Citations

Background: Foam-mediated external suction (FMES) has previously shown to improve tissue microcirculation. We hypothesized that preconditioning fasciocutaneous perforator flaps with FMES would augment perfusion and demonstrate greater capillary recruitment. Methods: Gluteal perforator flaps were designed on sixteen 400 g rats. Continuous FMES at −125 mm Hg was applied on one side (intervention) to precondition tissue for 5 days, with the contralateral side as a paired control. In group A, we assessed changes following pretreatment, after surgery, and 7 days postprocedure, and in group B, we evaluated changes during preconditioning alone. In group A (N = 8), control and intervention flaps were assessed using laser-assisted indocyanine green fluorescence angiography. In group B, flap regions were assessed using 4-dimensional computed tomographic angiography. All flaps were analyzed for microvessel density using micro–computed tomography and histological assessment using hematoxylin and eosin and CD3 immunohistochemistry. Results: Thirty-two flaps were included in this study (N = 16 intervention and matched controls). Four-dimensional computed tomographic angiography demonstrated 17% greater tissue perfusion in preconditioned flaps (mean, 78.7 HU; SD, 8.8) versus controls (mean, 67.3 HU; SD, 15.7; P < 0.01). Laser-assisted indocyanine green fluorescence angiography showed a 30% higher mean absolute intensity in preconditioned flaps versus controls (P < 0.01). Postsurgery mean absolute intensity in preconditioned flaps remained 21% higher than in controls (P = 0.03). Preconditioned flaps demonstrated a 2-fold increase in mean vessel volume of 9.1 mm3 (SD, 7) versus 4.5 mm3 (SD, 3) in controls (P = 0.04); there was a 33% higher mean area fraction of CD31 in preconditioned flaps, 3.9% (SD, 3) versus 2.9% (SD, 3) in controls (P = 0.03). Conclusion: FMES preconditioning has the potential to augment vascularity of tissue for flap harvest; however, further experimental studies are required to optimize strategies and evaluate long-term effects for clinical applications.

Background: The authors compared long-term health care use and cost in women undergoing immediate autologous breast reconstruction and implant-based breast reconstruction. Methods: This study was conducted using the OptumLabs Data Warehouse, which contains deidentified retrospective administrative claims data, including medical claims and eligibility information from a large U.S. health insurance plan. Women who underwent autologous or implant-based breast reconstruction between January of 2004 and December of 2014 were included. The authors compared 2-year use rates and predicted costs of care. Comparisons were tested using the t test. Results: Overall, 12,296 women with immediate breast reconstruction were identified; 4257 with autologous (35 percent) and 8039 with implant-based (65 percent) breast reconstruction. The proportion of autologous breast reconstruction decreased from 47.2 percent in 2004 to 32.7 percent in 2014. The mean predicted reconstruction cost of autologous reconstruction was higher than that of implant-based reconstruction in both unilateral and bilateral surgery. Similar results for mean predicted 2-year cost of care were seen in bilateral procedures. However, in unilateral procedures, the 2-year total costs were higher for implant-based than for autologous reconstruction. Two-year health care use rates were higher for implant-based reconstruction than for autologous reconstruction for both unilateral and bilateral procedures. Women undergoing unilateral implant-based reconstruction had higher rates of hospital admissions (30.3 versus 23.1 per 100; p < 0.01) and office visits (2445.1 versus 2283.6 per 100; p < 0.01) than those who underwent autologous reconstruction. Emergency room visit rates were similar between the two methods. Bilateral procedures yielded similar results. Conclusion: Although implant-based breast reconstruction is a less expensive index operation than autologous breast reconstruction, it was associated with higher health care use, resulting in similar total cost of care over 2 years.

Background: The superficial femoral artery and medial thigh region has been an underused donor site for perforator flaps. This study evaluated perforasomes of the superficial femoral artery and its principal branches to review the clinical applications for locoregional reconstruction. Methods: Twenty-six fresh cadaveric lower extremities were dissected. Perforator size and anatomical course from the superficial femoral artery, descending genicular artery, and saphenous artery branch were documented. Perforators were selectively injected with iodinated contrast to assess vascular territories using computed tomography. A retrospective chart review was conducted on consecutive patients (2014 to 2015). Results: One hundred thirty perforators were mapped in the medial thigh region. Eleven extended medial thigh perforator flaps and 15 hemicircumferential flaps were harvested. The mean distance from the joint line was 16.7 ± 7.3 cm. Perforators arose from the superficial femoral artery (62 percent), saphenous artery branch (23 percent), and descending genicular artery (15 percent). Superficial femoral artery perforators were located around the mid and proximal thigh region (p < 0.001). The median perforasome surface area was 244 cm2, representing 36 percent in hemithigh flaps with preferential filling in the anteromedial region. Proximal perforasomes were the smallest. Perforasome areas based on vessel origin were comparable; however, saphenous artery perforators had a broader perforasome compared with descending genicular (p = 0.01) and superficial femoral artery perforators (p = 0.04). Six clinical case examples were presented for knee, thigh, and lower leg reconstruction. Conclusions: The superficial femoral artery or its branches can provide nontraditional reconstructive perforator flap options in regional reconstruction. They can be simple to harvest using a free-style approach, do not require preoperative imaging, offer a one-stage reconstructive method with low morbidity, and obviate the need for microsurgery or muscle flaps.