Background: Autologous breast reconstruction with deep inferior epigastric perforator flaps is considered a standard of care in the treatment after mastectomy, yet vascular anatomy is highly variable and perforator selection remains challenging. The use of preoperative imaging can influence surgical planning and assist intraoperative decision-making. However, this imaging can inevitably uncover incidental findings. The purpose of this study was to analyze incidental findings, evaluate correlation with patient factors, and examine effects on overall care. Methods: A retrospective review was performed on 350 consecutive patients who received magnetic resonance angiography (MRA) or computed tomographic angiography (CTA) as a preoperative evaluation for deep inferior epigastric perforator flap breast reconstructions done between August 2015 and June 2019. Radiology reports were analyzed for incidental findings. Patient charts were reviewed for patient history, genetic history, cancer treatment, and type of reconstruction. Results: Of the 350 patients meeting the criteria, 56.9% were noted to have incidental findings on preoperative imaging, 12.9% received additional imaging, and 4.0% underwent additional interventions. There was no difference in the percentage of patients with incidental findings between immediate and delayed reconstructions or between CTA and MRA. Five patients were found to have malignancies. Conclusions: Preoperative CTA and MRA is a valuable tool to optimize outcomes and efficiency in breast reconstruction with abdominal perforator flaps. However, this imaging can also be beneficial to the overall wellness of the patient. With the high prevalence of incidental findings on preoperative imaging, it is important to counsel patients and adjust surgical plans, if necessary.
Background Glioblastoma multiforme (GBM) produces a hypercoagulable environment and is associated the highest rates of deep venous thrombosis (DVT) and pulmonary emboli (PE) of any malignancy. The use of postoperative radiation in this generally compromised patient group is associated with the development of complex scalp wounds. Free tissue transfer reconstruction will be essential in selected cases despite the presence of an underlying hypercoagulable state. Methods A 67-year-old female with a history of previous DVT presented with osteoradionecrosis and infected scalp wound following GBM treatment. She underwent reconstruction with a free vastus lateralis flap and skin graft. Initial anticoagulation was provided with intravenous heparin and transitioned to oral apixaban. Wound cultures demonstrated coagulase-negative Staphylococcus, Actinomyces neuii, and Peptoniphilus harei and were treated with a 6-week course of intravenous cefepime and vancomycin. Results Despite the initial failure of a local scalp rotation flap, successful wound healing was achieved with a free muscle flap and a course of culture specific antibiotics. The patient succumbed to recurrent disease 22 months after surgery, underscoring the importance of limiting hospitalization and maximizing quality of life in this group of patients. Conclusion Free tissue transfer can be successfully achieved in the hypercoagulable GBM patient. Heparin and apixaban were employed successfully in the prevention of thrombotic events. Antiplatelet therapy should also be considered to counteract platelet aggregation induced by the transmembrane glycoprotein (podoplanin) that is expressed on GBM tumor cells. Enzyme-linked immunosorbent assay testing (ELISA) of blood soluble podoplanin may help determine the degree of hypercoagulability and guide therapy.
Introduction Fascia lata and tendon grafts are frequently utilized to support the paralyzed midface and to extend muscular reach in McLaughin style, orthodromic temporalis transfers. The grafts are frequently placed in a deep subcutaneous positioning that can lead to the development of a, bowstring deformity in the cheek. This paper describes insertion of tendon grafts into the midfacial corridor collectively formed by the buccal, submasseteric and superficial temporal spaces. Methods Over a seven-year period, all patients that underwent insertion of facia lata and tendon grafts in the midfacial corridor were included. Demographic information, perioperative variables and clinical outcomes were collected and analyzed. Results A total of 22 patients were included with a mean age of 64.3 years (33–86). There were multiple etiologies for the facial weakness including acoustic neuroma (9.1%), Bell's palsy (13.6%), facial nerve schwannoma (9.1%), temporal bone fracture (4.6%) and malignancy (22.7%). Midfacial corridor grafts were utilized in combination with nerve transfers (V-VII and XII-VII) in nine patients, McLaughin style temporalis transfers in 12 and as a standalone procedure in one individual. During the study period, no patients exhibited a tethering, or concave deformity in the midface. Additionally, no impingement, difficulties with mastication, parotitis or hematoma were encountered. One patient developed a postoperative infection, that was successfully managed. Conclusion Placement of tendon or fascia grafts for static support or tunneling of an orthodromic temporalis transfer through the midfacial corridor can be performed rapidly while providing midfacial support and avoiding the creation of visible cutaneous deformities.
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