Microvascular Breast Reconstruction: Experience With 1000 ...



Microvascular Breast Reconstruction: Experience With 1155 Flaps

William W. Shaw, Babak J. Mehrara, Andrew L. Dalio, James P. Watson, Eric Arcilla, Andrew D. Smith, Timothy D. Santoro, and Jeffery Sebastian

Introduction

Numerous studies have demonstrated the importance of breast reconstruction in improving quality of life and body image after mastectomy. Although the optimal method of breast reconstruction varies from patient to patient, most authors agree that autogenous tissues are the gold standard because they enable reconstruction of a natural looking and natural feeling breast mound. What is less clear, however, is the choice between microvascular transfer versus pedicled flaps. Those who favor pedicled flaps cite the traditional figure of 5-10% free flap loss to justify higher rates of partial flap loss, major fat necrosis and abdominal wall complications with pedicled TRAM flaps. In contrast, proponents of microvascular free flaps have shown that the improved circulation using these techniques enables improved cosmetic reconstruction with decreased risk of fat necrosis and partial flap loss. 1-5 The purpose of this study was to clarify the rates of major complications in the largest reported series of consecutive mastectomy patients treated with free tissue transfer for breast reconstruction.

Methods

A retrospective analysis of all patients treated with microvascular breast reconstruction at UCLA Medical Center from December 31, 1991 to December 31, 20002 was performed. Patient demographics and the incidence of postoperative complications were recorded. Untoward events occurring within 30 days of the operation were considered early complications while all others were considered late complications. Complications requiring operative intervention, intensive care monitoring or readmission (ie. early return to the operating room for microvascular failure, total or partial flap loss (more than 25% or greater than 7.5cm2), postoperative hematomas, significant infections/wound complications) were considered major complications. All other complications, including mild fluid overload, infections, mastectomy flap necrosis, minor wound complications, clinically insignificant fat necrosis (less than or equal to 1cm2), minor fat necrosis (less or equal to 3cm2), moderate fat necrosis (greater than 3cm2 but less than 7.5cm2), abdominal wall laxity, and hernias were considered minor complications.

Results

Unilateral reconstruction was performed in 673 patients while 241 underwent bilateral reconstruction (1155 flaps). The median age was 48.9 years (range 21-79) and 17% of patients had co-morbid conditions (obesity, diabetes, hypertension, asthma, CAD). Immediate reconstruction was performed in 58% of cases. TRAM flaps were performed in 952 cases (82.5%) while the superior gluteal (10.1%), TFL (4.5%), DICA (2.2%), gracilis (0.3%), and latissimus (0.4%) were performed in the remaining patients. The overall complication rate was 30%. Early complications occurred in 176 (19.3%) patients while late complications occurred in 144 patients (15.7%). Seventy eight (8.5%) of patients experienced a major complication including: 6 total flap losses (0.5%), 26 partial flap losses (2.3%), 7 arterial thrombosis (0.6%), 17 venous thrombosis (1.5%), 18 hematomas (2.0%), 8 cases of pulmonary edema requiring intubation (0.9%), 1 case of life threatening sepsis (0.3%), and 1 case of intestinal compartment syndrome. The salvage rate after microvascular thrombosis was 75%. There were no deaths related to breast reconstruction. Minor complications consisted of: fat necrosis (9.9% overall), wound healing complications (9.5%), abdominal wall hernia or laxity (3.2%), mild CHF (1.6%), DVT (0.3%), and brachial plexus palsy (temporary; 1.2%%). In most cases (6.2%) fat necrosis was small ( ................
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