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Background: Rectus abdominis is a muscle that is commonly used clinically as a muscle flap, especially in reconstructive surgery. Its intramuscular innervation, however, has rarely been examined in detail or accurately mapped. The purpose of this study was to use biopsied, histological specimens complemented with a staining technique to investigate intramuscular nerve connections and distribution of the rectus abdominis., Methods: Four fresh human cadavers were included in the study and rectus abdominis was dissected bilaterally. Nerve sections innervating the rectus abdominis were biopsied and histologically processed. Sections were viewed under the microscope, and axons within each fascicle were counted using imaging software. All specimens were stained with a modified Sihler's staining technique. Intramuscular innervation was observed and the number as well as distribution was recorded., Results: Macroscopically stained specimens showed that the eighth, ninth, 10th and 12th intercostal nerves innervated the eight muscle bellies of rectus abdominis. The greatest number of minor nerve branching as well as intramuscular nerve communications originated from nerve roots T9 and T10. Minor nerve branches crossed tendinous intersections to communicate with adjacent nerves and innervate adjacent muscle bellies. Nerves originating from T9 had the greatest number of nerve fascicles and the highest axon count in each cadaver., Conclusion: The rectus abdominis is divided into four compartments with each receiving its own independent nerve supply. Minor nerve branches crossed tendinous intersections to communicate with adjacent muscle bellies and nerves suggesting that rectus abdominis can be used as a whole in innervated free flap transfer procedures., (© 2020 Royal Australasian College of Surgeons.)

Background: Limb salvage surgery in conjunction with adjuvant radiotherapy is the preferred treatment for soft tissue sarcoma. This study aims to determine if ipsilateral pedicled anterolateral thigh (ALT) flap reconstruction of groin defects post soft tissue sarcoma resection results in acceptable rates of lymphoedema, while also providing good soft tissue cover and minimal donor site morbidity., Methods: A retrospective chart audit was conducted with ethics approval, obtaining a case series of 16 patients operated on at a single institution by the senior surgeon. Patients who underwent ipsilateral pedicled ALT flap coverage of irradiated groin defects following soft tissue sarcoma resection were included. Comparative six-point limb circumference measurements were utilized to diagnose lymphoedema, with a difference of 10% when compared to the non-operative side being deemed significant., Results: Lymphoedema was noted in three patients (18.8%) with an average follow-up period of 40.9 (range 8-59) months., Conclusion: Previously published lymphoedema rates in sarcoma limb salvage surgery of 15.5-30% are comparable to the rates obtained in this cohort. Lymphoedema rates do not appear to be higher in patients undergoing ipsilateral pedicled ALT flap reconstruction, thus making it a useful soft tissue coverage technique in this cohort., (© 2019 Royal Australasian College of Surgeons.)

Background: Reconstruction of lip defects following neoplasia and trauma is a common procedure in plastic surgery. Reconstruction of large lip defects is a difficult undertaking and some degree of residual functional impairment and disability are likely to occur. Microsurgical reconstruction is the recommended technique for large lip defects; however, limitations exist regarding optimal aesthetic and functional outcomes with current free flap options., Method: We propose a new composite flap design based on the innervated pronator quadratus with the radial forearm free flap for a more dynamic reconstruction of total or near total lip defects. Results of our series of four patients have been reviewed., Results: The radial forearm flap - innervated pronator quadratus flap has been used in four patients thus far for lip reconstruction. This flap, in our limited series has shown excellent results in achieving oral competence, good motor function and acceptable cosmetic appearance., Conclusion: The composite radial forearm-pronator quadratus flap is a promising new lip reconstruction technique that has potential to provide a higher level of oral competence, sphincteric function and symmetrical lip movement, than current microsurgical options in dynamic lip reconstruction. This method warrants further investigation in plastic surgery literature., (© 2019 Royal Australasian College of Surgeons.)

Background: Reconstruction of posterior thoracic and trunk defects can prove challenging even to the most seasoned surgeons. Many commonly used techniques for closing back defects include primary closure and split skin grafts. Often times, however, other techniques are needed in order to give the patient the best aesthetic and functional outcome. In this study, we focus on and evaluate donor site closure techniques for defects in the back created by harvesting scapular and parascapular flaps., Methods: Twenty patients were operated on to remove pathologically diagnosed sarcomas using a wide local excision. The defects, ranging from 5 to 22 cm in width, were closed using donor flaps from the scapular/parascapular region. Nine donor sites were then closed primarily with wide undermining, while 11 donor sites were closed using multiple techniques, such as large transposition flaps, large rotation advancement flaps, keystone neurovascular island flaps, latissimus dorsi advancement flap and large Y-V advancement flaps., Results: All recipient and donor flaps survived with good aesthetic and functional outcome. Patient satisfaction was high and only two of 20 donor site flaps required further surgery due to wound dehiscence. No other complications were seen during the follow-up period., Conclusion: The proposed advanced techniques for donor site closure in back defects have shown that primary wound healing can be achieved with the use of a variety of different techniques and the avoidance of the complications of a skin graft., (© 2017 Royal Australasian College of Surgeons.)

