The April 2016 #PRSJournalClub Wrap-Up: Impact of Prior Tissue Expander/Implant on Postmastectomy Free Flap Reconstruction

by M. Shuja Shafqat, MD

The April edition of #PRSJournalClub – led by Resident Ambassadors to the PRS Editorial Board Raj Sawh-Martinez (@docrfsm), Amanda Silva (@AmandaKSilvaMD), and Sammy Sinno (@sammysinnoMD) – was yet another example of how the PRS Journal Club is so powerful and why it is so important. The entire team should be congratulated on a job well done and it is clear that each month is getting bigger and better.

This months article is from the Division of Plastic and Reconstructive Surgery at the University of California, Los Angeles. The article is excellent and is a must read for all plastic surgery residents and plastic surgeons performing breast reconstruction. The article is then discussed on the podcast with all the resident ambassadors and Dr. Jeff Janis, Vice Chairman of Plastic Surgery at the Ohio State University.

For those that are unfamiliar with what PRS Journal club is, 3 articles in each month’s edition of PRS are designated as journal club articles.

  • Each of the articles, along with paired classic PRS articles, are available for FREE on PRSJournal.com. All of these articles are must reads!
  • Each of the articles has an accompanying podcast discussion of the article with an expert! These are available on our website, iTunes, and the PRSJournal YouTube channel.
  • One of the articles is chosen for a live social medial Q&A and discussion via Twitter using the #PRSJournalClub hashtag. This month’s discussion was another great one.

Here is a summary of the top tweets from the Q&A for all those who missed the live chat or want to re-visit any of the participants answers!

The article:  Impact of Prior Tissue Expander/Implant on Postmastectomy Free Flap Reconstruction

The authors:

Dr. Jason Roostaeian (@DrJasonPlastics)

Dr. Alfred Yoon (@YoonAlfred)

Shannon Ordon

Dr. Chris Gold

Dr. Christopher Crisera

Dr. Jaco Festekjian (@FestekjianJaco)

Dr. Andrew Da Lio

Dr. Joan Lipa

 

Discussion points:

Image1Image2Image3Image4Image5Image6

The Best Tweeted Q&A:

  1. Question: Raj Sawh-Martinez – Did patients prefer implant reconstruction or were they not candidates for autologous reconstruction?

Answer: Jason Roostaeian – Patients mostly chose implant reconstruction but are routinely offered autologus reconstruction unless body habitus is unsuitable

 

  1. Question: Pallab Chatterjee – Did you have any patients who required flap reconstruction that had ADM covered implants?

Answer: Jason Roostaeian – Yes the majority of patients had ADM at the time of TE/implant placement

 

  1. Question: Rizwan Sheikh – What percent of implant cohort was TE/implant + flap or mostly prostesis+ADM

Answer: Alfred Yoon – The majorty if patients had prosthesis + ADM at the time of implant placement

 

  1. Question: Amanda Silva – Do you think these patients had adequate education on initial breast reconstruction options?

Answer: Alfred Yoon: All patients who undergo breast reconstruction are counceled about the risks and benefits of both reconstruction options

 

  1. Question: Pallab Chatterjee – Did you find the effects of radiation therapy going deep up to the IMA?

Answer: Alfred Yoon – Not observed directly. Vessel scarring likely due to prior prosthesis not radiation therapy

Follow up: Pallab Chatterjee- Thank you, Sir! But how can prosthesis affect deep IMA and cause vessel scarring?

Answer: Jason Roostaeian – There is periprosthetic inflammation and compression of the ribs during TE expansion that likely accounts for IMA fibrosis

Answer: Alfred Yoon – Potentially due to compressive forces during TE process or foreign body reaction

Reply: Daniel Liu – With increased prepectoral implant/TE placement, hopefully we’ll see less of this in delayed-IMM

Follow up: Jordan Frey – Have you done any prepectoral implants? How do you select patients/assess masectomy flaps?

Replay: Daniel Liu – Yes, when anticipating delayed-immediate free flap and skin is clinically viable +/- ICG angiography

 

  1. Question: Amanda Silva – Think there’s a big difference between delayed & failed implant reconstruction? Is problem scar or capsule +/- pressure from implant?

