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When the entire abdominal tissue is inadequate to match the contralateral breast volume and shape or in bilateral cases, the deep inferior epigastric perforator (DIEP) flap alone might not be adequate, even if bipedicled. In such cases, using combinations of donor sites is useful and more effective. We present our series of breast reconstruction using stacked DIEP and transverse upper gracilis (TUG) flaps to achieve better breast volume and shape. Between 2015 and 2021, 7 patients underwent reconstruction with stacked flaps. Three surgical teams performed the surgery simultaneously. Flaps were stacked and shaped on a table; the DIEP was de-epithelised completely and placed upside down with the pedicle anteriorly. A cranial extension of the DIEP pedicle was anastomosed in series to the TUG vessels. The TUG was coned and placed above the DIEP, the skin paddle was used both to create a new nipple-areola complex and for monitoring. The stacked flaps were anastomosed to the recipient vessels and buried under the mastectomy flaps. No flap losses were encountered. The aesthetic outcome was good or excellent and patients considered the surgery as an improvement for their self-appearance. In patients with loose skin and minimal fat, or in bilateral reconstructions, the presented procedure can be considered as a reliable approach to obtain a better breast shape and simultaneously improve body contouring in the donor sites.

Summary Introduction When the DIEP flap is unavailable, autologous reconstruction of a moderate-to-large breast presents a surgical challenge. We retrospectively review our experience of unilateral breast reconstruction using double TUG flaps and highlight specific technical considerations. Methods Thirty-four patients underwent double TUG flaps for unilateral breast reconstruction between 2012 and 2020. The average patient age was 50 years and the average BMI was 23.1kg/m2. In all cases, the indication for surgery was breast cancer: 31 patients had immediate reconstruction, 11 had simultaneous axillary surgery and eight had primary contralateral symmetrising surgery. Results Of the 68 TUG flaps, 67 (98.5%) were successful. The mean operative time was 5 hours 50 minutes (195- 460mins) and the mean combined flap weight was 551g (279- 916g). Eight patients returned to the operating theatre in the early post-operative period and five patients underwent secondary lipofilling to address contour deformities. Most commonly (n=22), the flaps were orientated horizontally/obliquely, with one flap anastomosed medially to the internal mammary axis and the other anastomosed lateral to the subscapular system. The internal mammary artery perforators and serratus anterior artery provided the best vessel calibre match with the TUG vessels. Conclusions Double TUG reconstruction is a safe and reliable option for unilateral breast reconstruction and is an important option when the DIEP flap is unavailable.

BackgroundThe global COVID-19 pandemic has significantly impacted all aspects of healthcare, including the delivery of elective aesthetic surgery practice. A national, prospective data collection was carried out of the first aesthetic plastic surgery procedures performed during the COVID-19 pandemic in the United Kingdom.ObjectivesThe aim of this study was to explore the challenges aesthetic practice is facing and to identify if any problems or complications arose from carrying out aesthetic procedures during the COVID-19 pandemic.MethodsOver a 6-week period from June 15 to August 2, 2020, data were collected by means of a proforma for aesthetic plastic surgery cases. All patients had outcomes recorded for an audit period of 14 days postsurgery.ResultsThe results demonstrated that none of the 371 patients audited who underwent aesthetic surgical procedures developed any symptoms of COVID-19–related illness and none required treatment for any subsequent respiratory illness.ConclusionsNo COVID-19–related cases or complications were found in a cohort of patients who underwent elective aesthetic procedures under strict screening and infection control protocols in the early resumption of elective service.

