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An illustration of serratus fascia in use in strattice and implant based breast reconstruction.
Since the introduction of ADM in breast reconstruction its use has significantly grown. Several advantages including better pocket control, reduced implant visibility and improved implant coverage have been attributed to its use. In our experience combination of serratus fascia and strattice provides an improved lateral pocket control. The serratus fascia has been successfully used in breast augmentation and reconstructive surgery for expander implant and as an autologous conjoint fascial flap to cover implants in breast reconstruction1e3 however, it’s use in combination with strattice has not been described before. Anatomically, the serratus fascia is the continuation of pectoralis fascia superomedially, rectus fascia inferomedially and axillary fascias superiorly. The serratus fascia offers several advantages. It is readily available and provides well vascularised autologous tissue which can be used for inferolateral coverage of an implant. It is robust, yet more expandable than Strattice therefore yielding a more aesthetically pleasing breast contour (Figures 1e2). Since the dissection is straightforward it does not add any significant time to the surgery or morbidity as the underlying Serratus muscle is left untouched. In patients with small to medium size breasts incorporation of serratus fascia also reduces the amount of strattice required for implant coverage, potentially curtailing the cost especially in patients undergoing bilateral immediate breast reconstructions since one piece can be halved and used for both breast. The senior author has used the Serratus fascia in 42 breast reconstructions in 31 patients (since 2011) without complication. In summary the Serratus fascia provides good pocket control and aesthetically pleasing contour in immediate implant and strattice breast reconstruction with minimal additional dissection or morbidity.
References 1. Kim YW, Kim YJ, Kong JS, et al. Use of the pectoralis major, serratus anterior, and external oblique fascial flap for immediate one-stage breast reconstruction with implant. Aesthet Plast Surg 2014 Aug;38(4):704e10. 2. Saint-Cyr M, Dauwe P, Wong C, et al. Use of the serratus anterior fascia flap for expander coverage in breast reconstruction. Plast Reconstr Surg 2010 Apr;125(4):1057e64. 3. Graf RM, Bernardes A, Rippel R, et al. Subfascial breast implant: a new procedure. Plast Reconstr Surg 2003 Feb;111(2):904e8.
Muhammad Javed Cathy Malcolm Dai Nguyen Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, SA6 6NL, United Kingdom E-mail address: [email protected]
ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.05.042
Comparison of perioperative outcomes of autologous breast reconstruction surgeries* Dear Sir,
Conflict of interest Authors have no conflict of interest.
Acknowledgement We would like to thank Steve Atherton (Medical Illustration department, Morriston Hospital, Swansea).
Over the last decade, there has been a significant increase in the number of breast reconstructions performed after * 1. This study was presented as oral presentation at the California Society of Plastic Surgeons 64th Annual Meeting, May 25, 2014, at the Marriott Hotel & Spa, Newport, California. 2. This study was presented as part of poster presentation session at the American Association Plastic Surgeons 92nd annual meeting, April 20-23, 2013, at the Roosevelt Hotel, New Orleans, Louisiana.
