Biomedical subjects
Publications and source records attributed to M A Schusterman.
Restoration of secondary deformities following mandible reconstruction is a difficult challenge. Prevention is sometimes possible by careful planning, but frequently these problems are unavoidable. Thoughtful analysis of the deformity and individualized treatment planning are key ingredients of proper management.
Advanced skin cancer of the head and neck is best managed by a multidisciplinary approach. The goal is to control the malignancy while maximizing function and aesthetics, and hence the quality of life, after therapy. As a member of the patient care team, the reconstructive surgeon brings specialized expertise in modern techniques of tissue transfer to provide the optimal restoration for patients following resection of the tumor. Microvascular surgery represents the current technical state of the art for reconstruction in these patients with advanced lesions.
This study was undertaken to elucidate the possible contribution of vessel anastomosis to the incidence of vessel thrombosis in an ischemia- reperfusion injury flap model in rabbits. Bilateral groin flaps were elevated on isolated vascular pedicles and rendered ischemic for 6 (n = 11), 8 (n = 5), 15.5 (n = 5), or 24 hr (n = 8). After the ischemic episode, an arterial anastomosis was performed on one side, and then perfusion was reestablished on both sides. Although the incidence of thrombosis increased with the interval of ischemia, there was no statistically significant difference in thrombosis rate between the two sides for any of the ischemia intervals studied. The authors conclude that the presence of an arterial anastomosis does not increase the rate of vessel thrombosis in flaps after primary ischemia-reperfusion injury in the rabbit model.
Resource costs, as measured by hours of time in the operating room, days of stay in the hospital, and other costs of care, were evaluated for 240 patients who underwent mastectomy with immediate breast reconstruction using either TRAM flaps or breast implants at The University of Texas M. D. Anderson Cancer Center. To make costs comparable, only patients who completed reconstruction of the nipple were included. As expected, the initial resource costs of implant-based reconstruction were much lower than those of TRAM flap reconstruction. After correcting for patients whose reconstructions were unsuccessful and including the costs of surgery subsequent to the initial reconstruction, however, the cost advantage of implant-based reconstruction disappeared. If current trends continue, it is likely that with increased follow-up, the long-term resource costs of implant-based reconstructions will continue to increase, while those of autogenous tissue reconstructions will not. Autogenous breast reconstruction with the TRAM flap therefore appears to be more cost-effective, in terms of time as well as dollars, in the long run than reconstruction based on prosthetic implants.
Tissue silicon assays were performed on 10 nonaugmented cadavers and 25 augmented women to confirm our previous cadaveric data and to establish silicon levels at local and distant sites in augmented women undergoing explant and further reconstruction. All assays were performed by inductively coupled plasma atomic emissions spectroscopy (ICP-AES). Cadaveric tissues were sampled from six sites: liver, spleen, breast, nipple, axilla (soft tissue and nodes), and subcutaneous tissue (abdominal). Augmented women undergoing explant surgery had a portion of their implant capsule, breast tissue, and for those undergoing autogenous reconstruction, a portion of the autogenous donor site or distant tissue sampled. Twenty-four women had silicone implants; one had saline. Results revealed baseline silicon levels in all 10 non-augmented cadavers. These results were equivalent to our previous data, confirming the validity of these baseline data. Silicon tissue levels in the 25 augmented women revealed elevated levels within the implant capsule and surrounding breast tissue. However, silicon levels obtained from distant sites in augmented women were equivalent to the baseline nonaugmented cadaveric levels. There was no correlation between intact or ruptured implants and symptoms of collagen-vascular disease. In conclusion, study validates our original data of baseline silicon levels in nonaugmented cadavers. Contrary to what some may perceive as silicone floating throughout the body, we have found elevated levels around the implant only, and levels at distant tissue sites were equivalent to the baseline cadaveric data.