Summary Background Electrosurgery makes dissection with simultaneous haemostasis possible. The produced heat can cause injury to the surrounding tissue. The PEAK PlasmaBlade™(PPB) is a new electrosurgery device which may overcome this by having the ability to operate on a lower temperature, therefore reducing collateral thermal damage. Method A single-centre, double-blinded, randomised controlled trial (RCT) was conducted which included 108 abdominal-based free-flap breast reconstruction patients who had their flap raise performed using either the PPB (n = 56) or the conventional diathermy (n = 52). Data were collected during their in-patient stay and out-patient appointments. The primary outcome value was the number of days the abdominal drains were required. Results Baseline characteristics were similar between the groups, except a significantly lower flap weight in the PPB group. The median number of days the drains were required did not differ significantly (p = 0.48; 6.0 days for the diathermy and 5.0 days for the PPB). The total drain output (p = 0.68), the inflammatory cytokine in the drain fluid (p>0.054) and complications (p>0.24) did not differ significantly between the two groups. At the 2-week follow-up appointment, there was a trend towards less abdominal seromas on abdominal ultrasound (p = 0.09) in the PPB group which were significantly smaller (p = 0.04). Conclusion The use of the PPB did not result in a significant reduction of drain requirement, total drain output or inflammatory cytokines but did reduce the size of seroma collections at the 2-week follow-up appointment. Therefore, the use of the PPB device could reduce early seroma formation after drain removal.

In this paper, we describe the development and evaluation of a novel tissue-holding device (THD) for use during robotic-assisted laparoscopic partial nephrectomy. The THD is a vacuum-based apparatus made of either 3D-printed polyethylene or stainless steel. The proximal end connects to suction tubing routed outside the body, while the distal end is conically shaped and designed to firmly interface with the tumor. Device feasibility studies were performed on six porcine kidneys, two porcine livers, and two embalmed human cadavers. A Likert-scale rating was used to assess device setup, suction, and tissue handling. Additional tests were performed using the daVinci Xi® robotic system. Finally, the holding force of the THD was assessed using different standard vacuum systems and pressure settings. In porcine tissue, the device setup, tissue suction, and handling were rated as “good”. THD insertion and removal was uncomplicated. In a simulated transabdominal approach on fixed human cadavers, the device setup, suction, and tissue handling were also rated as “good”. No macroscopic tissue compromise or device deterioration was noted. The handling and holding abilities using the daVinci Xi® robotic system were also rated “good”. The device was able to successfully hold over 300 g of tissue at a suction pressure of −600 mmHg. The preliminary evaluation of the THD demonstrated satisfactory results.

Introduction Microsurgery is a surgical technique that uses optical magnification as well as specific instruments to address necessary reconstructive procedures in different medical specialties. The apprenticeship of this technique requires overcoming a steep learning curve. There is a need for standardization of the training criteria in microsurgery. The International Microsurgery Simulation Society (IMSS) was born in 2011, since then its main objective has been to connect the main international specialists and educators of this sub-specialty to share and discuss the ethical and scientific basis of preclinical microsurgery teaching. Methods In order to achieve a consensus on the minimum standards for the organization of basic microsurgery training courses, the requirements for a microsurgical anastomosis global rating scale and minimum thresholds for training, a total of nineteen independent global experts participated in a formal consultative consensus development program. The agreement criteria for each statement was established when consensus of 65–100% was reached. Results There have been established six recommendations concerning minimum standards for a basic microsurgery course, one recommendation in relation to minimum thresholds for training and four recommendations regarding the global rating scale as gold standard for a microsurgical anastomosis assessment. The eleven defined recommendations reached the agreement threshold of 65–100%. Conclusions The development of this consensus sets the minimum recommended requirements for conducting basic microsurgery training courses, as well as suggestions for objective assessment of the learning curve and skills of trainees.

