153 research outputs found
Co-Surgeons in Breast Reconstructive Microsurgery: What Do They Bring to the Table?
No full textAs the content in this document has been previously published in the journal Microsurgery, an internal indefinite embargo will be placed on this document through the department of Medical Student Research at UT Southwestern. This will ensure that this document will not be published online and will remain only within the UT Southwestern system to not infringe upon copyright regulations established between the authors and Microsurgery.The general metadata -- e.g., title, author, abstract, subject headings, etc. -- is publicly available, but access to the submitted files is restricted to UT Southwestern campus access and/or authorized UT Southwestern users.INTRODUCTION: Current research within other surgical specialties suggests that a co-surgeon approach may reduce operative times and complications associated with complex bilateral procedures, possibly leading to improved patient and surgical outcomes. We sought to evaluate the role of the co-surgery team and its development in free flap breast reconstruction.
METHODS: A retrospective review of free-flap breast reconstruction by two surgeons from 2011-2016 was conducted. We analyzed 128 patients who underwent bilateral-DIEP breast. Surgical groups were: single-surgeon reconstruction (SSR; 35 patients), Co-Surgery where both surgeons are present for entire reconstruction (CSR-I; 69 patients), and Co-Surgery reconstruction where co-surgeons appropriately assist in two concurrent or staggered cases (CSR-II; 24 patients). Efficiency data collected was OR time and patient length-of-stay (LOS). The rate of flap-failure, return to OR, infection, wound breakdown, seroma, hematoma and PE/DVT were compared.
RESULTS: Single-surgeon reconstruction had significantly longer OR time (678 vs 485 minutes, p< 0.0001), LOS (5 vs 3.9 days, p<0.001), higher wound occurrences of the umbilical site that required surgical correction [11.4 percent (n=4) versus 1.5 percent,(n=1); p<0.043] compared to CSR-I. Similarly, SSR had significantly longer average OR time (678 vs 527 minutes p< 0.0001), average LOS (5 days vs 4 days, p=0.0005) when compared to CSR-II. There were no total increased patient related complications associated with co-surgery (CSR- I or II).
CONCLUSION: The addition of a Co-surgeon, even with concurrent surgery, reduces operative time, average patient LOS, and post-operative complications. This work lends a strong credence that Co-surgery model is associated with increased operative efficiency
Protein and energy nutrition of marine gadoids, Atlantic cod (Gadus morhua L.) and haddock (Melanogrammus aeglefinus L.)
No full text Primary goals of this thesis were to: 1) examine the in vivo digestion of macronutrients from conventional or alternative feed ingredients used in practical diets of juvenile gadoids (Atlantic cod and haddock), 2) document growth potential of fish at the juvenile grower phase given varying levels of dietary protein and energy and 3) assess the potential of in vitro pH-Stat methods for rapid screening protein quality of feed ingredients, specifically for gadoids. All primary research questions were linked to and built upon one another with the goal of gaining a better understanding of protein and energy utilization of juvenile grower phase gadoids. Studies showed that cod and haddock have a high capacity to utilize a wide range of dietary feed ingredients, such as fish meals, zooplankton meal, soybean products (meal, concentrate and isolate) and wheat gluten meal. New dietary formulations for gadoids may also utilize pulse meals, corn gluten meal, canola protein concentrate and crab meal. Digestibility data in this thesis is currently the only research that examined both in vivo and in vitro macronutrient digestibility of a large number and wide range of individual ingredients, specifically for gadoids. This is essential to gain new knowledge on protein and energy utilization as well as for least-cost ration formulations and effective substitution of ingredients into new formulations. Data has demonstrated a dietary digestible protein/digestible energy (DP/DE)ratio of 30 g DP/MJ DE is required for gadoids during the juvenile phase (in vitro closed-system pH-Stat assay for rapid screening protein quality of test ingredients that is ‘species-specific’ to gadoids. It is demonstrated that in vitro results generally reflected results obtained through conventional in vivo protein digestibility methods. Studies resulted in the first generation of a ‘gadoid-specific’ proteolytic enzyme extraction method and in vitro closed-system pH-Stat assay which may be useful to investigate protein digestion, absorption and metabolism of gadoids and further development of their feeds. </p
Challenges Associated with Internal Mammary Vessels in Multiple Free Flap Breast Reconstruction
No full textThe 55th Annual Medical Student Research Forum at UT Southwestern Medical Center (Monday, January 17, 2017, 2-5 p.m., D1.600)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.Southwestern Medical Foundatio
Abdominal Based Free Flap Breast Reconstruction: Stratifying Complications with Perforator Numbers
No full textThe 55th Annual Medical Student Research Forum at UT Southwestern Medical Center (Monday, January 17, 2017, 2-5 p.m., D1.600)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.Southwestern Medical Foundatio
Immediate vs Delayed Breast Reconstruction: A Single Institution Experience
No full textThe 55th Annual Medical Student Research Forum at UT Southwestern Medical Center (Monday, January 17, 2017, 2-5 p.m., D1.600)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.Southwestern Medical Foundatio
The Impact of Radiation and Chemotherapy on Outcomes in Two-staged Implant-Based Breast Reconstruction
No full textThe 56th Annual Medical Student Research Forum at UT Southwestern Medical Center (Tuesday, January 23, 2018, 2-5 p.m., D1.600)INTRODUCTION: Treatments for breast cancer include neoadjuvant chemotherapy (NACT), adjuvant chemotherapy (ACT), radiation (RAD), and combinations of these therapies. Many of these patients will choose to pursue implant-based breast reconstruction concurrently with these treatments. Effects of these therapies on the outcomes of implant-based reconstructions have not been studied fully.
