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Using the principles of sternal wound debridement and early flap coverage, the authors have achieved a significant reduction in mortality after sternal wound infection and have reduced the mean hospital stay after sternal wound closure of these critically ill patients. Further reductions in mortality will depend on earlier detection of mediastinitis, before onset of septicemia, and ongoing improvements in the critical care of patients with multisystem organ failure.

Inadequate tissue perfusion is a key contributor to early complications following reconstructive procedures. Accurate and reliable intraoperative evaluation of tissue perfusion is critical to reduce complications and improve clinical outcomes. Clinical judgment is the most commonly used method for evaluating blood supply, but when used alone, is not always completely reliable. A variety of other methodologies have been evaluated, including Doppler devices, tissue oximetry, and fluorescein, among others. However, none have achieved widespread acceptance. Recently, intraoperative laser angiography using indocyanine green was introduced to reconstructive surgery. This vascular imaging technology provides real-time assessment of tissue perfusion that correlates with clinical outcomes and can be used to guide surgical decision making. Although this technology has been used for decades in other areas, surgeons may not be aware of its utility for perfusion assessment in reconstructive surgery. A group of experts with extensive experience with intraoperative laser angiography convened to identify key issues in perfusion assessment, review available methodologies, and produce initial recommendations for the use of this technology in reconstructive procedures.

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Therapeutic mammaplasty is a useful procedure for shape and symmetry preservation in women with large or ptotic breasts. Versatility exists using various pedicles and skin patterns to reconstruct all breast shapes and defect locations. Younger patients with extensive DCIS are poor candidates for simultaneous reconstruction, and should be deferred until confirmation of negative margins. If surgical management of residual disease requires completion mastectomy, immediate reconstruction is possible, with skin preservation and no adverse effects.

Recent trends in breast reconstruction have transitioned toward the skin-sparing type of mastectomy and immediate reconstruction using autologous tissue. This study was designed to document trends in the management of patients with unilateral breast cancer and to determine how they influence management of the contralateral breast. All patients who underwent unilateral breast reconstruction at Emory University Hospitals from January of 1975 to December of 1999 were reviewed. The cohort was stratified by timing of reconstruction (immediate versus delayed), method of reconstruction, and mastectomy type (skin-sparing versus non-skin-sparing). The methods of reconstruction included implant, latissimus dorsi flap, and transverse rectus abdominis musculocutaneous (TRAM) flap. Contralateral procedures to achieve symmetry included augmentation, mastopexy, augmentation/mastopexy, and reduction. A total of 1394 patients were evaluated, including 689 delayed and 705 immediate reconstructions. Sixty-seven percent of delayed-reconstruction patients (462 of 689) had a symmetry procedure performed on the opposite breast, compared with 22 percent for the immediate-reconstruction patients (155 of 705) (p

Single-stage direct-to-implant reconstruction using a prepectoral approach appears to be a safe and effective means of breast reconstruction in many patients, assuming adequate skin perfusion is present.

This study provides a retrospective analysis of 60 patients who underwent thoracic reconstruction with the omentum. Patients were identified by searching several databases to determine demographics, indications for surgery, operative technique, and postoperative course, including donor and recipient site morbidity. From January 1975 to May 2000, the authors harvested and transferred the omentum successfully (57 pedicled, 3 free) in 60 patients (mean age, 60 years; age range, 21-86 years) for sternal wound infections (N = 34), chest wall resections (N = 17), pectus deformities (N = 2), intrathoracic defects (N = 4), and breast reconstruction (N = 3). The omentum was used as a primary flap in 39 patients and as a salvage flap in 21 patients. Average operative time was 3.9 hours and average hospital stay was 34.3 days. Partial flap loss occurred in 7 patients, with no total flap failures. Morbidity included six abdominal wound infections and seven epigastric hernias. Mortality was 11.7%. The omentum can be harvested safely and used reliably to reconstruct varying thoracic wounds and defects. Specific indications from this series include osteoradionecrosis, chest wall tumors, massive sternal wounds, and refractory mediastinitis. Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruction with the omentum: indications, complications, and results.