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

The Incorporation of Biologics and Free Flaps in My First One Hundred Lower Extremity
Procedures
Institution where the work was prepared: Medical College of Wisconsin, Milwaukee, WI, USA
Robert Whitfield, MD; Medical College of Wisconsin
Lower extremity reconstruction involves in many instances multiple methods to gain a stable soft tissue envelope. This may involve local
tissue rearrangement, skin grafting, rotational muscle flaps with or without skin grafting and free muscle flap with skin graft. One hundred
lower extremity procedures were performed on 49 patients, 34 males and 15 females. Evaluation of the first 100 lower extremity
procedures in my practice showed that this was not entirely true. Of those patients, eighteen, who required free tissue transfer, 57%
(15/26) of the flaps utilized were perforator flaps, 3 Deep Inferior Epigastric Artery Perforator (DIEAP) flaps and 12 Anterolateral Thigh
(ALT) flaps. There was one complete flap loss due to damage of the perforator during the dissection. Also there were two cases of
venous congestion requiring reoperation and in one case vein grafting. Both of these flaps suffered partial flap necrosis of approximately
25% and 33% respectively. In those patients where muscle flaps were used, 43% (11/26), there were two complete flap failures secondary
to venous thromboses. In both instances the flaps that failed were latissimus dorsi muscle free flaps. In one case the contralateral
latissimus was used for salvage. In the other case a free Transverse Rectus Abdominus Myocutaneous (TRAM) flap ultimately was
chosen secondary to the patient's difficulty dealing with the donor site of the initial latissimus flap harvest. In addition the use of biologics,
both Integra and Alloderm, have been usefull in the management of these patients. In 50% (6/12) ALT flaps Integra was used to
cover exposed blood vessels or to use as coverage for partially debrided flaps. In 16% (2/12) alloderm was used in addition to an ALT
flap to reconstruct the lower extremity over an orthopedic prosthesis. Integra was used in 45% (5/11) as temporary coverage of muscle
flaps. Based on this early experience perforator flaps and biologics are reliable and can be a useful adjuncts in the algorithm of treating
lower extremity injuries.
Navigating the DIEP SIEA: A Perforator Progression Algorithm for Microsurgical Breast
Reconstruction
Institution where the work was prepared: University of Chicago Medical Center, Chicago, IL, USA
Charles Y. Tseng, MD; Amir H. Dorafshar, MD; David H. Song, MD; University of Chicago Medical Center
BACKGROUND:
An increasing number of women are undergoing breast reconstruction due to increased awareness, screening, and improved surgical
technique. SIEA, DIEP, and MS-TRAM free flaps reliably replace and closely approximate the look and feel of lost breast tissue. Among
the alternatives for autologous breast reconstruction, the SIEA flap provides the least donor-site morbidity, as dissection of the rectus
abdominis sheath and muscle is not required. However, because of inconsistencies in the existence and size of the SIE artery, its use is
limited. In previous reports, free flap breast reconstruction using the SIEA flap is about 30-40%
PURPOSE:
To perform a prospective study of the reliability and outcomes of SIEA, DIEP, and MS-TRAM free flap reconstruction and develop an
algorithm for flap selection in autologous breast reconstruction that the developing reconstructive microsurgeon will find useful.
METHODS:
From January 2005 - 2007, 61 consecutive patients underwent SIEA, DIEP, or MS-TRAM free flap breast reconstruction utilizing a specific
algorithm. 66 flaps were used in 56 unilateral and 5 bilateral breast reconstructions. Patient demographics, procedure type, diagnosis,
adjuvant treatment, and complications were recorded.
RESULTS:
22 SIEA (33%), 35 DIEP (53%), and 9 MS-TRAM (13%) free flap breast reconstructions were performed. Fat necrosis was observed in 2
SIEA (9%), 3 DIEP (8.5%), and 1 MS-TRAM (11%) flap. Other complications included 4 intraoperative anastomotic avulsions in the SIEA
group, 1 complete flap loss in the DIEP group, and 1 hematoma in the MS-TRAM group.
CONCLUSION:
This prospective study compares the reliability and outcomes of SIEA, DIEP, and MS-TRAM free flaps in breast reconstruction. Similar
to previous reports, we find that the SIEA flap can be employed in about 30% of cases to achieve breast reconstruction equal in aesthetic
quality to that achieved with DIEP and MS-TRAM flaps while decreasing abdominal donor-site morbidity. Based on the experience
gained from this study and the data collected, we present an algorithm for flap selection in autologous breast reconstruction incorporating
the MS-Free TRAM, DIEP, and SIEA flaps. It is our hope that this algorithm will be useful to the developing microsurgeon.
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