METHODS: From January 2012 to December 2016 two surgeons performed 542 breast reconstructions using tissue expanders (TE). The number of patients choosing implants who completed reconstruction was n=272. They were split into 8 groups based on therapy received: Group 1 (no treatment, n=139), Group 2 (NACT, n=32), Group 3 (ACT, n=44), Group 4 (NACT+ACT, n=14), Group 5 (NACT+RAD, n=17), Group 6 (ACT+RAD, n=13), Group 7 (RAD, n=12), Group 8 (ACT+NACT+RAD, n=1). Group 8 was excluded because it had only one patient, leaving n=271. ANOVA (df between groups = 6, df within groups = 264) and Tukey HSD were run to compare differences in the percentages of patients with infections requiring IV antibiotics, necrosis requiring operation, seroma, and TE exchange for new TE. Numbers of different surgeries were also counted.
RESULTS: Comorbidities and age were equivalent across groups, except for Group 7 (55.7 yr) and Group 4 (41.6 yr), p=.03. There were no significant differences in percentages of patients with infection requiring IV antibiotics (p=.32), necrosis requiring operation (p=.09), or seroma (p=.40). For patients who required replacement of TE with another TE due to complication, only Group 1 (1.4%) vs Group 6 (15.4%) had a significant difference, p=.04.
There were no differences in the mean numbers of complication-related surgeries before implant placement (p=.07), complication-related surgeries after implant placement (p=.30), revision surgeries (p=.98), or total surgeries (p=.29). There were no significant differences in the percentages of patients receiving at least one complication-related surgery before implant (p=.16), at least one complication-related surgery after implant (p=.85), or at least one revision surgery (p=.94).
CONCLUSION: Among most patients who choose to undergo implant-based reconstruction in an academic practice, we found no significant differences in complication rates, mean numbers of surgeries per patient, and percentages of patients undergoing different types of surgeries. Although patients with combined adjuvant chemotherapy and radiation had a higher rate of TE exchange for new TE due to complication, the rates of other complications and surgeries were comparable. Given these results, practice trends in breast reconstruction can remain cautiously optimistic for patients choosing implant-based reconstruction concurrently with cancer treatments.Southwestern Medical Foundatio
Free Flap Breast Reconstruction in Cancer Patients: Effect of BMI on Outcomes of the Deep Inferior Epigastric Perforator (DIEP) Flap
No full textThe 54th Annual Medical Student Research Forum at UT Southwestern Medical Center (Monday, January 19, 2016, 2-5 p.m., D1.700)BACKGROUND: The Deep Inferior Epigastric (DIEP) flap has achieved marked acceptance in free flap breast reconstruction, yet the effect of body mass index (BMI) on the procedural outcome can vary depending on the literature. This study aims to evaluate the effect of BMI on flap and donor-site complications in patients undergoing DIEP flap reconstruction.
METHODS: A retrospective analysis of 233 DIEP flaps in 135 patients was performed, and the patients were stratified as three groups based on BMI: Normal (BMI30). Data with regard to age, smoking history, comorbid conditions, preoperative radiation, preoperative chemotherapy, and complications post-DIEP flap reconstruction at the flap and donor-sites was analyzed and compared among groups.