Resource costs, which are the costs to the hospital of providing a service, were measured for 154 patients who underwent mastectomy and immediate breast reconstruction with TRAM flaps. Unilateral and bilateral reconstructions were evaluated separately. The resource costs required to perform mastectomy and reconstruction with free TRAM flaps were then compared with those required when conventional TRAM flaps were used. The mean total resource cost in the free TRAM group was slightly higher than in the conventional TRAM group, but the difference was small (4.1 percent) and not statistically significant (p = 0.290). The mean resource cost of performing bilateral mastectomy and reconstruction was higher than that of unilateral mastectomy and reconstruction, but the difference was only 5.0 percent (p = 0.046). This study shows that the cost to an institution of providing breast reconstruction with free TRAM flaps is not significantly higher than that of performing reconstruction with conventional TRAM flaps. Also, our findings show that the resource costs of performing bilateral mastectomy and reconstruction are not much higher than those of treating only one breast.
A review of 854 consecutive free flaps was performed to determine whether the choice of flap used for the reconstruction influenced the probability of a successful outcome. Flaps were grouped into nine categories: rectus abdominis, free transverse rectus abdominis myocutaneous, radial forearm, jejunum, latissimus dorsi, fibula, scapula, iliac crest, and other. There were significant differences among the success rates of different flaps (p < 0.0001). Rectus abdominis-based flaps used for breast or head and neck reconstruction had lower failure rates (0.9 percent) than did non-rectus abdominis flaps (6.6 percent; p < 0.0001). Flaps requiring vein grafts had a higher rate of flap loss (18.4 percent) than did flaps that did not require vein grafts (2.9 percent; p < 0.0001). There was a strong trend favoring survival of flaps without a bone component (compared with osteocutaneous flaps), and a weaker trend favoring survival of flaps in nonobese patients (compared with flaps in obese patients). Smoking, age, and previous irradiation had no significant effect on flap failure rates. Surgeons should consider the flap success rate as one (but not necessarily the most important) factor in choosing the best reconstruction for any individual patient.
A series of 990 consecutive free flaps was reviewed to determine how often pedicle thrombosis occurred, when it occurred, and if the timing of thrombosis detection had any relationship to the probability of flap salvage. The overall thrombosis rate was 5.1 percent, and the flap loss rate was 3.2 percent. The majority (80 percent) of thrombi occurred within the first 2 postoperative days. Only 5 thrombi (10 percent) were known to have occurred after the third postoperative day. No flaps that developed thrombosis after the third postoperative day were salvaged successfully. Had flap monitoring been discontinued after the first 3 postoperative days, our results in this series would have been unchanged. Thrombosis of the vein (54 percent) was more common than arterial thrombosis (20 percent) or thrombosis of both artery and vein (12 percent). Almost all purely arterial thrombi (90 percent) occurred before the end of the first postoperative day, whereas 41 percent of all venous thrombi occurred later. We conclude that arterial monitoring is most critical immediately after surgery. Beginning on the second postoperative day, venous monitoring becomes progressively more important to flap success. The cost-effectiveness of postoperative monitoring of free flaps is greatest during the first 2 days, after which it decreases significantly.