Objective: To report the outcomes of active surveillance (AS) for low-risk prostate cancer (PCa) in a single-center cohort. Patients and Methods: This is a prospective, single-center, observational study. The cohort included all patients who underwent AS for PCa between December 1999 and December 2020 at our institution. Follow-up appointments (FU) ended in February 2021. Results: A total of 413 men were enrolled in the study, and 391 had at least one FU. Of those who followed up, 267 had PCa diagnosed by transrectal ultrasound (TRUS)-guided biopsy (T1c: 68.3%), while 124 were diagnosed after transurethral resection of the prostate (TURP) (T1a/b: 31.7%). Median FU was 46 months (IQR 25–90). Cancer specific survival was 99.7% and overall survival was 92.3%. Median reclassification time was 11.2 years. After 20 years, 25% of patients were reclassified within 4.58 years, 6.6% opted to switch to watchful waiting, 4.1% died, 17.4% were lost to FU, and 46.8% remained on AS. Those diagnosed by TRUS had a significantly higher reclassification rate than those diagnosed by TURP (p < 0.0001). Men diagnosed by targeted MRI/TRUS fusion biopsy tended to have a higher reclassification probability than those diagnosed by conventional template biopsies (p = 0.083). Conclusions: Our single-center cohort spanning over two decades revealed that AS remains a safe option for low-risk PCa even in the long term. Approximately half of AS enrollees will eventually require definitive treatment due to disease progression. Men with incidental prostate cancer were significantly less likely to have disease progression., Cancers, 14 (2), ISSN:2072-6694

Background: The plasmakinetic cautery is a surgical dissection instrument that combines scalpel-like cutting precision with electrocautery-like haemostasis properties, and operates at lower temperatures (40–170 °C) than conventional electrocautery (200–350 °C). The aim of this study is to evaluate the clinical benefits of using plasmakinetic cautery in abdominal free flap dissection for breast reconstruction. Methods: Forty women undergoing abdominal-based microsurgical breast reconstruction (DIEP/MS-TRAM) were randomized to plasmakinetic cautery (n=20) or conventional electrocautery (n=20) for dissection of the abdominal free flap. Total abdominal wound drainage volume/duration, operation time and complications such as seroma and haematoma were examined. Results: Age, body mass index, type of reconstruction and abdominal flap weight were similar in both groups. Mean abdominal drainage volume was (279±262) mL in conventional electrocautery group and (294±265) mL in plasmakinetic cautery group (P=0.853). Plasmakinetic cautery group mean drainage duration (4.3±2.2 days) was no difference compared to conventional diathermy group (3.8±2.0 days, P=0.501). Mean operation time in the conventional electrocautery group and plasmakinetic cautery group was 157±50 vs . 174±70 min respectively (P=0.195). There was more seroma detected in the conventional electrocautery group compared to plasmakinetic cautery group at days 7, 14 and 42 post-operation, but this was not statically significant. 2 haematomas in conventional diathermy group and 1 haematoms in the plasmakinetic cautery group required evacuation. Conclusions: This study demonstrates that there are no significant differences between the use of plasmakinetic cautery and conventional electrocautery for abdominal free flap dissection.

Autologous breast reconstructions have grown in popularity because of their durability, aesthetic outcomes, symmetry, increase in external beam radiotherapy use, and potential aesthetic enhancement at the donor site. Increasing patient expectations for predictable high aesthetic outcomes with minimal complications or need for further procedures has been met by refinement in the use of flaps. The authors' microsurgical breast reconstruction center aims to provide this while delivering efficient service. The deep inferior epigastric flaps form 85% and transverse upper gracilis and profunda artery perforator flaps account for 10%; lumbar artery perforator flaps are a new addition to the authors' armamentarium.

Summary Introduction This study evaluates COVID-19 related patient risk, when undergoing management within one of the largest specialist centres in Europe, which rapidly implemented national COVID-19 safety guidelines. Method A prospective cohort study was undertaken in all patients who underwent surgical (n = 1429) or non-operative (n = 191) management during the UK COVID-19 pandemic peak (April–May 2020); all were evaluated for 30-day COVID-19 related death. A representative sample of elective/trauma/burns patients (surgery group, n = 729) were selected and also sub-analysed within a controlled cohort study design. Comparison was made to a random selection of non-operatively managed (non-operative group, n = 100) or waiting list (control group, n = 250) patients. These groups were prospectively followed-up and telephoned from the end of June (control group) or at 30 days post-first assessment (non-operative group)/post-operatively (surgery group). Results Complex general (9.2%, 136/1483) or regional (5.0%, 74/1483) anaesthesia cases represented 14.2% (210/1483) of operations undertaken. There were no 30-day post-operative (0/1429)/first assessment (0/191) COVID-19 related deaths. Neither the three sub-speciality plastic surgery, or non-operative groups, displayed increases in post-operative/first assessment symptoms in comparison to each other, or to control. The proportion of COVID-19 positive tests were: 7.1% (1/14) (non-operative), 5.9% (2/34) (burns) and 3.0% (3/99) (trauma); there were however no significant differences between these groups, the elective (0%, 0/54) and control (0%, 0/24) groups (p = 0.236). Conclusion We demonstrate that even heterogeneous sub-speciality patient groups, who required operative/non-operative management, did not incur an increased COVID-19 risk compared to each other or to control. These highly encouraging results were achieved with described, rapidly implemented service changes that were tailored to protect each patient group and staff.

