Epidural morphine analgesia compared with intravenous morphine for oral cancer surgery with pectoralis major myocutaneous flap reconstruction

BACKGROUND: Oral cancer surgery with reconstruction is a complex operative procedure with morbidities such as respiratory complications and post-operative pain. These morbidities may be reduced with appropriate operative and post-operative pain management. Epidural analgesia provides better pain control than intravenous opioids after major thoraco-abdominal surgical procedures. We planned to undertake a prospective study to compare the efficacy and side-effects of epidural morphine analgesia vs. intravenous morphine in patients undergoing oral cancer surgery with pectoralis major myocutaneous flap reconstruction. METHODS: Sixty patients undergoing a major surgical procedure for oral cancer with pectoralis major myocutaneous flap reconstruction were prospectively randomized to receive either epidural morphine or intravenous morphine in the post-operative period. The intensity of pain was assessed daily using a 100-mm visual analogue scale. The post-operative side-effects, time to ambulation, time to tolerate first nasogastric feed, total length of hospital stay and global satisfaction score were recorded. RESULTS: The epidural morphine group had statistically significant lower pain scores at the three evaluation times through the post-operative 48 h (P < 0.05). However, the mean visual analogue scores were always below 35 in the intravenous morphine group. Patients in the epidural morphine group ambulated and accepted nasogastric feed significantly earlier than those in the intravenous morphine group. The incidence of nausea/vomiting or pruritus, the length of hospital stay and the global satisfaction score were not statistically different between the groups. CONCLUSION: This study illustrates that epidural morphine offers better pain control than intravenous morphine after oral cancer surgery with pectoralis major myocutaneous flap reconstruction. Nevertheless, both methods appear to provide very good pain relief, and perhaps the extra risks inherent to epidural catheter insertion are not outweighed by the benefits in this type of surgery.     

Patient controllediv analgesia is an acceptable pain management strategy in morbidly obese patients undergoing gastric bypass surgery. A retrospective comparison with epidural analgesia

PURPOSE: To examine the hypothesis that pain treatment with patient controlled analgesia (PCA) using iv morphine is a suitable and safe alternative to epidural analgesia in morbidly obese patients undergoing gastric bypass surgery. We retrospectively compared the postoperative periods in all patients undergoing this procedure in our institution between November 1999 and November 2001. METHODS: According to their perioperative pain treatment, patients were assigned to a PCA group (with iv morphine) or an epidural analgesia group, in which patients received either intermittent doses of morphine or continuous infusions of bupivacaine/fentanyl. Study endpoints included quality of pain control, incidence of cardiovascular and respiratory complications, analgesia related side effects, time to ambulation and first flatus, length of hospital stay, and wound infections. RESULTS: Data from 86 patients were analyzed with 40 patients in the PCA group and 46 patients in the epidural group. Groups were similar with respect to age, body mass index, and gender. The type of analgesia did not affect the quality of pain control at rest, the frequency of nausea and pruritus, the time to ambulation and return of gastrointestinal function, and the length of hospital stay. Patients receiving epidural analgesia had a greater risk of wound infection than subjects with PCA (epidural group: 39%, PCA group: 15%, P = 0.01). CONCLUSION: We conclude that in grossly obese patients undergoing gastric bypass surgery PCA with iv morphine is an acceptable strategy for pain management and may confer some advantages when compared to epidural analgesia.     

The infected chest wall prosthesis: management by excision and contralateral transverse rectus abdominis musculocutaneous flap

A patient with a chest wall sarcoma whose original prosthetic reconstruction became infected after a course of radiation therapy is described. After removal of the prosthesis, salvage reconstruction was performed using a transverse rectus abdominis musculocutaneous flap. Management of the infected chest wall prosthesis, with emphasis on the indications for use of the transverse rectus abdominis musculocutaneous flap, is discussed.     

乳腺癌切除术后乳房再造

目的 探讨乳腺癌切除术后乳房再造的方法及时间.方法 总结30例不符合保乳条件的乳腺癌病例,乳房切除术后假体置人乳房再造16例,下腹部横行腹直肌肌皮瓣(TRAM瓣)乳房再造10例,背阔肌肌皮瓣乳房再造4例.其中即刻乳房再造27例,延期乳房再造3例.结果 16例假体置入乳房再造术后外观评价均为良,未出现术后并发症.10例TRAM瓣乳房再造术后发生皮瓣部分坏死2例,腹壁疝1例,术后外观评价7例为良.2例为较好,1例为差.4例背阔肌肌皮瓣再造术后外观评价为良.结论 乳房再造术是乳腺癌综合治疗不可忽视一部分,对于有强烈的保乳愿望,而又不符合保乳条件的患者,乳房再造术是一种较好的选择.即刻乳房再造优于延迟乳房再造.乳房再造的方法选择要因人而异.局部晚期乳腺癌患者可以选择性进行即刻乳房再造术.     