Correspondence and communications
mastectomy, with a substantial portion of these procedures utilizing autologous tissue.1 The purpose of this study was to conduct a multicenter analysis of autologous breast reconstruction using the National Inpatient Sample (NIS) database to compare the various methods of autologous breast reconstruction with respect to (1) incidence of perioperative complications and (2) economic impact as defined by length of hospital stay and related hospital charges. Using the NIS database, discharge data related to patients who underwent autologous breast reconstruction surgery from 2009 until 2010 was analyzed. We used the International Classification of Disease ninth revision, Clinical Modification (ICD-9-CM) procedure codes for autologous breast reconstructions including the latissimus dorsi myocutaneous flap (LDF), the pedicled transverse rectus abdominis myocutaneous flap (P-TRAM), the free transverse rectus abdominis myocutaneous flap (F-TRAM), the free deep inferior epigastric artery perforator flap (DIEP), the free superficial inferior epigastric artery flap (SIEP), the free gluteal artery perforator flap (GAP) and others including non-otherwise specified to identify patient populations. Preoperative factors that were analyzed are described in Table 1. Postoperative complications, length
of hospital stay and total hospital charges among different types of autologous breast reconstructions were compared. Chi-square and t-tests were performed with SAS version 9.3. Statistical significance was achieved at a p-value <0.05. During 2009 to 2010, a total of 35,883 patients underwent autologous breast reconstruction in the United States, the majority of which were performed at teaching hospitals (74.3%). The most common breast reconstruction type was the LDF (29.4%) and the least common was the GAP flap (0.6%) (Table 1). The lowest perioperative complication rate was observed in the LDF group (7.6%) and the highest in the SIEA flap group (19.6%) (Table 2). The shortest, mean length of hospital stay was 2.9 days in LDF group, and the lowest, mean total hospital charges were also observed in the LDF group ($44,873). This study highlights the LDF as the most commonly used reconstructive method compared to the alternative pedicled and free flap techniques. The popularity of LDF can be attributed to several factors including the relative simplicity of the procedure, reliability of its blood supply and decreased postoperative morbidity.2 In a recent study by Gart et al.3 examining outcomes of autologous breast reconstruction in 3296 patients, the LDF constituted 32.7%
Characteristics of patients who underwent autologous breast reconstruction in the United States in 2009e2010.
Number % Age (year) Mean Median Mode Over 65 (%) Race (%) White Black Hispanic AsianyIslander Native American Other Comorbidity (%) Diabetes mellitus Hypertension CHF Chronic lung disease Chronic kidney disease Liver disease PVD Smoker Obesity Teaching hospitals (%) Immediate reconstruction (%) Prior chemotherapy (%) Prior radiation (%)
52.1 10.6 52 52 12.7
51.6 9.5 52 52 9.0
50.8 9.2 51 47 7.2
49.6 8.7 50 52 3.9
48.8 8.2 48 47 1.8
50.0 9.6 50 40 7.3
72.7 12.2 7.5 1.9 0.30 2.4
70.5 12.5 10.0 3.5 0.40 3.1
69.9 13.0 9.6 3.8 0.19 3.5
71.5 10.0 10.9 3.7 0.23 3.6
72.9 3.3 11.0 3.4 0.0 9.4
91.3 2.8 2.5 3.4 0.0 0.0
7.7 26.1 0.74 10.3 0.34 0.41 0.56 17.5 7.7 66.1 31.2 4.5 14.2
6.0 27.6 0.44 7.1 0.33 0.41 0.28 15.5 5.7 72.1 41.2 6.7 14.1
6.7 25.3 0.30 7.5 0.15 0.94 0.38 15.9 7.3 75.9 41.6 5.4 9.2
4.8 21.4 0.20 7.0 0.18 0.44 0.26 11.7 7.7 85.1 43.3 5.0 9.0
1.5 22.4 0.0 8.4 0.0 0.0 1.5 16.2 4.8 95.5 50.8 4.7 4.6
2.2 12.2 0.0 4.8 0.0 0.0 0.0 10.7 2.2 77.7 45.7 5.0 6.6
LDF indicates latissimus dorsi myocutaneous flap; P-TRAM, Pedicled transverse rectus abdominis myocutaneous flap; F-TRAM, Free transverse rectus abdominis myocutaneous flap: DIEP, Free deep inferior epigastric perforator flap; SIEA, Free superficial inferior epigastric artery flap; GAP, Free gluteal artery perforator flap; CHF, Congestive heart failure; PVD, Peripheral vascular disease, US, United States.
