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Background: The purpose of this study was to evaluate outcomes in breast reconstruction combining lower abdominal flaps with implants and to compare the impact of timing of implant placement on complication and revision rates. Methods: A retrospective review of all patients who underwent free transverse rectus abdominis musculocutaneous, muscle-sparing transverse rectus abdominis musculocutaneous, deep inferior epigastric perforator, or superficial inferior epigastric perforator flaps with implants at a single center over the past decade was performed. Patients were classified as having implant placement at the time of flap reconstruction or during a second procedure. The flap types, implant types/planes, flap and implant-related complications, and revision rates were compared between the groups. Results: Sixty-nine patients underwent 110 abdominal free flap breast reconstructions with an implant (immediate placement group, 35 patients; staged placement group, 34 patients). The mean follow-up periods were 32 months and 43 months for the immediate placement and staged placement groups, respectively. There was no statistically significant difference in flap type, implant type or plane, flap-related complications, or early implant-related complications between groups. The immediate placement group had a significantly higher rate of late implant-related complications: 25 percent (15 of 59) versus 4 percent (two of 51) in the staged placement group (p = 0.007). The implant revision rate was 63 percent (22 of 35) in the immediate placement group versus 26 percent (nine of 34) in the staged placement group (p = 0.081). Conclusions: The authors conclude that it is safe to combine implants with autologous lower abdominal free flaps for breast reconstruction. However, it may be preferable to perform this procedure in a staged fashion to minimize late complications and the need for future revisions because of complications or dissatisfaction with the aesthetic result.

BACKGROUND: Pharyngoesophageal defects traditionally have been reconstructed using a jejunal or radial forearm flap. In 2002, the authors began using the anterolateral thigh flap for pharyngoesophageal reconstruction, and it has become our preferred method. The purpose of this study was to analyze the clinical and functional outcomes achieved using this technique. METHODS: The medical records of 91 male and 23 female patients who underwent pharyngoesophageal reconstruction using an anterolateral thigh flap were retrospectively reviewed. Outcomes analyzed included length of hospital and intensive care unit stay, fistula and anastomotic stricture formation and other complications, swallowing and tracheoesophageal speech function, and survival. Most patients had primary (27%) or recurrent (42%) squamous cell carcinoma. Before reconstruction, 71% of patients had undergone surgery, radiotherapy, or both. There were 67 circumferential and 47 near-circumferential defects. RESULTS: Mean intensive care unit stay was 1.9 ± 2.2 days, and mean hospital stay was 9.0 ± 4.7 days. Two patients experienced total flap loss, and 1 patient had partial flap necrosis. Pharyngocutaneous fistulas and strictures occurred in 9% and 6% of patients, respectively. Ninety-one percent of patients tolerated an oral diet without the need for tube feeding. Tracheoesophageal puncture was performed for speech rehabilitation in 51 patients. Eight-one percent of patients with a secondary tracheoesophageal puncture achieved fluent speech versus 41% of patients with a primary tracheoesophageal puncture. CONCLUSIONS: This series demonstrates that excellent clinical and functional outcomes, with minimal donor site morbidity and quick recovery, are possible with pharyngoesophageal reconstruction using an anterolateral thigh flap. Cancer 2010. © 2010 American Cancer Society.

Importance The most appropriate dose fractionation for whole-breast irradiation (WBI) remains uncertain. Objective To assess acute and 6-month toxic effects and quality of life (QOL) with conventionally fractionated WBI (CF-WBI) vs hypofractionated WBI (HF-WBI). Design, Setting, and Participants Unblinded randomized trial of CF-WBI (n = 149; 50.00 Gy/25 fractions + boost [10.00-14.00 Gy/5-7 fractions]) vs HF-WBI (n = 138; 42.56 Gy/16 fractions + boost [10.00-12.50 Gy/4-5 fractions]) following breast-conserving surgery administered in community-based and academic cancer centers to 287 women 40 years or older with stage 0 to II breast cancer for whom WBI without addition of a third field was recommended; 76% of study participants (n = 217) were overweight or obese. Patients were enrolled from February 2011 through February 2014 and observed for a minimum of 6 months. Interventions Administration of CF-WBI or HF-WBI. Main Outcomes and Measures Physician-reported acute and 6-month toxic effects using National Cancer Institute Common Toxicity Criteria, and patient-reported QOL using the Functional Assessment of Cancer Therapy for Patients with Breast Cancer (FACT-B). All analyses were intention to treat, with outcomes compared using the χ 2 test, Cochran-Armitage test, and ordinal logistic regression. Results Of 287 participants, 149 were randomized to CF-WBI and 138 to HF-WBI. Treatment arms were well matched for baseline characteristics, including FACT-B total score (HF-WBI, 120.1 vs CF-WBI, 118.8; P = .46) and individual QOL items such as somewhat or more lack of energy (HF-WBI, 38% vs CF-WBI, 39%; P = .86) and somewhat or more trouble meeting family needs (HF-WBI, 10% vs CF-WBI, 14%; P = .54). Maximum physician-reported acute dermatitis (36% vs 69%; P P P = .001), hyperpigmentation (9% vs 20%; P = .002), and fatigue (9% vs 17%; P = .02) during irradiation were lower in patients randomized to HF-WBI. The rate of overall grade 2 or higher acute toxic effects was less with HF-WBI than with CF-WBI (47% vs 78%; P P = .01), and patients randomized to HF-WBI reported less lack of energy (23% vs 39%; P P = .01). Multivariable regression confirmed the superiority of HF-WBI in terms of patient-reported lack of energy (odds ratio [OR], 0.39; 95% CI, 0.24-0.63) and trouble meeting family needs (OR, 0.34; 95% CI, 0.16-0.75). Conclusions and Relevance Treatment with HF-WBI appears to yield lower rates of acute toxic effects than CF-WBI as well as less fatigue and less trouble meeting family needs 6 months after completing radiation therapy. These findings should be communicated to patients as part of shared decision making. Trial Registration clinicaltrials.gov Identifier:NCT01266642

CONCLUSIONS: Anastomosing the cavernosal arteries may augment corporal inflow, which is necessary for erection. While the dorsal arteries are critical for distal penile skin perfusion, the external pudendal artery should be used in proximal transplantation to ensure adequate shaft skin perfusion. Each of these arteries has a distinct and seemingly important perfusion territory that should be considered in the setting of penile transplantation.