OBJECTIVES: To determine the complications of extensive cranial-base resection requiring free-tissue transfer (FTT) and the effect of these resections on local control and survival among patients with malignant neoplasms of the skull base. BACKGROUND: Before the advent of FTT, cranial-base surgery was often limited by our inability to adequately repair defects comprising communication between the central nervous system and upper aerodigestive tract. The use of FTT in cranial-base resections was therefore assessed to determine whether the improved procedure (ie, extensive resections) would improve local control and prolong survival. DESIGN: A retrospective review of 39 consecutive craniofacial resections with FTT reconstruction in patients with malignant neoplasms involving the cranial base. PATIENTS: All 39 patients had malignant neoplasms, including 20 squamous cell carcinomas, eight basal cell carcinomas, two melanomas, two neuroendocrine carcinomas, two adenoid cystic carcinomas, and various other malignant neoplasms. Resections involved the anterior, middle, or posterior cranial fossa in 19 patients (49%), 10 patients (26%), and three patients (8%) of cases, respectively. The remaining seven surgeries (18%) involved resection of more than one of these cranial base sites. RESULTS: Early (< 14 days after surgery) complications occurred in 14 (36%) of 39 patients. Major complications included failure of microvascular anastomosis (n = 1), pneumonitis (n = 3), perioperative myocardial infarction (n = 1), and cerebrovascular accident (n = 1). The microvascular anastomosis failure was promptly treated with surgical intervention. Two patients (5%) experienced late postoperative complications; one had cellulitis at the donor site, and the other had pneumonitis. No perioperative deaths or complications such as meningitis, epidural abscess, or tension pneumocephalus occurred. The 2-year disease-specific survival rate was 55%, and the 2-year local control rate, 49%; both were determined by the Kaplan-Meier method. The nine patients who died of their disease had a median survival of 9 months. Log-rank testing showed that pathologically positive margins and transdural pathology were the most significant predictors of local recurrence and death of disease. CONCLUSIONS: Contemporary surgical approaches provide an opportunity for wide surgical excision of dura and skull-base structures that normally separate the intracranial and extracranial cavities. These major skull-base resections can be reconstructed safely and effectively with FTT. Patients with malignant neoplasms of the dura and skull base should be approached with the understanding that transdural disease portends an increased risk of local recurrence and death of disease.
BACKGROUND: Resections of large malignancies involving the middle and upper thirds of the face and cranium result in complex defects, posing a difficult challenge for the reconstructive surgeon. Free tissue transfer may be the best means of reconstruction. METHODS: We reviewed 54 consecutive microvascular craniofacial reconstructions after tumor ablation performed at the University of Texas M.D. Anderson Cancer Center from May 1988 to September 1992. Information regarding patient characteristics, tumor stage and histology, history of prior therapy, the defect after tumor ablation, and the details of the reconstruction were entered in a microcomputer database at the time of the initial surgery. Free flap outcome, the number and type of complications, control of malignant disease, and the use of adjuvant therapy were recorded prospectively. RESULTS: Patients had defects of the scalp and cranium (15 of 50) or of the maxilla/orbit/cranial base (35 of 50) after resections for a variety of tumors. Immediate reconstruction was completed in 40 patients and delayed in 10. Prior therapy included surgery (39 of 50) and/or radiotherapy (35 of 50). The free flap success rate was 96% (52 of 54). In patients with successful flaps, significant wound complications occurred in 13.5% of patients (seven of 52) and donor site problems in 11.1% (six of 54) for an overall complication rate of 24.1% (13 of 54). There were no operative deaths or neurologic complications. The timing of surgery or a history of prior surgical therapy or radiotherapy did not significantly influence the complication rates. CONCLUSION: Free tissue transfers provide optimal restoration of large craniofacial defects resulting from cancer resection.
BACKGROUND: We describe the transpelvic rectus abdominis musculocutaneous flap for closing large, often irradiated, perineal defects in patients with cancer. METHODS: We studied 9 men and 17 women who underwent wide excision of advanced T3 and T4 tumors and who had preoperative chemotherapy, radiotherapy, or both. After tumor ablation, we used a transpelvic rectus abdominis musculocutaneous flap to fill pelvic dead space and primarily close the perineal wounds. Twelve simultaneous vaginal reconstructions were performed. RESULTS: Wounds healed promptly in 14 patients. Healing was delayed in the remaining 12 patients due to poor flap adherence to irradiated tissue beds (9), complete flap loss (2), or partial flap loss (1). Delayed healing was associated with the combination of obesity and prior irradiation. Other perioperative complications included localized abdominal wound infection (2), enterocutaneous fistula (1), and abdominal herniation (1). Local disease was controlled in 20 of 26 patients. Mean follow-up was 22 months. CONCLUSION: Transpelvic rotation of the rectus abdominis musculocutaneous flap facilitates healing large, difficult, perineal wounds, resulting from cancer ablation.