Technical aspects of one stage reconstruction of mammary glands using autologous tissue after mastectomy for the mammary gland cancer

In 36 patients the first experience of performance of one-stage mammarial glands reconstruction is presented, using tissues of their own after conduction of mastectomy for the mammarial gland cancer. In 27 women patients the transposition or free microvascular transplantation of lower musculocutaneous flap basing on m. Rectus abdominis (transverse rectus abdominis musculocutaneous TRAM-flap) was performed, in 9--transposition of m. Latissimus dorsi flap.     

Indications for vascularized free rectus abdominis musculocutaneous flap in oromandibular region in terms of efficiency of anterior rectus sheath

The anterior rectus sheath, efficacious in reconstructive surgery, is used in oromandibular reconstruction with the free rectus abdominis musculocutaneous flap. This study describes reconstruction with this sheath in 20 patients: to preserve only the swallowing function in 10 patients (formation of the bulge of the reconstructed oral floor and prevention of its sinking); to preserve both swallowing and articulation in 5 patients (formation of the bulge of the reconstructed tongue and prevention of its sinking, concurrent with a money-pouch-like reconstruction of the tongue, laryngeal suspension, and neuroanastomosis); and to prevent exposure of the reconstruction plate, replacing the resected mandibular continuity in 5 patients. The purpose of reconstruction was achieved in all patients. The vascularized free rectus abdominis musculocutaneous flap with a firm anterior rectus sheath may be the first choice for these types of reconstruction.     

Intrathoracic application of the transverse rectus abdominis musculocutaneous flap.

The use of extrathoracic muscles for intrathoracic transposition of healthy tissues for correction of intrathoracic pathology has many precedents. The lower transverse rectus abdominis musculocutaneous flap as elevated in a manner identical to that more commonly used for breast reconstruction may also serve that role especially for basilar thoracic defects if more traditional muscle flap options are unavailable. A unique case of intrathoracic transfer of a lower transverse rectus abdominis musculocutaneous flap for obliteration of a chronic empyema cavity is presented.     

Single-stage maxillary and nasal floor reconstruction with the double-paddle rectus abdominis musculocutaneous free flap

Palatal integrity is essential for useful speech, deglutition, good oral hygiene, and prevention of nasal regurgitation. Maxillary defects after tumor extirpation, therefore, can have serious functional and cosmetic implications. Given the often disappointing results obtained with local and regional pedicled flaps for maxillary reconstruction, a variety of microvascular free flaps have been utilized in recent years, including the rectus abdominis, fibular, radial forearm, and latissimus dorsi flaps. Experience with these techniques has been documented in a limited number of case reports. We describe our single-stage approach to maxillary and nasal floor reconstruction with the double skin-paddle rectus abdominis musculocutaneous free flap. A series of five patients is presented; six of these immediate free flap reconstructions were performed for defects resulting from tumor resection. A vertical rectus abdominis musculocutaneous free flap was used in all cases, designing two separate skin paddles to accommodate the measured maxillary and nasal floor deficiencies. Anastomoses of the deep inferior epigastric artery and vena comitans were performed end-to-end to the facial artery and vein, respectively. In addition, orbital floor reconstruction with calvarial bone grafts or titanium mesh was performed in all five patients. Separation of the oral and nasal cavities was maintained postoperatively. No intraoperative complications, perioperative mortalities, flap losses, instances of skin paddle necrosis, hematomas, or oronasal fistulae were observed. One patient required bedside drainage of a surgical site abscess that resolved without adverse sequelae. Over the past 4 years, the double skin-paddle rectus abdominis musculocutaneous free flap has provided reliable results at our institution for single-stage reconstruction of maxillary and nasal floor defects. This reconstructive technique should be considered a viable method that can alleviate the functional and cosmetic debility associated with these defects.     

Physiological studies using laser Doppler flowmetry to compare blood flow to the zones of the free TRAM flap

The latissimus dorsi musculocutaneous island flap was once the standard for breast reconstruction. With the increased use of tissue expanders and the development of the transverse rectus abdominis musculocutaneous flap for autologous tissue breast reconstruction, use of the latissimus dorsi has decreased. To reassess the role of the latissimus dorsi musculocutaneous flap in breast reconstruction, a retrospective review was performed to evaluate women who had skin-sparing mastectomy followed by immediate reconstruction with a latissimus dorsi flap and permanent implants. The postoperative aesthetic results and donor site morbidity, including contour deformity and scarring, were examined. Satisfactory results were obtained in 17 of 18 patients. Complications were noted in 5 patients, and all were minor. Using the latissimus dorsi musculocutaneous flap and a permanent breast prosthesis for immediate reconstruction is successful because it provides sufficient muscular coverage of the implant. In addition, it provides a good aesthetic result using a single-stage procedure. Illustrative cases are presented.     

