• Archives of Plastic Surgery
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• 제36권2호
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• pp.140-146
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• 2009

Purpose: Autologous breast reconstruction with abdominal tissue is one of the best options after mastectomy. In a free transverse rectus abdominis myocutaneous(TRAM) or deep inferior epigastric artery perforator(DIEP) flap, a preoperative evaluation of the precise location of perforating vessels and vascular run - off systems is required. The objective of this report is to demonstrate the usefulness of multidetector computed tomography(MDCT) in the preoperative planning of patients undergoing breast reconstruction with abdominal flap. Methods: From June 2006 to January 2008, 28 patients underwent MDCT evaluation before breast reconstruction. All subjects were females with an age range of 30 to 55 years. The CT scan was performed using a 64 - slice MDCT scanner(Brilliance 64; Philips Medical Systems, Best, Netherlands). Results: One perforator or two major perforators were marked on image in good relation with a hand - held Doppler examination and intraoperative findings. All vascular run - off systems were cleared before operation. Conclusion: Preoperative evaluation of perforator arteries with MDCT angiography is beneficial in patients undergoing breast reconstruction. This technique provides a noninvasive approach of the vascular anatomy of the entire anterior abdominal wall.

• Archives of Plastic Surgery
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• 제51권2호
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• pp.156-162
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• 2024

Background Perioperative management in autologous breast reconstruction has gained focus in recent years. This study compares two pain management protocols in patients undergoing abdominal-based free flap breast reconstruction: a past protocol (PP) and a current protocol (CP)-both intended to reduce opioid consumption postoperatively. The PP entails use of a pain catheter in the abdominal wound and the CP consists of an intraoperative nerve block in addition to refinements in the oral pain management. We hypothesize that the CP reduces opioid consumption compared to PP. Methods From December 2017 to January 2020, 102 patients underwent breast reconstruction with an abdominal-based free flap. Two postoperative pain management strategies were used during the period; from December 2017 to September 2018, the PP was used which entailed the use of a pain catheter with ropivacaine applied in the abdominal wound with continuous distribution postoperatively in addition to paracetamol orally and oxycodone orally pro re nata (PRN). From October 2018 to January 2020, the CP was used. This protocol included a combination of intraoperative subfascial nerve block and a postoperative oral pain management regime that consisted of paracetamol, celecoxib, and gabapentin as well as oxycodone PRN. Results The CP group (n = 63) had lower opioid consumption compared to the PP group (n = 39) when examining all aspects of opioid consumption, including daily opioid usage in morphine milligram equivalents and total opioid usage during the stay (p < 0.001). The CP group had shorter length of hospital stay (LOS). Conclusion Introduction of the CP reduced opioid use and LOS was shorter.

• Archives of Plastic Surgery
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• 제49권2호
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• pp.150-157
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• 2022

Patients undergoing treatment for breast cancer who undergo an axillary dissection and require adjuvant therapies such as radiation and chemotherapy are at high risk of developing lymphedema of the associated extremity. Historically, patients with lymphedema were treated with ablative procedures aimed simply to remove excess fluid and adiposity; however, the field of lymphatic surgery employing super-microsurgery techniques has witnessed tremendous advances in a relatively short period of time. Advancements in surgical instruments, microscope magnification and optics, imaging technology, and surgeon experience have ushered in a new era of hope to treat patients suffering from breast cancer-related lymphedema (BCRL). Here we aim to present the available options for patients suffering from BCRL, and the pinnacle in reconstruction and restoration for these patients.

• Archives of Plastic Surgery
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• 제47권5호
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• pp.428-434
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• 2020

Background Three-dimensional (3D) model printing improves visualization of anatomical structures in space compared to two-dimensional (2D) data and creates an exact model of the surgical site that can be used for reference during surgery. There is limited evidence on the effects of using 3D models in microsurgical reconstruction on improving clinical outcomes. Methods A retrospective review of patients undergoing reconstructive breast microsurgery procedures from 2017 to 2019 who received computed tomography angiography (CTA) scans only or with 3D models for preoperative surgical planning were performed. Preoperative decision-making to undergo a deep inferior epigastric perforator (DIEP) versus muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flap, as well as whether the decision changed during flap harvest and postoperative complications were tracked based on the preoperative imaging used. In addition, we describe three example cases showing direct application of 3D mold as an accurate model to guide intraoperative dissection in complex microsurgical reconstruction. Results Fifty-eight abdominal-based breast free-flaps performed using conventional CTA were compared with a matched cohort of 58 breast free-flaps performed with 3D model print. There was no flap loss in either group. There was a significant reduction in flap harvest time with use of 3D model (CTA vs. 3D, 117.7±14.2 minutes vs. 109.8±11.6 minutes; P=0.001). In addition, there was no change in preoperative decision on type of flap harvested in all cases in 3D print group (0%), compared with 24.1% change in conventional CTA group. Conclusions Use of 3D print model improves accuracy of preoperative planning and reduces flap harvest time with similar postoperative complications in complex microsurgical reconstruction.

• Archives of Plastic Surgery
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• 제37권4호
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• pp.396-399
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• 2010

Purpose: In hand injury, pedicle is usually damaged by avulsion injury or crushing injury. Because of postoperative pedicle obliteration, it is often hard to save the injured hand and fingers, even after successful replantation. The author introduces three cases of extensive hand injury, and successful results after applicatoin of multiple venous grafts to these patients. Methods: In all cases there was no circulation in any finger. In the first case, some vessels were extracted, so venous graft was applied to two sites of severely damaged venous sites. In the second case, venous grafts were applied to all four digital arteries of all fingers except thumb which got severely crushed, and two sites of dorsal veins. In the third case, venous graft was applied to all four digital arteries of all five fingers, and two sites of dorsal veins and palmar veins each. Results: In all cases, survival of hands and fingers was successful. In the second case, however, amputation in thumb and little finger at DIP joint level was inevitable, because of its severe damage, and the large dorsal defect on index finger was filled with DIEP free flap. Thumb was reconstructed with toe-to-thumb free flap, and additional debulking procedures and contracture release is furtherly needed. In the first case, additional surgery was done, as FDP tendon got re-ruptured, but in long term follow-up, satisfactory range of motion was attained. In the third case, FTSG on dorsal skin region was planned. as flap on dorsal area got partial necrosis. Conclusion: In hand injury, there are many structures to be repaired, but sometimes venous graft is avoided for its long operating time. Even though the length of damaged vessel is enough for anastomosis, the endothelium is often damaged (zone of injury). In extensive hand injury, successful reconstruction would be possible with active venous graft to all vessels suspicious for damage.