and March of 2011 was reviewed. Surgical outcomes were compared. Results One hundred twenty patients were identified who underwent a nonbridged, inlay abdominal wall reconstruction with porcine [69 patients (57.5 percent)] or bovine acellular dermal matrix (51 patients (42.5 percent)]. The mean follow-up time was 21.0 ± 9.9 months. The overall complication rate was 36.6 percent; the porcine matrix group had a significantly higher complication rate (44.9 percent) than the bovine matrix group (25.5 percent; p = 0.04) and statistically equivalent surgical complications (29.2 percent versus 21.6 percent; p = 0.34). There were no significant differences in rates of recurrent hernia (2.9 percent versus 3.9 percent; p = 0.99) or bulge (7.2 percent versus 0 percent; p = 0.07). However, the rate of intraoperative adverse events in the porcine matrix group [seven events (10.1 percent)] was significantly higher than that in the bovine matrix group (0 percent; p = 0.02). Conclusions In patients who undergo complex abdominal wall reconstruction, both bovine and porcine acellular dermal matrix are associated with similar rates of postoperative surgical complications and appear to result in similar outcomes. Porcine acellular dermal matrix may be prone to intraoperative device failure. Clinical question/level of evidence Therapeutic, III.

Objective: The anterolateral thigh flap is a versatile flap that can be used in a free or pedicled fashion. Because of the large amount of potential soft tissue, low donor site morbidity, and long pedicle lengths, many researchers consider it to be the perfect free flap. However, dissection of this and other perforator flaps can become an arduous experience with learning curves to overcome. Near-infrared laser angiography using indocyanine green provides a useful adjunctive tool to more predictably assess direct perforator perfusion zones. Laser-assisted angiography with SPY-Q analysis gives live localization of the flap's dominant perforator perfusion zones while quantifying the relative tissue perfusion for immediate skin paddle design. Methods: Fifteen patients with head and neck cancer defects were reconstructed with a free anterolateral thigh flap using laser-assisted near-infrared indocyanine green perforator mapping. The mid-point of a line between the anterior superior iliac spine and the patella was determined and the laser was centered over this. Indocyanine green (12.5 mg) was injected intravenously and fluorescence patterns were recorded. Optimal perforators were chosen using real-time imaging and SPY-Q analysis software. The anterolateral thigh skin paddle was centered over perforators based on best relative perfusion values. The hand-held Doppler was not used to identify perforators. All flaps were elevated in standard fashion. Patient demographics, defect characteristics, reconstructive techniques, and clinical outcomes were assessed. Results: All 15 free flaps were raised with the assistance of laser-assisted angiography. Cutaneous Doppler did not aid in the design of the skin paddle. There was only 1 flap loss due to venous congestion. All donor defects were closed primarily without the need for a skin graft. Conclusions: Laser-assisted indocyanine green angiography using SPY-Q analysis software provides robust, intraoperative, objective data to optimize anterolateral thigh skin paddle design while potentially minimizing patient morbidity. Future studies will be needed to further evaluate the use of this new technology.

Minimally invasive harvest of the latissimus dorsi (LD) muscle is a desirable goal because of both the wide utility of this muscle and the length of incision required to harvest it. In this study, robotic harvest of the LD muscle was evaluated in a cadaver model and clinical series. Ten LD flaps were robotically harvested in eight cadavers. Positioning, port placement, procedural steps, instrumentation, and technical obstacles were all critically analyzed and reported. After modifying the technique based on experience gained in the cadaver study, eight LD muscles were robotically harvested and transferred in eight patients. Access included a short axillary incision and two additional port sites along the anterior border of the muscle. Insufflation was used to maintain the optical cavity. Indications included pedicled flaps for implant-based breast reconstruction and free flaps for scalp reconstruction. All flaps were successfully transferred without converting to open technique. In the clinical series, average time for setup and port placement was 23 minutes, and average robotic time was 1 hour and 51 minutes. There were no major complications. Robotic harvest of the LD is feasible and effective and permits full muscle harvest without a visible incision.

