Floor plan - 2013 Annual Meeting - American Association for Hand ...

Late Venous Thrombosis in Free Flap Breast Reconstruction
Institution where the work was prepared: Hospital of the University of Pennsylvania, Philadelphia, PA, USA
Elizabeth M. Kim, MD; Liza C. Wu; Joseph M. Serletti; University of Pennsylvania
PURPOSE:
Identify the phenomenon and management of late postoperative venous thrombosis after free flap breast reconstruction.
PATIENTS/ METHODS:
Most venous thromboses occur within 48 hours following free flap surgery. It has been the senior author's experience that in free flap
breast reconstruction, there is a group of patients who develop late venous thrombosis, frequently following discharge. A retrospective
chart review of this surgeon's experience was performed to determine the incidence, management, and outcome of late venous thrombosis.
All patients undergoing free flap breast reconstruction were monitored post-operatively by following a surface arterial Doppler
signal every hour in an ICU for a minimum of 48 hours and then every 4 hours until discharge. The skin paddle was examined for signs
of congestion; venous flow was not directly monitored. Late venous thrombosis was defined as venous occlusion that occurred 72 hours
or more post-operatively.
RESULTS:
More than 1000 free flap breast reconstructions were performed by the senior surgeon between 1992 and 2007. Ten free flaps in ten
patients were identified with late venous thrombosis. The thromboses occurred on post op day 3 in two patients, day 4 in three patients,
day 5 in one patient, day 6 in two patients, day 8 in one patient, and day 12 in one patient. Two cases were identified on the day of
planned discharge and three came from home. Eight of these ten patients were urgently taken to the operating room where thrombectomy
and repeat venous anastamosis was performed. In 6 patients, a thrombolytic was infused into the recipient artery following repeat
venous anastomosis. The remaining two patients received heparin infusion only. 7 of these 10 flaps survived. Two patients were not
taken to the OR because the flap changes appeared to be very late. One of these flaps was lost and the other did survive but has developed
significant fat necrosis. Mean follow-up was 21 months.
CONCLUSION:
With only one per cent of our free flap breast reconstruction series suffering a late venous thrombosis, it would appear that this is a rare
entity. The late timing of this thrombosis in free flap breast reconstruction has, for us, been the rule and not the exception. Surgeons
who perform free flap breast reconstruction should be made aware of this potential event and instruct patients on the signs of venous
thrombosis. Prompt diagnosis and surgical treatment including thrombolytics increases the likelihood of total flap salvage.
Chimeric Stacked Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A New
Solution to an Old Problem
Institution where the work was prepared: The Center for Restorative Breast Surgery, New Orleans, LA, USA
Frank J. DellaCroce, MD; Scott Keith Sullivan, MD, FACS; The Center for Restorative Breast Surgery
Breast reconstruction continues to evolve. Autogenous breast reconstruction has proven to provide the most natural and lasting result
over time. The Deep Inferior Epigastric Perforator flap is a well described and increasingly accepted means of providing natural tissue
reconstruction with minimum associated morbidity. For patients with insufficient abdominal fat for DIEP breast reconstruction, secondary
options such as GAP flap or implant reconstruction are usually considered. For patients with need for autogenous reconstruction of
a single breast and heretofore insufficient abdominal fatty volume, we present a new option that allows for incorporation of the entire
abdominal fatty composite with chimeric linkage and stacked inset of two individual abdominal flaps. The ability to take advantage of
the entirety of the abdominal donor volume allows those with relatively thin body habitus to enjoy candidacy for DIEP reconstruction.
Sophisticated microsurgical technique transcends procedures with similar goals such as the bipedicled TRAM flap by avoiding muscle
sacrifice and allowing precise, independent flap inset. We describe our experience with this technique in 50 patients with 100 flaps over
2 years.
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