Correspondence and communications Table 2 Outcomes
Perioperative outcomes of autologous breast reconstruction in the United States in 2009e2010. LDF
Postoperative Complications (%) Urinary tract infection 0.69 Pneumonia 0.19 AKD 0.43 Respiratory failure 0.61 VTE 0.08 MI 0.09 CVA 0.05 Wound infection 0.33 Wound dehiscence 1.4 Bleeding 0.33 Hematoma 1.4 Seroma 1.4 Flap complication rate 1.7 Complication rate (%) 7.6 In-hospital mortality (%) 0.09 LOS (day) Mean 2.9 2.7 Median 2.0 Mode 2.0 Total hospital charges ($) Mean 44,878 Median 37,139
0.95 0.90 0.67 0.89 0.26 0.0 0.06 0.53 0.78 0.39 1.6 0.90 1.4 7.9 0.0
0.56 0.64 0.46 1.0 0.08 0.07 0.0 0.69 0.92 0.60 3.2 0.94 2.6 9.8 0.09
0.76 0.19 0.12 1.2 0.19 0.0 0.0 0.64 0.31 0.88 3.1 0.97 3.7 10.4 0.0
0.0 0.0 0.0 5.0 0.0 0.0 0.0 0.0 3.4 4.6 10.0 0.0 13.0 19.6 0.0
0.0 2.2 0.0 5.1 0.0 0.0 0.0 0.0 0.0 2.8 5.3 0.0 5.0 15.5 0.0
4.3 4.3 4.0 3.0
4.7 2.8 4.0 4.0
4.6 2.7 4.0 4.0
4.6 1.9 4.0 4.0
5.2 2.9 4.0 4.0
AKD: Acute kidney disease; VTE, Venous thromboembolism; MI, Myocardial infarction; CVA, Cerebrovascular accident; LOS, Length of hospital stay.
of all autologous reconstructions, similar to the 29.4% described here. However, the authors reported a greater proportion of P-TRAM flaps (48.8%) than what was discovered in this study (20.2%). The lower percentage of P-TRAM flaps in our study may be explained by the relatively high percentage of autologous free flap reconstructions (42.4% versus 18.5%).3 If microvascular capabilities are available at a particular hospital, it is likely that free tissue transfer would be the preferred reconstructive technique over pedicled abdominal flaps. In contrast, a recent survey of five-hundred ASPS members by Kulkarni et al.4 concluded that only 20.4% of the reported autologous breast reconstructions were free flaps. The higher rate of free flaps observed in our study may be due to a heavier sampling of academic hospitals. The lowest overall complication rate was in the LDF group (7.6%), correlating with the study by Gart et al. (7.1%).3 The robust vascular supply, relative simplicity of the procedure and the shorter operating times associated with the LDF may explain these results. However, as the majority of LDF reconstructions utilize implants to augment volume, complications such as capsular contracture need to be evaluated to provide a more accurate assessment of the overall morbidity of the LDF. As the NIS database does not differentiate between implant and non-implant LDF reconstructions, this confounding factor could not be completed addressed in this study. Overall, the free flap perioperative complication rates in our study were lower than those reported in other series.5 It should be noted that the NIS database only aggregates patient information pertaining to the initial
hospital stay and does not record complications encountered in post-operative outpatient visits, which may confound the analysis. Furthermore, the limited follow-up period may also affect overall cost of reconstruction with regards to secondary procedures and may also underestimate donor site morbidity. Although the safety of reconstruction is the primary driving force, important clinical data objects such as patient satisfaction, psychosocial effects and aesthetic results were not available in the curated data. These alternative endpoints are important factors to consider were determine overall reconstruction outcomes. In addition as a result of retrospective study, we were unable to identify the rational of selecting reconstruction type. Our results indicate that the LDF was the most commonly performed autologous breast reconstruction surgery from 2009 to 2010, and was associated with the lowest complication rate, shortest hospital stay and lowest total hospital charges, suggesting it remains a stalwart among the newer, more complicated reconstructive techniques.
