Objective A chimerically configured gracilis and profunda artery perforator (PAP) flap is highly prevalent based on recent computed tomography (CT)-imaging data. The purpose of this study is to further characterize the vascular anatomy of this novel flap configuration and determine the feasibility of flap dissection. Materials and Methods To characterize flap arterial anatomy, lower extremity CT angiograms performed from 2011 to 2018 were retrospectively reviewed. To characterize venous anatomy and determine the feasibility of flap harvest, the lower extremities of cadavers were evaluated. Results A total of 974 lower extremity CT angiograms and 32 cadavers were included for the assessment. Of the 974 CT angiograms, majority (966, 99%) were bilateral studies, yielding a total of 1,940 lower extremities (right-lower-extremity = 970 and left-lower-extremity = 970) for radiographic evaluation. On CT angiography, a chimerically configured gracilis and PAP flap was found in 51% of patients (n = 494/974). By laterality, chimeric anatomy was present in 26% of right lower extremities (n = 254/970) and 25% of left lower extremities (n = 240/970); bilateral chimeric anatomy was found in 12% (n = 112/966) of patients. Average length of the common arterial pedicle feeding both gracilis and PAP flap perforasomes was 31.1 ± 16.5 mm (range = 2.0–95.0 mm) with an average diameter of 2.8 ± 0.7 mm (range = 1.3–8.8 mm).A total of 15 cadavers exhibited chimeric anatomy with intact, conjoined arteries and veins allowing for anatomical tracing from the profunda femoris to the distal branches within the tissues of the medial thigh. Dissection and isolation of the common pedicle and distal vessels was feasible with minimal disruption of adjacent tissues. Chimeric flap venous anatomy was favorable, with vena commitante adjacent to the common pedicle in all specimens. Conclusion Dissection of a chimeric medial thigh flap consisting of both gracilis and PAP flap tissues is feasible in a cadaveric model. The vascular anatomy of this potential flap appears suitable for future utilization in a clinical setting.
Introduction Autologous fat grafting (AFG) is a popular and effective method of breast reconstruction after mastectomy; however, the oncological safety of AFG remains in question. The aim of this study was to determine whether AFG increases the risk of cancer recurrence in the reconstructed breast. Methods A matched, case-control study was conducted from 2000 to 2017 at the senior author's institution. Inclusion was limited to female patients who underwent mastectomy and breast reconstruction with or without AFG. Data were further subdivided at the breast level. χ2 analyses were used to test the association between AFG status and oncologic recurrence. A Cox proportional-hazards model was constructed to assess for possible differences in time to oncologic recurrence. The probability of recurrence was determined by Kaplan-Meier analyses and confirmed with log-rank testing. Results Overall, 428 breasts met study criteria. Of those, 116 breasts (27.1%) received AFG, whereas 312 (72.9%) did not. No differences in the rates of oncologic recurrence were found between the groups (8.2% vs 9.0%, P < 1.000). Unadjusted (hazard ratio = 1.03, confidence interval = 0.41–2.60, P < 0.957) and adjusted hazard models showed no statistically significant increase in time to oncologic recurrence when comparing AFG to non-AFG. In addition, no statistical differences in disease-free survival were found (P = 0.96 by log rank test). Conclusion Autologous fat grafting for breast reconstruction is oncologically safe and does not increase the likelihood of oncologic recurrence. Larger studies (eg, meta analyses) with longer follow-up are needed to further elucidate the long-term safety of AFG as a reconstructive adjunct.
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Background: This retrospective study compared the change in serum creatinine between African American and Caucasian Total Knee Arthroplasty (TKA) patients. The authors hypothesized that African Americans would demonstrate significantly greater change, and that a significantly greater proportion would demonstrate creatinine changes consistent with acute kidney injury (AKI). Methods: Primary TKAs performed at a single institution between July, 2011-June, 2016 were identified: 1035 primary TKAs met inclusion and exclusion criteria (110 African American, 925 Caucasian, excluding Hispanic and Asian patients). None were excluded based on sex, age, BMI, preoperative diagnosis or comorbidities. All patients had pre-operative and post-operative creatinine levels available in the EMR. Each patient received the same pre-op and post-op protocol for NSAID use along with other drugs administered including anesthesia. All patients received 1 gram of IV (intravenous) vancomycin with some patients additionally receiving 1 gram of vancomycin powder administered locally at the end of surgery. All patients were controlled for fluid intake and blood loss, along with no patient receiving a transfusion or IV contrast. Patient demographics and pre/postoperative serum creatinine were recorded then analyzed for presence of AKI (≥0.3mg/dL). Pre/postoperative serum creatinine concentrations were compared between African American and Caucasian patients using 2×2 repeated measures ANOVA. Prevalence of patients in each group demonstrating AKI was calculated using Fisher Exact test. Results: African American patients had significantly greater serum creatinine preoperatively (1.00±0.26 vs. 0.90±0.22, p<0.001) and a significantly greater increase postoperatively (0.10 vs. 0.03, p<0.001). A significantly greater number of African American patients demonstrated AKI (10.9% vs. 5.1%, p=0.03). Furthermore, a significantly greater number of African American patients stayed in the hospital an additional 2 or more days for renal issues (2.7% vs. 0.4%, p=0.03).
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