Reconstructive measures in local recurrence after breast saving therapy of breast cancer]

Local recurrence after breast preserving treatment of breast cancer will usually be treated by simple mastectomy. Safe immediate reconstruction is only possible by use of a musculocutaneous flap, the latissimus dorsi flap or better by the rectus abdominis musculocutaneous flap in it's vertical (VRAM) or transverse (TRAM) variation. As a sequel of the irradiation, one stage reconstruction with a simple submuscular implant or an expander prosthesis has a higher complication rate. Personal experience with 42 rectus flaps is reported. The rate of total necrosis was 5%, in one patient a late desmoid tumor was found in the donor area.     

Dorsal thoracic fasciocutaneous flap salvage of the failed transverse rectus abdominis musculocutaneous flap.

The pedicled lower transverse rectus abdominis musculocutaneous flap, now considered the standard for breast reconstruction using autologous tissues, still may be plagued occasionally by significant flap necrosis in spite of the best intentions. Rather than discarding the residual flap, it may suffice as an autologous implant if an additional source of tissue can be used for surface coverage. The dorsal thoracic fasciocutaneous free flap provides such a large, yet reasonably thin, skin territory that can uniformly cover the new breast, ultimately salvaging an acceptable result after a partially failed transverse rectus abdominis musculocutaneous flap.     

三叶状下腹部腹直肌肌皮瓣乳房重建

目的 用改善血供的下腹部械行腹直肌肌皮瓣（ＴＲＡＭＦ）重建乳房。方法 在通常以上部腹直肌为蒂的ＴＲＡＭＦ的肌蒂表面附加一块脐旁三角形皮瓣,使共同组成三叶状,藉以增加同皮穿支动脉的血供及肌皮瓣提供的组织量,便于乳房塑形和腋部瘢痕挛缩的充分松解修复,以及胸壁的的放射性烧伤创面的修复。结果 乳癌术后单侧乳房缺失伴胸壁放射性溃疡及腋部瘢痕挛缩６例,肌皮瓣完全成活者４例,皮瓣最远端少量坏死及脂肪液化者２例。     

Burned breast: treatment with a transverse rectus abdominis island musculocutaneous flap

A contralateral transverse rectus abdominis island musculocutaneous flap was employed in the treatment of a unilateral burned breast. The vascularization of the flap was based on the superior epigastric pedicle. The advantages of this method are that a transverse island musculocutaneous flap of the rectus muscle can be used with good results in the reconstruction of the burned breast; and that in patients with hypertrophic contralateral breasts, the inferior pole of the opposite breast can be added to obtain a larger area of the flap. The cutaneous color and the texture offered by this method assure a more symmetrical appearance in the area.     

Experience with the ipsilateral upper TRAM flap for postmastectomy breast reconstruction

Twenty-seven patients who underwent postmastectomy breast reconstruction using the ipsilateral upper transverse rectus abdominis musculocutaneous (TRAM) flap are presented. We believe that there are several advantages in using this flap instead of the lower TRAM flap. The ipsilateral upper TRAM flap has a stronger and more predictable blood supply, involves easier and stronger abdominal wall repair and less operating time with less blood loss, and has a very acceptable donor site.     

The deep inferior epigastric perforator free flap for breast reconstruction

Deep inferior epigastric perforator (DIEP) flap breast reconstruction is an improved method of autologous tissue breast reconstruction with minimal insult to the abdominal wall. This study summarizes the data collected on 148 consecutive DIEP flaps used for breast reconstruction in 109 patients. Of the patients, 90.7% had immediate breast reconstruction after mastectomy, 6.5% had secondary reconstruction, and 2.8% had bilateral reconstruction after having had a mastectomy and having a new primary cancer diagnosed in the remaining breast. A total of 78.7% patients underwent unilateral reconstruction, 21.3% underwent bilateral reconstruction, and 15.7% needed two flaps to make a single larger breast. There was one flap failure. Incidence of fat necrosis was 6.8% and incidence of incisional hernia was 1.4%. The advantages of a free transverse rectus abdominis musculocutaneous flap breast reconstruction are inherent in DIEP flap breast reconstruction. The increased technical effort for DIEP flap reconstruction is offset by the lesser insult to the abdominal wall with maintenance of the entire rectus abdominis muscle.     