The internal oblique repair, a new method for repair of abdominal bulging following TRAM flap breast reconstruction, involves identification and repair of the internal oblique fascia. To assess the usefulness of this repair and to compare it with simple plication of the deep abdominal fascia, we retrospectively reviewed all abdominal bulge repairs performed by the first author over the past 7 1/2 years. Of 30 abdominal bulge repairs, the internal oblique repair was used in 14 patients and plication in 16 others. The bulge recurrence rate was lower after the internal oblique repair (21 percent) than after the plication repair (69 percent; p = 0.028). When synthetic mesh reinforcement was added to the internal oblique repair, the bulge recurrence rate dropped to 13 percent. We conclude that the internal oblique repair is the preferred technique for the correction of abdominal bulges secondary to TRAM flap breast reconstruction.
The incidence of postoperative abdominal bulge, hernia, and the ability to do sit-ups was reviewed in a series of 268 patients who had undergone free TRAM (FTRAM) or conventional TRAM (CTRAM) flap breast reconstruction. Minimum follow-up was 6 months. Patients were divided into four groups: unilateral FTRAM (FT1P; n = 123), double-pedicle bilateral FTRAM (FT2P; n = 45), single-pedicle CTRAM (CT1P; n = 40), and double-pedicle or bilateral CTRAM (CT2P; n = 60). The incidence of abdominal bulges (3.8 percent) and hernia (2.6 percent) was similar in the four groups. Synthetic mesh, however, was required for reinforcement of donor site closure twice as often in the CTRAM patients. The ability to perform sit-ups was greatest in the FT1P group (63.0 percent), slightly lower in the CT1P group (57.1 percent), still lower in the FT2P group (46.2 percent), and lowest in the CT2P group (27.1 percent; p = 0.0005). Patients reconstructed with an FTRAM flap were more likely to be able to do sit-ups (58.3 percent) than were those reconstructed with a CTRAM flap (38.2 percent; p = 0.0074). Patients who had only one muscle pedicle used were more likely to be able to do sit-ups (61.7 percent) than were those who had two muscle pedicles used (35.6 percent; p = 0.0003). We conclude that the incidence of abdominal bulge or hernia is relatively independent of the type of TRAM flap used and the number of muscle pedicles harvested. On the other hand, postoperative abdominal strength, as measured by the ability do sit-ups, is influenced significantly by both of these factors.
A review of systemic anticoagulant use in 517 free flap procedures was performed to determine the associated risk of hematoma formation. Patients were divided retrospectively (not randomly) into five groups: no anticoagulation (227 flaps, 5.3 percent hematomas), low-dose heparin bolus of 2000 to 3000 units and postoperative infusion at a rate of 100 to 400 units/hr for 5 to 7 days (192 flaps, 6.7 percent hematomas), intraoperative bolus of 5000 units of heparin without postoperative anticoagulation (46 flaps, 6.5 percent hematomas), high-dose heparin infusion at a rate of 500 to 1200 units/hr (30 flaps, 20 percent hematomas), and dextran 40 infusion at a rate of 25 ml/hr (22 flaps, 9.1 percent hematomas). Intraoperative blood loss was similar for all groups. The flap loss rate was lower in the bolus (1.0 percent) and low-dose (1.0 percent) heparin groups than in the no-anticoagulation group (4.4 percent), but this difference was not statistically significant. The pedicle thrombosis rate also was lower in the bolus (2.2 percent) and low-dose (2.1 percent) heparin groups than in the no-anticoagulation group (6.2 percent). A cause-and-effect relationship between the use of anticoagulants and flap loss or prevention of thrombosis could not be established. We can conclude, however, that the use of low-dose heparin does not increase significantly the risk of hematoma or intraoperative bleeding.
