Browsing by Author "Zhou, Michael"
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Item Abdominal Based Free Flap Breast Reconstruction: Stratifying Complications with Perforator Numbers(2017-01-17) Wang, Jenny; Zhou, Michael; Kayfan, Samar; Teotia, Sumeet S.; Haddock, Nicholas T.BACKGROUND: Single perforator flaps in breast reconstruction have been reported to have increased fat necrosis. We were motivated to evaluate our experience and the effect of number of perforators on DIEP flap complications and donor site morbidity. METHODS: 199 patients underwent 328 DIEP flaps by two surgeons from 2010 to 2016 at a university hospital. Perforator selection was guided by CT imaging and clinical observation. First, perforator average size was compared among flaps with 1 perforator (n= 110 flaps), 2 perforators (n= 136 flaps), and 3 perforators (n= 82 flaps). Next, rates of fat necrosis, flap failure, and abdominal bulging were analyzed among the same three perforator groups. In addition, rates of postoperative abdominal bulge requiring surgical intervention was compared to the presence of a nerve-preserving type flap harvest. RESULTS: Average perforator size significantly decreased as the number of perforators increased (1 perforator = 2.11mm, 2 perforators = 1.80mm, 3 perforators = 1.65mm, p-value = 0.02 and 0.01 for 1 versus 2 perforator flaps and 1 versus 3 perforator flaps, respectively). However, no significant differences were noted in fat necrosis, flap failure, and abdominal bulging rates across perforator groups. Additionally, flap weights were not significantly different across the three groups (Average: 1 perforator-774 grams, 2 perforators-797 grams, and 3 perforators- 749 grams). Neither perforator number nor nerve preserving techniques were found to result in significant decreases in abdominal bulge rates. CONCLUSIONS: Contrary to other studies, we found that the number of perforators harvested in DIEP flap breast reconstruction was not associated with increase or decrease in flap survival or fat necrosis. This occurrence could be attributed to the surgeons' choosing to proceed with single perforator flaps only when perforator size was adequately large, maintaining consistent blood supply. There was no association among perforator number, utilization of nerve sparing procedures, and abdominal bulge that required subsequent surgical intervention. Despite this, we still cautiously advocate nerve-preserving techniques that may have a subclinical effect.Item Challenges Associated with Internal Mammary Vessels in Multiple Free Flap Breast Reconstruction(2017-01-17) Kayfan, Samar; Zhou, Michael; Wang, Jenny; Teotia, Sumeet S.; Haddock, Nicholas T.INTRODUCTION: As breast reconstructive microsurgeons increase their armamentarium of flaps with experience, the need for stacked and multiple flaps may generate an improved aesthetic outcome. Bi-pedicled and stacked flaps have been performed by microsurgeons using the cranial and caudal internal mammary system. We present our experience utilizing this system for flap reliability. METHOD: 736 flaps for breast reconstruction were performed from 2010-2016 (DIEP/SIEA and PAP flaps) by 2 senior surgeons at a university hospital. 220 (30%) of those flaps were either: Stacked PAP flaps, 4-flap (Bilateral PAP+DIEP flap), or Double-pedicle DIEP/SIEA flaps. Specific data regarding number, type, and locality of anastomosis was analyzed. RESULTS: 454 anastomosis were performed in 87 patients who underwent 220 flaps. Out of 454 anastomosis, 167 were to Caudal IMA/V (37%), 171 were to Cranial IMA/V (38%), and 116 were intra-flap (25%). There were 0 flap losses in Double-pedicle DIEP group (58-patients, 116-flaps), 3 flap losses in 4-Flap group (23-patients, 92-flaps), and 0 in Stacked-PAP group (6-patients, 12-flaps). In the 3 flap losses of 4-Flap group, 2 flaps were to Caudal IMA/V (1 arterial thrombosis, 1 venous thrombosis), and 1 cranial IMA/V (venous thrombosis). Also, in the 4-Flap group, 3 flaps were salvaged by converting to intra-flap anastomosis due to intraoperative caudal arterial thrombosis. In the Stacked-PAP group, there were 2 flaps salvaged, 1 by converting to intra-flap artery from caudal IMA, and other was venous congestion from caudal IMV pedicle kink seen POD#1. In the Double-pedicle DIEP group, 1 flap was salvaged by converting 1 arterial anastomosis from caudal IMA to intra-flap. Total flap loss rate in entire group was 1.4%. Flap loss avoidance by either conversion to intra-flap anastomosis or early suspicion of caudal system compromise was 2.7%. CONCLUSION: Caudal IMA/V system remains a viable and safe option for anastomosis in multiple flap procedures. However, based on our large experience with stacked and multiple flaps, we add caution utilizing the caudal system, particularly in patients with radiation, anastomosis mismatch and intraoperative spasm. The enthusiasm towards usage of caudal IMA/V system should be appropriately attenuated in certain circumstances with preference towards intra-flap anastomosis.Item Immediate vs Delayed Breast Reconstruction: A Single Institution Experience(2017-01-17) Zhou, Michael; Kayfan, Samar; Wang, Jenny; Haddock, Nicholas T.; Teotia, Sumeet S.BACKGROUND: Deep inferior epigastric perforator (DIEP), superficial inferior epigastric artery (SIEA), and profunda artery perforator (PAP) flaps are acceptable options for autologous breast reconstruction. This study comprehensively evaluates the differences in outcomes between patients receiving immediate, delayed/immediate (staged with the use of tissue expanders), and delayed breast reconstructions (without the use of tissue expanders). METHODS: 547 free flaps (DIEP, SIEA, or PAP) on 331 patients were performed. Patients were grouped based on reconstruction timing: immediate (n=175 flaps), delayed-immediate (n=247 flaps), and delayed (n= 125 flaps). Comorbidities, preoperative radiation, neoadjuvant/postoperative chemotherapy, length of hospital stay, number of subsequent revision surgeries, and breast and donor site complications were analyzed among the groups. RESULTS: Immediate reconstructions, when compared to delayed-immediate reconstructions, encountered more infections (p<0.01), more wound occurrences (p = <0.01), longer lengths of stay (5.2 versus 4.1 days), longer procedure times (p = <0.01), and larger number of revision surgeries (2.4 vs 1.4 revisions) in patients receiving a single unilateral flap. Between outcomes of single flap immediate and delayed reconstructions, immediate reconstruction resulted in longer lengths of stay (5.2 vs 4.0 days), longer procedure time (p = <0.01), larger number of revision surgeries (2.4 vs 1.7 revisions), and higher chance of wound necrosis (p = <0.01). In patients receiving 2 free flaps (bilateral or double-pedicle unilateral reconstruction), immediate reconstructions encountered larger numbers of subsequent revision surgeries (1.7 versus 1.1 revisions) and no other significant differences compared to delayed-immediate reconstructions. There were no significant differences between delayed and delayed-immediate reconstructions. CONCLUSION: Immediate, delayed-immediate, and delayed reconstructions are all reasonably safe options for breast reconstruction. However, higher rates of complications among immediate reconstructions imply delayed-immediate and delayed reconstructions may be superior options to immediate reconstructions, not only in bilateral reconstructions, but especially in single free flap reconstructions. These results should be considered between the surgeon and patient when deciding an appropriate reconstruction plan based on the risks, benefits, and potential costs associated with different breast reconstruction timings.