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Background and Objective: Mastectomies have a significant socio-psychological impact, motivating patients to undergo breast reconstruction. Initially, silicone implants were used to reconstruct the breast. However, breast implants have been the subject of successive crises throughout the years. Indeed, rupture, silicone bleeding, and capsular contracture remain topical. In 2019, the BIOCELL textured breast implants was banned and recalled due to the discovery of the breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). More recently, the breast implant illness has been depicted in the media. To cope with these issues and to respond to some patients' expectations for a natural reconstruction, plastic surgeons have developed autogenous solutions for breast reconstruction. Since Taylor's research on angiosomes, the development of the microsurgery and more recently fat grafting, autogenous breast reconstruction has known a tremendous expansion. Autologous breast reconstruction allows a more natural feeling and texture. This narrative review aims to provide to the readers a comprehensive and updated evidence-based overview of state of the art about autologous breast reconstruction after total mastectomy., Methods: We conducted a narrative review of the literature searching for papers published between January 2010 and December 2022. The MeSH terms with different combinations were used to identify articles for inclusion. After screening article titles and abstracts independently by three authors, 66 papers were included in this review., Key Content and Findings: In this review, the authors describe and discuss the different autogenous techniques in breast reconstruction., Conclusions: Autologous reconstructions provide very satisfactory, durable, and reliable results with relatively low complication rates. Deep inferior epigastric perforator (DIEP) flaps, latissimus dorsi flaps and autologous fat grafting are the most common type of autogenous breast reconstructions., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-23-1471/coif). The series “The Modern Plastic and Reconstructive Surgeon – Collaborator, Innovator, Leader” was commissioned by the editorial office without any funding or sponsorship. M.A.D. is a consultant for Allergan, Johnson and Johnson, Establishment labsand and receives payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from them. M.A.D. participated in the safety board of Knight therapy and Activis med and receives payment for expert testimony from them. The authors have no other conflicts of interest to declare., (2024 Annals of Translational Medicine. All rights reserved.)

Background: The use of social media, has been a major upheaval in our lifestyles in the last decade. At the forefront in the crisis of BIA-ALCL, as soon as February 2019, our university centre took steps to identify and contact all patients with macro-textured implants. The purpose of this recall was to educate patients and establish a monitoring system. The purpose of this work is to analyse the patients' decision-making process., Methods: A retrospective study of patients, who requested and attended appointments with a surgeon, was made. The number of patients with clinical symptoms of BIA-ALCL, the number of patients who requested implant removal surgery, the histological diagnoses found after surgery were collected. We then calculated the proportion of Facebook group members among patients who required implant removal in the absence of a diagnosis or even warning signs., Results: Seven hundred and seventy women requested an appointment with one of the surgeons in our department. Of all the women who requested consultation, 497 (64.55%) had symptoms. 199 patients were members or had attended one of the Facebook groups of patients. At the end of the consultation with their surgeon, almost 25% of patients made a decision to have the implant removed against medical advice. Among these patients, 67% were part of a group of patients on the Facebook network. To date, no patient has been diagnosed with BIA-ALCL., Conclusions: These results support the hypothesis that belonging to Facebook groups of patients becomes, for some, a key element in the decision-making process beyond expert opinion. In the future, preliminary work with patient groups on social networks should be done in order to obtain additional health efficiency., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Background: Opportunities for international missions are highly sought after by medical students, residents, and attending plastic surgeons. The educational benefits and ethical considerations of trainees participating in these ventures have been extensively debated. At the time of this writing, many surgical training programs lack the necessary infrastructure or funds to support missions of this sort. Despite the increasing interest, the perceived benefit of international work has not yet been well studied. The authors seek to evaluate residents' perspectives on the personal and educational benefits of international mission work., Methods: A 24-item online questionnaire was designed to measure residents' perspectives on humanitarian missions. Residents' perceptions on how participation in these missions may have influenced their career path were also evaluated. This questionnaire was disseminated to the plastic surgery residents in Accreditation Council for Graduate Medical Education (ACGME) accredited programs in the United States during the 2015 to 2016 academic year., Results: Of the 123 responses collected, 49 (40%) indicated that they had participated in international mission work prior to beginning residency, while 74 (60%) had not. Fifty-seven percent (n = 25) of those who had participated agreed that this experience impacted their choice to pursue plastic surgery as a specialty. Twenty-nine (24%) participated in 1 or more missions during residency. The most common type of mission work focused on cleft lip/palate repairs (n = 24) followed by nonsurgical medical relief (n = 18) and general plastics/combined (n = 6). Most respondents reported trips lasting 6 to 8 days (n = 29, 48%), though several reported trips lasting 9 to 10 days (n = 6, 10%) and 11 days or more (n = 16, 27%). When asked about the volume of procedures performed, 32 (65%) reported participating in more than 15 procedures, with 15 (31%) residents reporting participation in 26 procedures or more. When asked to evaluate the educational benefits in light of the 6 core competencies from the ACGME, there was an overwhelmingly positive response., Conclusions: Residents perceive international mission experiences to be valuable for professional development as well as an effective tool for surgical education, particularly in the setting of competency-based education goals and these ventures should be supported by training programs. An appropriately planned mission experience can impact the professional and educational development of the trainee.