BACKGROUND Portable high-frequency ultrasound is a useful adjunct to a plastic surgeon's practice. With a short learning curve, this patient-friendly imaging modality has a variety of uses that aid patient management/treatment plans. The authors describe clinical cases and review the literature regarding ultrasound performed by the surgeon. METHODS The Sonosite S-Nerve machine with the L25X transducer was used (depth, 4.3 cm). Clinical cases that ordinarily would have been referred to the radiology department were taken from the day-to-day practice of the senior author (M.G.). The clinical scenarios ranged from acute presentations to planned elective settings. RESULTS Ultrasound was a useful adjunct in a variety of applications, ranging from acute hand trauma visualizing neurovascular bundles and tendons, to elements of reconstructive breast surgery such as fat grafting over an implant and scar release. The ultrasound machine was also used for determination of the depth and size of collections such as seromas to facilitate drainage, for identification of lymph nodes before transfer, and for acute presentations of conditions ranging from undiagnosed swelling to foreign body localization. CONCLUSIONS The portable ultrasound machine has become an invaluable tool in the senior author's practice. In a short time and with a short learning curve, the authors' unit identified numerous applications for its use. From a patient perspective, it is noninvasive/nonpainful and has no deleterious radiation effects, and treatment plans can be enacted without delay. It is highly recommended that surgeons become familiar with this imaging modality and assimilate it into their daily practice. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.

Background: The transverse upper gracilis (TUG) flap is the senior authors’ second choice for autologous breast reconstruction when the DIEP flap is not available. It provides durable, pliable tissue with well hidden scars. The main criticism of this flap is the limited volume, donor site complications, short pedicle and vessel mismatch depending on which recipient vessels are used. We described methods of reducing vessel mismatch, complications of venous coupler and refinements to help give a more superior aesthetic outcome. Methods: We describe several maneuvers to help reduce vessel mismatch with the use of the internal mammary (IM) perforator vessels with a modification of the Harashina fish-mouth technique or the use of a vessel bifurcation to increase vessel diameter. We also describe the optimum method of perforator preparation and potential methods to prevent palpable venous couplers. The author’s describe their case series of 14 TUG flaps to reconstruct 13 breasts in 12 patients. Results: Eight unilateral, 2 partial breast reconstruction, 1 bilateral and 1 bilateral TUG flap for a unilateral reconstruction was carried out. All flaps survived with one partial flap necrosis, one donor site seroma and two cases of palpable/tender venous couplers. The mean reconstructed breast was 320 grams. Conclusions: The TUG flap is a reconstructive challenge, but with correct planning a good aesthetic outcome is possible. The IM perforator is our first choice recipient vessel in TUG breast reconstructions. With meticulous preparation and by overcoming vessel mismatch the use of this recipient vessel is a reliable option.

Summary:. We present the “needle-splint” technique, a microsurgical suturing technique that enhances micro-suturing technique, while ensures finer apposition and vessels walls eversion during the placement of sutures in microvascular anastomosis. This report demonstrates the usefulness of this technique in simple interrupted, continuous-interrupted, or multi-loops microsurgical suturing. It further allows direct visualization of the intra-wall-edges space and intimal sutures surface and could be utilized as a safety stabilizer to errors as it allows optimal vessels alignment while the needle curvature is acting as a “pusher” to separate the posterior wall during knot tying.

