Breast reconstruction with the internal mammary artery pedicled fasciocutaneous island flap: description of a new flap

Postburn skin contracture of the inframammary sulcus is a commonly encountered problem, especially in pubescent girls. Release of these contractures is commonly performed by split-thickness skin grafts, which necessitate further operations as the child grows. If the contracture of the inframammary sulcus is only one-sided, then the inframammary tissues of the contralateral breast can be used for reconstruction with the fasciocutaneous island flap. The donor site can be closed primarily without disrupting the appearance of the healthy breast, and the skin incision is hidden in the inframammary sulcus. The flap described here is a fasciocutaneous island flap based on the internal mammary artery and the perforating branches to the skin and subcutaneous tissues that the artery gives off as it leaves the thoracic cavity through the seventh intercostal space. After being supported by fresh cadaver and angiographic studies, the flap was applied to seven female patients (four of whom were pubescent) with burn contracture of the breast; satisfactory results were obtained. In defects of the mammary region that required volume or for which repair by skin grafting was planned, in sternal defects, or in young patients, this flap seems to be the best choice.     

Arterial end-to-side grafting in coronary artery bypass grafting: the Tector procedure

Background. The current treatment of choice in patients with three-vessel coronary disease is coronary artery bypass grafting. The use of the left internal mammary artery in bypass grafting has shown superior long-term outcomes compared with venous grafting. In our study we assess the safety and feasibility of all-arterial coronary artery bypass graft surgery using the procedure as described by Tector et al. in 2001.Methods. Between June 2001 and February 2007, we studied 133 patients eligible for non-emergency surgical revascularisation. Primary endpoints were death or re-infarction within a 30-day period. Secondary endpoints were the need for emergency coronary surgery, angioplasty and mediastinitis. Long-term follow-up had a mean duration of 33 months postoperatively.Results. All 133 patients were successfully revascularised, 98% with the off-pump technique. In 93% of the patients (n=124) full arterial grafting was achieved using both internal mammary arteries. Thirty-day mortality was 1.5% (n=2), ten re-thoracotomies were performed, one myocardial infarction and one case of mediastinitis were reported. In the next four years six additional patients died. Most of these deaths were due to non-cardiovascular causes. Two patients required angioplasty because of distal bypass graft failure and one for new native coronary artery disease. Conclusion. All-arterial bypass grafting using both internal mammary arteries with the technique as described by Tector is safe and feasible without excess deep sternal wound infections. Late major adverse cardiac events are rare and due to distal graft dysfunction, which can be treated by percutaneous coronary intervention. (Neth Heart J 2010;18:7-11.)     

Outcomes in octogenarians undergoing coronary artery bypass grafting

Background

Although octogenarians are being referred for coronary artery bypass grafting (CABG) with increasing frequency, contemporary outcomes have not been well described. We examined data from 4 Canadian centres to determine outcomes of CABG in this age group.

Methods

Data for the years 1996 to 2001 were examined in a comparison of octogenarians with patients less than 80 years of age. Logistic regression analysis was used to adjust for preoperative factors and to generate adjusted rates of mortality and postoperative stroke.

Results

A total of 15 070 consecutive patients underwent isolated CABG during the study period. Overall, 725 (4.8%) were 80 years of age or older, the proportion increasing from 3.8% in 1996 to 6.2% in 2001 (p for linear trend = 0.03). The crude rate of death was higher among the octogenarians (9.2% v. 3.8%; p < 0.001), as was the rate of stroke (4.7% v. 1.6%, p < 0.001). The octogenarians had a significantly greater burden of comorbid conditions and more urgent presentation at surgery. After adjustment, the octogenarians remained at greater risk for in-hospital death (odds ratio [OR] 2.64, 95% confidence interval [CI] 1.95–3.57) and stroke (OR 3.25, 95% CI 2.15–4.93). Mortality declined over time for both age groups (p for linear trend < 0.001 for both groups), but the incidence of postoperative stroke did not change (p for linear trend = 0.61 [age < 80 years] and 0.08 [age ≥ 80 years]). Octogenarians who underwent elective surgery had crude and adjusted rates of death (OR 1.31, 95% CI 0.60–2.90) and stroke (OR 1.59, 95% CI 0.57–4.44) that were higher than but not significantly different from those for non-octogenarians who underwent elective surgery.

Interpretation

In this study, rates of death and stroke were higher among octogenarians, although the adjusted differences in mortality over time were decreasing. The rate of adverse outcomes in association with elective surgery was similar for older and younger patients.The population is rapidly aging, and an increasing number of octogenarians are being referred for coronary artery bypass grafting (CABG).^1,2 Previous single-centre reports from Canada^3,4,5 and from abroad^1,2,6,7,8have concluded that elderly patients undergoing cardiac surgery have worse outcomes than younger patients. In addition, these studies have reported higher costs and slower recovery for octogenarians undergoing CABG, a finding that has generated debate over the appropriate use of health care resources.^1,5,7,9It has become increasingly clear that the results of CABG among octogenarians, although worse than among younger patients, are better than for percutaneous coronary interventions or medical therapy alone when the extent of the patient''s coronary disease is such that revascularization with CABG is indicated.^10,11 Similarly, the superior results of percutaneous coronary intervention relative to medical therapy in elderly patients with coronary disease will likely continue to increase the total number of octogenarians undergoing coronary angiography, which in turn will probably increase the number of patients being referred for CABG.^10,12 Contemporary outcomes for octogenarians undergoing CABG in Canada have not been well described. If we are to have an informed debate and determine appropriate policy, it is important for these outcomes to be known.We aimed to describe the characteristics and outcomes of patients 80 years of age and older undergoing CABG in Canada and to compare their outcomes with those of younger patients. In addition, we examined changes in results over time.     

The inferior gluteal free flap in breast reconstruction

The inferior gluteal musculocutaneous free flap usually provides a sufficient amount of autogenous tissue for breast reconstruction when adequate tissue is not present in the lower abdomen or back. Its arteriovenous pedicle is longer than the superior gluteal musculocutaneous free-flap pedicle and permits microvascular anastomosis in the axilla, avoiding medial rib and cartilage resection. In the thin patient, there is more available donor tissue than with the superior gluteal musculocutaneous free flap. Cadaver dissections confirm the greater pedicle length and the local area of the lower gluteus maximus muscle needed to carry the skin island and have helped define a safe approach to flap elevation. We have used four flaps for breast reconstruction without vascular compromise or the need for reexploration. The low donor-site scar in the inferior buttock fold has been acceptable, especially for a bilateral reconstruction. The anatomy of the gluteal region, the surgical technique for the inferior gluteal free-flap transfer, and a 3-year patient follow-up are presented.