Background: The double capsule is a complication mostly described in aggressive macrotextured implants. Mechanical shear stress applied onto an immature periprosthetic capsule has been linked to their formation. The authors aim to demonstrate the role of bacterial phenotype and biofilm in the development of the double capsule., Methods: Seven double capsules formed at the interface of macrotextured breast expander implants were studied using scanning electron microscopy. Two samples for each surface of the inner capsule layer (the prosthesis interface and the intercapsular space) were analyzed for bacteria cell size, bacterial density, and biofilm deposition., Results: Although all routine bacterial cultures were negative, the prosthesis interface had both higher bacteria load and biofilm deposition compared with the intercapsular space (Mann-Whitney U test, p = 0.004 and p = 0.008, respectively). Moreover, bacteria cell sizes were significantly smaller at the prosthesis interface in six of seven samples. Comparison of bacteria density and biofilm dispersion showed an increase of biofilm extracellular matrix deposition over 2000 cells/mm (linear regression, p = 0.0025). These results indicate a common trend among bacteria species., Conclusions: Bacterial expression between the different surfaces of the double capsule displays significant differences; bacteria at the prosthesis interface are mostly in a biofilm state, whereas they demonstrate a planktonic phenotype at the intercapsular space. When a sufficient amount of bacteria are present at a specific location, quorum sensing may trigger a biofilm phenotypic switch in planktonic bacteria cells. Biofilm formation may alter capsule formation through immune response, thereby weakening capsule strength and facilitating extracellular matrix delamination and double-capsule formation., Clinical Question/level of Evidence: Therapeutic, V.

Background: Music is commonly played in operating rooms (ORs) throughout the country. If a preferred genre of music is played, surgeons have been shown to perform surgical tasks quicker and with greater accuracy. However, there are currently no studies investigating the effects of music on microsurgical technique. Motion analysis technology has recently been validated in the objective assessment of plastic surgery trainees' performance of microanastomoses. Here, we aimed to examine the effects of music on microsurgical skills using motion analysis technology as a primary objective assessment tool., Methods: Residents and fellows in the Plastic and Reconstructive Surgery program were recruited to complete a demographic survey and participate in microsurgical tasks. Each participant completed 2 arterial microanastomoses on a chicken foot model, one with music playing, and the other without music playing. Participants were blinded to the study objectives and encouraged to perform their best. The order of music and no music was randomized. Microanastomoses were video recorded using a digitalized S-video system and deidentified. Video segments were analyzed using ProAnalyst motion analysis software for automatic noncontact markerless video tracking of the needle driver tip., Results: Nine residents and 3 plastic surgery fellows were tested. Reported microsurgical experience ranged from 1 to 10 arterial anastomoses performed (n = 2), 11 to 100 anastomoses (n = 9), and 101 to 500 anastomoses (n = 1). Mean age was 33 years (range, 29-36 years), with 11 participants right-handed and 1 ambidextrous. Of the 12 subjects tested, 11 (92%) preferred music in the OR. Composite instrument motion analysis scores significantly improved with playing preferred music during testing versus no music (paired t test, P <0.001). Improvement with music was significant even after stratifying scores by order in which variables were tested (music first vs no music first), postgraduate year, and number of anastomoses (analysis of variance, P < 0.01)., Conclusions: Preferred music in the OR may have a positive effect on trainees' microsurgical performance; as such, trainees should be encouraged to participate in setting the conditions of the OR to optimize their comfort and, possibly, performance. Moreover, motion analysis technology is a useful tool with a wide range of applications for surgical education and outcomes optimization.