The aesthetic results of TRAM flap breast reconstructions were assessed in 237 consecutive breast cancer patients. Nine independent judges, none of whom were plastic surgeons or members of the reconstructive team, assigned an aesthetic score to each patient after viewing postoperative photographs. We found that bilateral reconstructions were aesthetically superior to unilateral reconstructions (p = 0.0013), that immediate reconstructions were aesthetically superior to delayed reconstructions (p = 0.0001), and that previous irradiation of the chest wall reduced the mean aesthetic score (p = 0.0010). We also found that the mean aesthetic score assigned to patients who had reconstructions with free TRAM flaps was superior to that assigned to those who had reconstructions with conventional TRAM flaps, but when tested by multiple regression analysis, this trend was not statistically significant (p = 0.2972).
Free jejunal transfer has been criticized by some surgeons as unreliable, poorly tolerant of radiation therapy, and associated with significant morbidity and dysphagia. To determine the validity of these criticisms, we reviewed 93 patients who underwent 96 free jejunal transfers for repair of circumferential pharyngoesophageal defects over a 5-year period. The free jejunal transfer success rate was 97 percent; all 3 failures were repaired with repeated free jejunal transfer. The complication rate was 57 percent (55 of 96); fistula (19 percent) and stricture (15 percent) were the most common complications. An oral diet was tolerated by 80 percent of patients; 85 percent of these resumed their diet within 2 weeks of surgery. Causes of dysphagia were multifactorial. Postoperative radiation therapy did not increase morbidity or dysphagia. The perioperative mortality rate was 2 percent. We conclude that free jejunal transfer is a reliable method of pharyngoesophageal reconstruction that has an acceptable morbidity rate and a low mortality rate. Postoperative radiation therapy is well tolerated by the free jejunal transfer.
Radiation therapy is used increasingly as a definitive or adjunctive treatment for cancer. Definitive irradiation allows functional preservation of structures critical to function. Adjunctive irradiation following surgical resection of the primary lesion treats regional lymph nodes and/or sites of primary extension at high risk for microscopic involvement. Specialized techniques can be applied to deliver higher total doses of irradiation and minimize late normal tissue effects to adjacent normal tissues. Local-regional tumor control combined with functional preservation represents the specific goals of radiation therapy applied alone or in conjunction with surgical resection.
The use of breast implants in irradiated patients is controversial. Recently, 39 irradiated implants were compared with 338 nonirradiated implants in 297 patients between January of 1975 and October of 1994 at The University of Texas M. D. Anderson Cancer Center. Tissue expanders and follow-up time of less than 6 months excluded patients from the study. Five groups of patients were identified. Group 1 consisted of 7 patients and 7 implants who received postoperative adjuvant radiotherapy after implant placement. Group 2 consisted of 5 patients and 7 implants who received preoperative adjuvant radiotherapy prior to implant placement. Groups 3 and 4 consisted of 2 and 12 patients (2 and 19 implants) placed beneath latissimus dorsi flaps who had postoperative and preoperative adjuvant radiotherapy, respectively. Group 5 contained 4 patients with 4 implants placed beneath a transverse rectus abdominis myocutaneous (TRAM) flap who had preoperative radiotherapy. All implants were placed submuscularly or beneath autogenous flaps. The average irradiated breast received 50 Gy. For statistical purposes, two categories were identified. Capsular contracture (Baker III or greater), pain, exposure, and implant removal in 6 of 14 implants that received radiotherapy were compared with similar complications in 33 of 266 implants without irradiation (p = 0.001). The second category contained 10 complications in 25 implants placed beneath autogenous reconstructions with radiotherapy compared with 6 of 72 similar complications in implants placed beneath autogenous reconstructions without radiotherapy (p = 0.000). Results showed that irradiation has significant negative effects on the reconstructive outcome with implants. Autogenous reconstruction did not appear to offer a protective role when placed over implants.(ABSTRACT TRUNCATED AT 250 WORDS)