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Timing of reconstruction
Published in Steven J. Kronowitz, John R. Benson, Maurizio B. Nava, Oncoplastic and Reconstructive Management of the Breast, 2020
Steven J. Kronowitz, John R. Benson, Maurizio B. Nava
Similar findings have also been observed in free-flap breast reconstruction. Clarke-Pearson and colleagues described a systematic approach that mitigated the deleterious effects of postmastectomy radiotherapy on deep inferior epigastric perforator flap (DIEP) flap reconstruction which included the following interventions: (1) routine use of preoperative magnetic resonance angiography, (2) preferential use of flap zones 1 and 2, (3) “de-skinning” rather than de-epithelializing flaps to minimize residual dermal elements that may lead to fibrosis and contracture after radiation, (4) minimizing dead space around the flap to prevent uncontrolled contracture and distortion after radiation, and (5) delivery of postmastectomy radiotherapy using 3-D conformal techniques that reduce exposure to adjoining normal tissue structures.10 They reported satisfactory aesthetic outcomes in all patients at 18 months, with no increase in rates of fat necrosis and only a slight loss of volume and mild increase in firmness in irradiated flaps. Overall, there was minimal distortion of breast shape and any deficits were usually readily corrected with minor outpatient revision. The latter involved a small reduction to the non-irradiated breast, with or without fat grafting to the radiated breast. It was concluded that immediate reconstruction with DIEP flaps could be performed successfully in patients who require postmastectomy radiotherapy when steps were taken to ensure flap vascularity, minimize fibrosis, optimize contour, and modulate radiation dosing.
Contralateral internal mammary vessels – a rescue recipient vessels option in breast reconstruction
Published in Case Reports in Plastic Surgery and Hand Surgery, 2022
Artur Nixon Martins, João Nunes Pombo, Catarina Paias Gouveia, Bruno Gomes Rosa, Gaizka Ribeiro, Carlos Pinheiro
Recipient vessels unavailability is a limiting factor for microsurgery. Arteriovenous loops, venous grafts or usage of cephalic vein may be part of the solution. However, they increase scar burden. This may be a limiting factor in an aesthetically demanding reconstructive procedure. In free flap breast reconstruction the conversion recipient vessels options include the IM, TD, circumflex scapular, subscapular, serratus and lateral thoracic [9,23]. Other options include IM perforators [7] as well as distal end of IM vessels [22], however the flowless homolateral IM artery rendered these options unavailable. The need to conversion may be due to vessel mismatch, scarring, short pedicle, poor flow, vessel friability and small recipient vein or retrosternal location (in case of IM) [9]. Inadequate or absent IM veins is more commonly reported on the left side [9,24–26]. This relates with our case. Left side anastomosis is also more prone to venous thrombosis and overall complications [13,14].
Avoiding the night terrors: the effect of circadian rhythm on post-operative urine output and blood pressure in free flap patients
Published in Journal of Plastic Surgery and Hand Surgery, 2021
Bara El-khayat, Deborah Foong, James Baden, Robert Warner, George Filobbos
Our patient set received an average of 1.81 ml/kg/hr infusion of crystalloid and 1420 ml oral fluid overnight. Some authors have suggested an ideal range of IV rate of 3.5–6.0 ml/kg/hr in the perioperative 24 h period [11]. However, this would include intraoperative fluids given which were excluded from our calculations, and these studies still advocated titration of fluid input to haemodynamic parameters and urine production [11,22,24]. Data from enhanced recovery after surgery protocol studies, which included more restrictive fluid regimes, demonstrated the safety of such practice. Moreover, survey data, at least for free flap breast reconstruction shows our practice to be in line with other UK units [25].