The authors report the case of a 30-year-old male with 52% TBSA high-voltage electrical injury of the upper half of the body. Injuries included a cervical burn with associated alteration of the left brachial plexus as well as extensive soft tissue burn of the right hand. Three months later, he developed osteomyelitis of the right thumb metacarpal bone requiring amputation proximal to the metacarpophalangeal joint. Following initial management, the patient had a permanent distal left upper extremity paralysis with nonfunctional but relatively undamaged ipsilateral hand digits. The right hand remained functional with four intact digits and a thumb stump. Usually, late reconstruction of proximal thumb amputation is performed by pollicization or free toe transfer procedures. In this particular case, right thumb reconstruction was done by free transfer of the left little finger. Four months postoperatively, the patient demonstrated a functional pinch between the reconstructed thumb and the ipsilateral digits along with improving sensation. This uncommon surgical procedure restored a functional thumb with minimal donor site morbidity. The decision-making process and operative technique are presented in detail along with a review of the thumb reconstruction literature.

Breast implants are amongst the most widely used types of permanent implants in modern medicine and have both aesthetic and reconstructive applications with excellent biocompatibility. The double capsule is a complication associated with textured prostheses that leads to implant displacement; however, its etiology has yet to be elucidated. In this study, 10 double capsules were sampled from breast expander implants for in-depth analysis; histologically, the inner capsular layer demonstrated highly organized collagen in sheets with delamination of fibers. At the prosthesis interface (PI) where the implant shell contacts the inner capsular layer, scanning electron microscopy (SEM) revealed a thin layer which mirrored the three-dimensional characteristics of the implant texture; the external surface of the inner capsular layer facing the intercapsular space (ICS) was flat. SEM examination of the inner capsule layer revealed both a large bacterial presence as well as biofilm deposition at the PI; a significantly lower quantity of bacteria and biofilm were found at the ICS interface. These findings suggest that the double capsule phenomenon's etiopathogenesis is of mechanical origin. Delamination of the periprosthetic capsule leads to the creation of the ICS; the maintained separation of the 2 layers subsequently alters the biostability of the macro-textured breast implant., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: In the first stage of expander-to-implant breast reconstruction, postoperative expansion is classically initiated at 10 to 14 days (conventional approach). The authors hypothesized that it may be beneficial to wait 6 weeks postoperatively before initiating serial expansion (delayed approach). Clinical and ultrastructural periprosthetic capsule analysis is first required before determining whether a delayed approach ultimately improves capsular tissue adherence and expansion process predictability., Methods: Patients undergoing two-stage implant-based breast reconstruction were enrolled prospectively in this study. During expander-to-implant exchange, the clinical presence of "Velcro" effect, biofilm, and double capsule was noted. Periprosthetic capsule samples were also sent for scanning electron microscopic observation of three parameters: surface relief, cellularity, and biofilm. Samples were divided into four groups for data analysis (group 1, conventional/Biocell; group 2, delayed/Biocell; group 3, conventional/Siltex; and group 4, delayed/Siltex)., Results: Fifty-six breast reconstructions were included. Each group comprised between 13 and 15 breasts. In group 1, no cases exhibited the Velcro effect and there was a 53.8 percent incidence of both biofilm and double capsule. In group 2, all cases demonstrated the Velcro effect and there were no incidences of biofilm or double capsule. Group 3 and group 4 cases did not exhibit a Velcro effect or double-capsule formation; however, biofilm was present in up to 20.0 percent. All group 2 samples revealed more pronounced three-dimensional relief on scanning electron microscopy., Conclusions: Variations in expansion protocols can lead to observable modifications in periprosthetic capsular architecture. There may be real benefits to delaying expander inflation until 6 weeks postoperatively with Biocell expanders.