Disclosure/conflict of interest None of the authors has a financial interest in any of the products, devices, or drugs mentioned in the manuscript. Also, this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. This is a retrospective study using the Nationwide Inpatient Sample (NIS) database. In this database, patients are
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not identifiable. Approval for use of the NIS patient-level data in this study was obtained from the Human Research Protection (HRP) of the University of California, Irvine Medical Center and the NIS. We have mentioned this statement in our manuscript in the Methods and Material section.
References 1. American Society of Plastic Surgeons. Reconstructive breast procedures, http://www.plasticsurgery.org/Documents/newsresources/statistics/2012-Plastic-Surgery-Statistics/full-plasticsurgery-statistics-report.pdf; 2012 [accessed 13.10.13]. 2. Hammond DC. Latissimus dorsi flap breast reconstruction. Clin Plast Surg 2007;34(1):75e82 [abstract vievii]. 3. Gart MS, Smetona JT, Hanwright PJ, et al. Autologous options for postmastectomy breast reconstruction: a comparison of outcomes based on the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg 2013; 216(2):229e38. 4. Kulkarni AR, Sears ED, Atisha DM, et al. Use of autologous and microsurgical breast reconstruction by U.S. plastic surgeons. Plast Reconstr Surg 2013;132(3):534e41. 5. Vega SJ, Bossert RP, Serletti JM. Improving outcomes in bilateral breast reconstruction using autogenous tissue. Ann Plast Surg 2006;56(5):487e90 [discussion 490e481].
Hossein Masoomi Department of Surgery, University of California, Irvine, Medical Center, Orange, CA, USA Garrett A. Wirth Keyianoosh Z. Paydar Ara A. Salibian Donald S. Mowlds Gregory R.D. Evans Department of Plastic Surgery, University of California, Irvine, Medical Center, Orange, CA, USA E-mail address: [email protected]
ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Figure 1 Rat femoral artery and vein on back ground seat with crack scale.
vessels and lymph ducts from surrounding tissues. Sutures can be handled easily during anastomosis by holding them in a cut notch of the background sheet. The thrombosis risk of silicone sheet was reported,5 but we have never experienced such undesirable influence. For effective anastomosis, precise measurement of vessel diameter is also important. Especially in supermicrosurgery, we must select the vessel and lymph duct that are precisely fitting in size each other. The sutures size affects the quality of anastomosis, so we usually measure their diameters before anastomosis and select suitable sutures. The vessel diameter is often measured by bringing a ruler or a crack scale close to the vessels. However, precise measurement is difficult because of the distance between the ruler and the vessels. Precise measurement can be accomplished if a scale is printed on the background sheet. There is already a background sheet with cross stripes by 1 mm, but it is not suitable for lymphaticovenular anastomosis because the diameter of lymphatic vessels is between 0.3 mm and 0.8 mm2,3 We developed a background sheet with a crack scale printed on it. A crack scale is usually used for measuring the width of fine cracks on walls or floors. This time we adopted a new measurement method using a background sheet with a crack scale by 0.1 mm. Precise measurement of vessels is possible by comparing the vessels with lines of crack scale (Figure 1).
Conflicts of interest
Precise measurement using a new background sheet with crack scales for super microsurgical anastomosis Dear Sir, Recently, with advancement of microvascular surgery, microvascular anastomosis is becoming an essential skill for plastic and reconstructive surgeons.1 Various techniques and tools have been developed for more effective anastomosis.2e4 One of important tools is a background sheet made of silicone or rubber, useful for distinguishing and separating
References 1. Koshima I, Narushima M, Yamamoto Y, Mihara M, Iida T. Recent advancement on surgical treatments for lymphedema. Ann Vasc Dis 2012;5(4):409e15. 2. Yamamoto T, Yoshimatsu H, Narushima M, et al. A modified side-toend lymphaticovenular anastomosis. Microsurgery 2013;33:130e3. 3. Yamamoto T, Narushima M, Kikuchi K, et al. Lambda-shaped anastomosis with intravascular stenting method for safe and