Background: Breast reconstruction after mastectomy in the treatment of locally advanced breast cancer is often done in stages and before radiotherapy. We have previously published an algorithm for immediate free autologous reconstruction after neoadjuvant chemotherapy and preoperative radiotherapy. This protocol was designed to provide a shorter and simpler reconstructive path whilst improving cosmesis and maintaining oncological efficiency., Methods: A total of 29 patients were included and underwent surgery for 30 cancers by the first author between 2010 and September 2015. Data were prospectively entered into a database and analysed for tumour size, chemotherapeutic response, lymph node involvement, surgical complications and tumour recurrence., Results: The mean age was 55 ± 7 years. Eighty percent of patients had either a partial or complete chemotherapeutic response defined as >25% decrease in tumour size. Twenty-eight patients had free abdominal tissue transfer. One patient was excluded due to advanced disease. There were no take-backs due to microsurgical issues. One patient was reoperated on for a haematoma. Four patients had recurrent cancer during follow-up, three of whom are deceased., Conclusion: Many, but not all, breast reconstructive surgeons consider autologous reconstruction as the 'gold' standard in the presence of radiotherapy. Rearranging the order of radiotherapy and surgery means operating in a recently irradiated field. We believe the surgical challenges are outweighed by a shorter and simpler reconstructive journey that additionally results in a better cosmesis. It is possible to perform immediate free autologous reconstruction after neoadjuvant chemotherapy and preoperative radiotherapy with excellent results and at least equivalent oncological efficacy., (© 2017 Royal Australasian College of Surgeons.)

Background: To date head and neck reconstructions of oncological defects have concentrated on primarily filling the defect to achieve primary wound healing, secondly restore function and lastly cosmesis. This paper describes a refinement of existing free tissue transfer techniques for improvement of contour, function and aesthetics., Methods: A retrospective review of 38 patients operated on by one surgeon at St Vincent's, Royal Melbourne and Western Hospitals over a 3-year period was conducted. Data were collected on patient demographics, tumour details, nature of the defect, type of reconstructive procedure, nature of additional tissue used, radiotherapy, complications and outcome., Results: We present refinements in using de-epithelialized skin paddles, flexor hallucis longus, and rectus and vastus lateralis muscle in order to achieve optimal reconstruction. Free tissue transfer refinements are discussed in anterolateral thigh, fibula, rectus and anteromedial thigh free flaps. The average defect size and volume of neck dissection prior to reconstruction is presented. A variation of radical, modified radical and selective neck dissections were required for oncological staging and clearance. Rare and minor associated complications are discussed. Post-operative radiotherapy treatment was used in the majority of patients with preoperative adjuvant therapy required in some salvage cases. All patients achieved primary wound healing post-operatively with no salivary leaks, flap failures or exposure of neck vessels., Conclusions: Supplementary microsurgical tissue transfer of de-epithelialized skin, vastus lateralis, flexor hallucis longus and rectus muscles is a valuable option for restoring contour, aesthetics and vessel protection post-radiotherapy., (© 2015 Royal Australasian College of Surgeons.)

Background: Current treatment for locally advanced breast cancer (LABC) includes neoadjuvant chemotherapy and post-mastectomy radiotherapy, which may be deleterious for immediate reconstruction. A few trials have instead combined neoadjuvant chemotherapy followed by preoperative radiotherapy. If safe and oncologically efficacious, mastectomy with immediate free autologous reconstruction (transverse rectus abdominis myocutaneous (TRAM)/deep inferior epigastric perforator (DIEP) flap) could then achieve a shorter, simpler reconstructive journey with better cosmesis. No trials have been performed combining this neoadjuvant regime with free autologous reconstruction as an assessment end point., Methods: We performed a Pubmed/Medline search for oncological efficacy of neoadjuvant chemotherapy followed by preoperative radiotherapy and flap reconstruction of the breast. A new treatment sequencing protocol is proposed in which patients suitable for neoadjuvant chemotherapy followed by preoperative radiotherapy and likely mastectomy are selected. Positive chemotherapeutic response is followed by radiotherapy then surgery within 6 weeks comprising mastectomy/axillary clearance and immediate reconstruction (TRAM/DIEP). Non-responders are offered mastectomy, tissue expander reconstruction, adjuvant radiotherapy then delayed autologous reconstruction. Local/systemic recurrence rates, disease-free survival, complications, patient satisfaction and aesthetics are examined., Results: Between 1995 and 2012, 10 trials treated LABC patients using combined neoadjuvant chemotherapy followed by preoperative radiotherapy. Compared with chemotherapy alone, increased complete pathological response, complete clinical remission, median survival and tumour-free survival were observed., Discussion: Our new treatment sequence protocol offers a simpler, more advantageous approach to LABC. We hypothesize equivalent oncological efficacy, optimized oncological management and surgical planning. The aim was to shorten and simplify the reconstructive journey through a single operation including gold-standard reconstruction, offering better cosmesis, fewer complications and reduced costs., (© 2013 The Authors. ANZ Journal of Surgery © 2013 Royal Australasian College of Surgeons.)

Background: The purpose of the present paper was to determine the radial nerve morbidity associated with harvest of different venous conduits in the radial artery free flap., Methods: Retrospective study comparing subjective and objective symptoms of radial nerve morbidity in 51 consecutive free flaps over a 3-year period., Results: Damage to the radial nerve occurred in 9% (1/11) of patients in the cephalic vein group versus 18% (4/28) in the venae comitante group., Conclusions: Raising the cephalic vein for venous drainage in the radial artery free flap doubles the incidence of radial nerve morbidity.