The microsurgical failure rate is almost constant for several decades. We present two case reports describing a novel method of free flap salvage using angioradiological techniques. Our first case shows the potential utility of in situ thrombolysis, our second case describes the first use of stents within a microsurgical anastomosis. In boths cases, the flap would have been lost immediately, because flap revisions failed. Thus, before abandoning on a flap, one could perform a simple angiography to evaluate further angioradiological salvage possibilities and hereby contribute to improve long term microsurgical failure rate., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Purpose: Scanning electron microscopy (SEM) is a powerful analytical tool that allows the study of interactions between commonly used biomaterials and the human body. In conventional SEM (HiVac), hydrated biological samples cannot be analyzed in their natural state and must be dried and metallized. The primary goal of this study is to present recent developments in SEM, notably Environmental SEM (ESEM). The secondary objective is to define the potential utility of these new technologies in the study of periprosthetic breast capsules., Materials and Methods: Our pilot study group prospectively included 10 patients with breast cancer undergoing 2-stage expander to implant reconstruction. Periprosthetic breast capsule specimens were sampled during expander removal. Each sample was analyzed using both HiVac and ESEM modalities. Energy dispersive X-ray (EDX) studies were also conducted in order to assess the chemical composition of the capsular tissue samples. Under each observation mode, comparisons of samples' three-dimensional surface relief, cellular composition and biofilm presence were made. For each image, a score from 1-3 on a Likert scale was attributed by three independent experts in electron microscopy., Results: HiVac mode was found to be superior to ESEM for the assessment of the three main study parameters (surface relief, cellularity, biofilm). The quality of the EDX analysis was equivalent under both SEM modalities., Conclusion: HiVac mode was shown to be more appropriate than ESEM for the global analysis of periprosthetic breast capsules. EDX analysis permits the identification of atypical chemical elements in tissue samples., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Objective: Interest in flaps based on the subscapular vascular system has decreased because of the need for intraoperative patient repositioning and the inability to employ a simultaneous 2-team approach. The aims of this study are to review our experience using dorsal decubitus patient positioning for subscapular-based flap harvest and to demonstrate the effectiveness and safety of this approach., Methods: A retrospective review of all subscapular-based flap cases performed by the senior author at 2 hospital centers from 1995 to 2010 was conducted. Variables studied included indications for reconstruction, flap characteristics, and postoperative complications. A longitudinal roll placed between the scapulae as well as an optional perpendicularly placed shoulder roll are used to achieve dorsal decubitus patient positioning., Results: One hundred five flaps were performed during the study period, and dorsal decubitus positioning was used in all cases. Eighty-four flaps were free and 21 were pedicled. Indications for reconstruction included cancer resection (n = 58), trauma (n = 32), infection (n = 9), and others (n = 6). A simultaneous 2-team approach was carried out in 70 cases. Major complications included 9 cases of arterial or venous thrombosis/insufficiency, 2 of which resulted in total flap failure. Intraoperative conversion to lateral decubitus positioning was never required., Conclusions: Dorsal decubitus harvesting for subscapular-based flaps is a practical and effective technique that enables a simultaneous 2-team approach in complex reconstructive cases. Previous limitations of these highly versatile flaps, such as the need for intraoperative patient repositioning, can thus be avoided. This approach is employed for all subscapular-based flap reconstructions performed by the senior author.

Flaps based on the subscapular vascular system are reliable and versatile tools that provide excellent coverage for a wide range of tissue deficits. Raising these flaps in the described dorsal decubitus position permits two surgical teams to work simultaneously while obviating the need for intra-operative position changes. In cases where a subscapular-based flap is deemed the most suitable option for reconstruction, the dorsal decubitus technique eliminates many of the limitations associated with the traditional lateral decubitus approach without compromising the range of tissue obtainable., (Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)