Clinical experience with immediate breast reconstruction using tissue expansion or transverse rectus abdominis musculocutaneous flaps

We retrospectively reviewed our experience with immediate breast reconstruction in 103 consecutive patients with stage 0 or I breast carcinoma between May 1983 and April 1988. Two reconstructive techniques were used, that is, either tissue expansion with secondary prosthesis implantation (60%) or transverse rectus abdominis musculocutaneous (TRAM) flap (40%). Chemotherapy was administered in 22% of patients without delay or compromise. The mean length of follow-up is 30 months. The complication rate was equal for both groups (24%) with infection being most common in the group of patients with tissue expansion and partial flap necrosis being most common in the group of patients with TRAM flaps. Aesthetic results were superior with use of the TRAM flap. Our experience concurs with previous reports that documented satisfactory results with immediate breast reconstruction without compromising further therapy. We conclude that although the tissue expansion technique yields acceptable results, the TRAM flap yields superior aesthetic results in terms of both appearance and consistency.     

Breast reconstruction with the transverse abdominal island flap using the banked nipple-areola complex in the lower abdomen

This article reports a case in which the author employed a technique using the previously banked nipple-areola complex in the lower abdomen in breast reconstruction with the lower abdominal transverse rectus abdominis musculocutaneous flap.     

应用中下腹横形腹直肌皮瓣修复胸壁慢性放射性溃疡

目的 探讨乳癌根治术后胸部慢性放射性溃疡的特点及防治特点.方法 对胸部放射溃疡并肋骨、肋软骨或胸骨外露的患者,采用中下腹部横形腹直肌肌皮瓣(TRAM)修复12例,其中单腹直肌蒂6例,单腹直肌蒂附加血管吻合双蒂皮瓣6例.结果 皮瓣全部成活,皮瓣和创缘均一期愈合.随访1～4年,皮瓣色泽、质地、弹性良好.周边瘢痕性组织血运得以改善.结论 TRAM皮瓣是修复胸壁放射性溃疡的理想选择,必要时可附加血管吻合形成双蒂皮瓣.     

Is the sensitivity of skin‐sparing mastectomy or nipple‐sparing mastectomy superior to conventional mastectomy with innervated flap?

The purpose of this study was to investigate sensory recovery in 33 patients who underwent conventional mastectomy, skin-sparing mastectomy, or nipple-sparing mastectomy with immediate breast reconstruction using abdominal flaps. Reconstructions included a pedicled transverse (28 cases) or vertical (five cases) rectus abdominis musculocutaneous flap. Sensory reconstruction was performed in 15 cases by neurorrhaphy using intercostal nerve. Patients were classified into six groups according to type of mastectomy and use of neurorrhaphy. Sensory recovery was estimated by touch, pain, and hot and cold sensation at the nipple, areola, and 4 points at a distance of 2 cm from the areolar circumference. For touch sensation, conventional mastectomy with innervated flap provided greater sensitivity than the other groups (P < 0.05). For pain sensation, conventional mastectomy with innervated flap provided greater sensitivity than the other groups (P< 0.05). In terms of short-term postoperative sensitivity, skin- and nipple-sparing mastectomies with abdominal flap appear inferior to conventional mastectomy with innervated abdominal flap.     

Results of immediate breast reconstruction after skin-sparing mastectomy

Skin sparing mastectomy (SSM) removes the breast, nipple-areolar complex, previous biopsy incisions, and skin overlying superficial tumors. Preservation of the native skin envelope facilitates immediate breast reconstruction. The procedure has been adopted for the treatment of breast cancer. All cases of SSM and immediate breast reconstruction performed by the senior author (G.W.C.) from January 1, 1993, through December 12, 1997, were reviewed. Patient demographics, cancer staging, treatment, types of surgery performed, and postoperative outcomes were examined. Aesthetic outcomes were measured using four 3-point subscales. A total of 100 patients underwent 118 SSMs during the study period. The American Joint Committee on Cancer staging was as follows: stage 0, 27 patients; stage I, 25 patients; stage II, 39 patients; stage III, 7 patients; stage IV, 3 patients; recurrent, 2 patients; and cystosarcoma phylloides, 1 patient. The mean follow-up was 42.7 months. Local recurrence occurred in 2 patients (2.7%). Reconstructive methods included the transverse rectus abdominis musculocutaneous flap (N = 82; pedicled, 73; free, 9), the latissimus flap (N = 18), and tissue expansion (N = 20). Two patients underwent contralateral delayed reconstruction. The aesthetic results achievable with the three methods were similar. The failure rate was higher for expander reconstruction (10%) than those observed for transverse rectus abdominis musculocutaneous (4.9%) and latissimus (5.6%) flaps. SSM can be used in the treatment of invasive breast cancer without compromising local control. The aesthetic results of the three methods were similar, but tissue expander reconstruction had a higher failure rate.