The latissimus dorsi muscle is a workhorse of reconstructive surgery. Traditional harvest technique requires a long, posterior donor-site incision. Endoscopic harvest is limited by technical challenges. Robotic technology permits a simpler, minimally invasive harvest technique.Seven consecutive robotic latissimus dorsi muscle harvests were performed by a single surgeon. Two were used as free flaps for scalp reconstruction and the remaining five as pedicled flaps for breast reconstruction; three were for immediate, implant-based reconstruction with nipple-areola complex-sparing mastectomies, and two were for radiated breasts when the expander was exchanged for an implant. Harvest technique employed a short, axillary incision for pedicle dissection and two to three additional ports for robotic instrumentation.All seven muscle flaps were harvested without converting to an open technique. Both free flaps were successfully transferred. All pedicled flaps resulted in successful breast reconstructions. Flap harvest complications included a single, temporary radial nerve palsy in the contralateral extremity, likely from positioning. There were no donor-site hematomas, seromas, or cutaneous thermal injuries. Robotic harvest time decreased from over 2 hours to about an hour over the study period.Robotic harvest of the latissimus dorsi is a novel and effective method of muscle harvest. It offers technical advantages over endoscopic harvest and aesthetic advantages over the open technique.Therapeutic, IV.

Mesh materials have undergone a considerable evolution over the last several decades. There has been enhancement of biomechanical properties, improvement in manufacturing processes, and development of antiadhesive laminate synthetic meshes. The evolution of bioprosthetic mesh materials has markedly changed our indications and methods for complex abdominal wall reconstruction. The authors review the optimal properties of bioprosthetic mesh materials, their evolution over time, and their indications for use. The techniques to optimize outcomes are described using bioprosthetic mesh for complex abdominal wall reconstruction. Bioprosthetic mesh materials clearly have certain advantages over other implantable mesh materials in select indications. Appropriate patient selection and surgical technique are critical to the successful use of bioprosthetic materials for abdominal wall repair.

Desmoid tumor, also known as aggressive or deep fibromatosis or musculoaponeurotic fibromatosis, is a rare tumor. Desmoids are characterized by their ability to locally infiltrate; while frequently locally recurrent, they lack metastatic potential. Desmoids typically arise within the abdomen or abdominal wall, but can be extra-abdominal, most commonly in the proximal extremities. The infiltrative and recurrent nature of desmoid tumors can render surgical resection challenging if acceptable function and cosmesis is to be maintained. Consequently, desmoid management frequently involves a multidisciplinary approach that combines the expertise of several surgical specialists, for example, surgical oncologists and plastic surgeons, and also medical and radiation oncologists. As will be reviewed in this article, working together before undertaking any definitive therapies, such expert teams may be optimally positioned to offer patients superior functional and aesthetic outcomes based on maximizing therapeutic efficacy while minimizing treatment-related morbidities.

PURPOSE: Accelerated partial breast irradiation (APBI) has gained popularity as an alternative to adjuvant whole breast irradiation; however, owing to limitations of delivery devices for brachyther- apy, APBI has not been a suitable option for all the patients. This report evaluates APBI using the strut-adjusted volume implant (SAVI) single-entry catheter to deliver brachytherapy for breast cancer in the setting of an augmented breast. METHODS AND MATERIALS: The patient previously had placed bilateral subpectoral saline implants; stereotactic core biopsy revealed estrogen receptor- and progesterone receptor-positive ductal carcinoma in situ of intermediate nuclear grade. The patient underwent needle-localized segmental mastectomy of her left breast; pathologic specimen revealed no residual malignancy. An SAVI 8-1 device was placed within the segmental resection cavity. Treatment consisted of 3.4 Gy delivered twice a day for 5 days for a total dose of 34 Gy. Treatments were delivered with a high-dose-rate 192 Ir remote afterloader. RESULTS: Conformance of the device to the lumpectomy cavity was excellent at 99.2%. Dosi- metric values of percentage of the planning target volume for evaluation receiving 90% of the prescribed dose, percentage of the planning target volume for evaluation receiving 95% of the prescribed dose, volume receiving 150% of the prescribed dose, and volume receiving 200% of the prescribed dose were 97.1%, 94.6%, 22.7 cc, and 11.6 cc, respectively. Maximum skin dose was 115% of the prescribed dose. The patient tolerated treatment well with excellent cosmetic results, and limited acute and late toxicity at 8 weeks and 6 months, respectively. CONCLUSIONS: Breast augmentation should not be an exclusion criterion for the option of APBI. The SAVI single-entry catheter is another option to successfully complete APBI using brachytherapy for breast cancer in the setting of an augmented breast. 2011 American Brachy