RESULTS: Overweight patients had statistically higher rates of overall complications (p=0.001), umbilical wound (p=0.03), and return visits to the operating room during same hospital stay (p=0.004) compared to normal weight patients. Obese patients experienced statistically higher rates of overall complications (p=0.000023), return visits to operating room during same hospital stay (p=0.02), abdominal necrosis (p=0.0008), breast wound (p=0.019), umbilical wound (p=0.0053), and vacuum-assisted closure wound therapy (p=0.0006) compared to normal weight patients. There were no significant differences between the groups in regards to infection of the abdominal, breast, and umbilical sites, abdominal wound, abdominal seroma, breast necrosis, breast seroma, breast hematoma, umbilical necrosis, blood transfusion, pulmonary embolism, average OR time, average hospital length of stay, or loss of flap viability (p>0.05). Age distribution and preoperative radiation were not statistically different. Compared to normal-weight patients, overweight patients had significantly lower rates of smoking history and higher rates of hypertension, diabetes, and preoperative chemotherapy. Obese patients had statistically higher rates of preoperative chemotherapy compared to normal weight patients. These confounding factors between the groups are a limitation to the BMI control.
CONCLUSION: Overweight and obese patients undergoing DIEP flap breast reconstruction are predisposed to statistically higher risk for the aforementioned complications than normal weight patients. However, there was no significant difference in loss of flap viability between the groups. Therefore, DIEP flap breast reconstruction is an appropriate option.Southwestern Medical Foundatio
Double-Pedicle Deep Inferior Epigastric Artery (DIEP) Flap for Unilateral Breast Reconstruction: Indications, Success, and Large Experience at UT Southwestern
No full textThe 54th Annual Medical Student Research Forum at UT Southwestern Medical Center (Monday, January 19, 2016, 2-5 p.m., D1.700)BACKGROUND: Unilateral breast reconstruction is challenging in patients with radiation defects, large post-mastectomy soft tissue deficits, and obese patients. Using a hemi-abdominal flap for unilateral breast reconstruction in patients may not be ideal due to paucity of abdominal tissue, presence of a lower abdominal midline scar, or a larger and/or ptotic contralateral native breast. The lower abdomen (hemi-abdominal flaps) can be used to create one breast, in a stacked manner or bipedicled non-split composite fashion.
METHODS: 51consecutive bipedicled abdominal composite free flaps for unilateral breast reconstruction were performed. Patient demographics, type/weights of flaps, number of anastomoses, length/type of pedicles, and flap related complications were recorded. Using a simplified unique algorithm that we created, the bi-pedicled flaps were anastomosed to split internal mammary artery/vein(IMA/V) or an intraflap anastomosis was performed and anastomosed to the IMA/V.
RESULTS: 51patients underwent composite DIEP and/or superficial inferior epigastric artery(SIEA) flaps (102 total flaps). Average flap weight was 1,074 +/- 466 grams (average age 57 yrs and average Body Mass Index(BMI) 26.6 +/- 3.9). 25 patients (49%) had flaps >1,000 grams (average 1,430 grams, range 1052-2400 gms), and 36 (71%) patients had flaps >750 grams. 39 patients had delayed reconstruction and 12 were immediate. 23 patients had intra-flap anastomosis over the abdomen and carried as single composite flap to cranial IMA/V; 28 patients had independent bi-pedicle flaps anastomosed to cranial and caudal split IMA/V. There were 39 DIEP-DIEP flaps,10 DIEP-SIEA flaps, and 2 SIEA-SIEA flaps. Flaps were not split in midline, but carried as a composite hemiabdominal flap with anastomosis to the IMA/V. There were no flap losses. Donor site morbidity was equivalent to bilateral breast reconstruction with DIEP flaps.
CONCLUSION: Composite bi-pedicle hemi-abdominal flaps for unilateral breast reconstruction are feasible with low complication rates but are technically challenging, chiefly in flaps >1,000 grams. To maximize aesthetic outcomes, use of highly complex double pedicle abdominal flaps is crucial in some patients, primarily those with delayed reconstruction and large contralateral breast, radiationdeficits, and large post-mastectomy defects. Technical considerations such as flap inset and handling, use of simplified algorithm, and selection of anastomosis and pedicles will be presented to make these flaps successful. This series represents an ongoing largest experience of composite bi-pedicle DIEP and/or SIEA combination for unilateral breast reconstruction.Southwestern Medical Foundatio
Discussion: The Stacked Hemiabdominal Extended Perforator Flap for Autologous Breast Reconstruction
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