Answer: Alfred Yoon – Chest wall changes + inflammatory process from failed implant/radiation = more difficult than just delayed

 

  1. Question: Sammy Sinno – Given the difficulty of secondary reconstruction, should it have its own CPT code?

Answer: Jason Roostaeian – An argument for this could definitely be made. Another option is to use the -22 modifier

Reply: Jaco Festekjian – I have tried the modifier 22 with limited success

Reply: Jaco Festekjian – I have used it but with poor return, even the ones that I have mentioned that time spent was more

Follow up: Sammy Sinno – What about higher reimbursement for reconstruction s/p radiation?

Reply: Jason Roostaeian – This would be reasonable given the greater complexity of these cases

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  1. Question: Raj Sawh-Martinez – Why do you hypothesize that there was a much higher complication profile with DIEP vs. TRAM flaps?

Answer: Alfred Yoon – In the setting of failed implant and post-radiation, existing technical challenges of a DIEP flap may be amplified

Follow up: Raj Sawh-Martinez – Given that more were minor complications, and TRAMs were mostly unilateral, any significant differences to account for this?

Reply: Alfred Yoon – Uncertain why there’s more unilateral TRAMs. But don’t think laterality accounted for increased DIEP complications

Image8

  1. Question: Sammy Sinno – Any tips for handling scarred vessels?

Answer: Jaco Festekjian – Scope sooner; minimal adventitial dissection; hydro dissection

Follow up: Sammy Sinno – do you find the left side more challenging?

Reply: Jaco Festekjian – Not technically. Left more likely to need back up SIEV

 

  1. Question: Sammy Sinno – Do you try to preserve mastectomy skin at all costs?

Answer: Alfred Yoon – We replace non-ideal mastectomy skin immediately at time of reconstruction

Follow up: Amanda Silva – How do you define non ideal? Clinical exam or use something like SPY?

Reply: Jaco Festekjian – Clinical exam

Image9

  1. Question: Jordan Frey – Do you access IMA with rib sparing or rib sacrificing? Any change with prior implant?

Answer: Alfred Yoon – Usually sacrifice rib to access IMA in either types of patients

Follow up: Amanda Silva – Good point! Think needed to take out rib more often to access good vessels in these cases?

Reply: Jason Roostaeian – We typically use a rib harvesting method. This approach is definitely recommended in prior implant cases

 

  1. Question: Pallab Chatterjee – With such scarring, did you have to modify/alter your surgical technique? 8/0 in preference of 9/0?

Answer: Jason Roostaeian – Typically no, although if significant calcification would consider 8-0, also may need to make sure needle goes intima to adventitia

Reply: Daniel Liu – Take larger bites on radiated vessel, pass needle from intima to adventitia to avoid dissection

 

  1. Question: Raj Sawh-Martinez – Was the length of stay increased for these secondary autologous cases? Was there a longer ICU Stay?

Answer: Jaco Festekjian – No and there were no ICU stays

Follow up: Amanda Silva – Do you have a flap monitoring unit of the floor? What do you use to monitor your flaps?

Reply: Raj Sawh-Martinez – Our patients go straight to the floor post op; but many places have ICU stay post op

Reply: Jaco Festekjian – Surgical unit with nurses in-serviced to recognize failures. Hourly Doppler and skin temp probes

Reply: Raj Sawh-Martinez – Our surgeons use implantable dopplers, or the gold standard, flap monitoring if skin paddle there

Reply: Jaco Festekjian – Ditto

 

  1. Question: Raj Sawh-Martinez – Do you allocate longer OR time when cases are secondary autologous after radiation?

Answer: Jason Roostaeian – We don’t allocate longer op times. No significant difference, likely because flap harvest done concurrent with recipient site

 

  1. Question: Jordan Frey – More non-abdominal flaps in secondary cases. What is your go to flap in that case?

Answer: Jason Roostaeian – Typically gluteal based flaps such as the SGAP most commonly and more recently the PAP

 

  1. Question: Raj Sawh-Martinez – Do you preserve or use the superficial system with DIEPs? Do you do so when faced with such secondary cases?

Answer: Jaco Festekjian – I routinely dissect and preserve the SIEV

 

  1. Question: Jordan Frey – What % of patients had implant removal at time of flap versus some time prior?

Answer: Alfred Yoon – All patients had implant removal prior to flap surgery during same operation

 

The May 2016 Edition of the #PRSJournal Club is Now Available:

  • Read the Articles

  • Listen to the Podcasts

  • Be prepared for the Live #PRSJournalClub Discussion

 

 

 

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