Therapeutic mammaplasty (TM) may be an alternative to mastectomy, but few well designed studies have evaluated the success of this approach or compared the short-term outcomes of TM with mastectomy with or without immediate breast reconstruction (IBR). Data from the national iBRA-2 and TeaM studies were combined to compare the safety and short-term outcomes of TM and mastectomy with or without IBR.The subgroup of patients in the TeaM study who underwent TM to avoid mastectomy were identified, and data on demographics, complications, oncology and adjuvant treatment were compared with those of patients undergoing mastectomy with or without IBR in the iBRA-2 study. The primary outcome was the percentage of successful breast-conserving procedures in the TM group. Secondary outcomes included postoperative complications and time to adjuvant therapy.A total of 2916 patients (TM 376; mastectomy 1532; mastectomy and IBR 1008) were included in the analysis. Patients undergoing TM were more likely to be obese and to have undergone bilateral surgery than those having IBR. However, patients undergoing mastectomy with or without IBR were more likely to experience complications than the TM group (TM: 79, 21·0 per cent; mastectomy: 570, 37·2 per cent; mastectomy and IBR: 359, 35·6 per cent; P 0·001). Breast conservation was possible in 87·0 per cent of patients who had TM, and TM did not delay adjuvant treatment.TM may allow high-risk patients who would not be candidates for IBR to avoid mastectomy safely. Further work is needed to explore the comparative patient-reported and cosmetic outcomes of the different approaches, and to establish long-term oncological safety.La mamoplastia terapéutica (therapeutic mammaplasty, TM) puede ser una alternativa a la mastectomía, pero hay pocos estudios bien diseñados que hayan evaluado el éxito de esta estrategia o hayan comparado los resultados a corto plazo de la TM con la mastectomía con o sin (+/-) reconstrucción mamaria inmediata (immediate breast reconstruction, IBR). Para comparar la seguridad y los resultados a corto plazo de la TM y la mastectomía +/- IBR se combinaron los datos de los estudios nacionales iBRA-2 y TeaM. MÉTODOS: En el estudio TeaM se identificó el subgrupo de pacientes al que se realizó una TM para evitar la mastectomía y se compararon los datos demográficos, las complicaciones, los resultados oncológicos y el tratamiento adyuvante con las pacientes sometidas a mastectomía +/- IBR del estudio iBRA-2. La variable principal fue el porcentaje de éxito de la cirugía conservadora de mama en el grupo TM. Las variables secundarias fueron las complicaciones postoperatorias y el intervalo de tiempo hasta el inicio del tratamiento adyuvante.Se incluyeron en el análisis 2.916 pacientes (TM n = 376; mastectomía n = 1.532; IBR n = 1.008). La TM era más frecuente en pacientes obesas o en las sometidas a cirugía bilateral en comparación con las pacientes con IBR. Sin embargo, las pacientes sometidas a una mastectomía +/- IBR tenían más probabilidades de desarrollar complicaciones que las del grupo TM (TM n = 79, 21,0%; mastectomía n = 570, 37,2%; mastectomía y IBR n = 359, 35,6%; P 0,001). La conservación de la mama fue posible en el 87% de las pacientes con TM y el procedimiento no retrasó el inicio del tratamiento adyuvante. CONCLUSIÓN: La TM puede permitir que pacientes de alto riesgo que no serían candidatas a IBR eviten la mastectomía de una forma segura. Se necesitan más trabajos para comparar los resultados percibidos por las pacientes y los estéticos de las diferentes estrategias terapéuticas y establecer la seguridad oncológica a largo plazo.

INTRODUCTION: There is paucity of data on primary interposition vascular grafts (IVG) use in microsurgery. Our study examines the characteristics, indications and outcomes of IVG in free flap breast reconstruction. METHODS: All cases of breast reconstruction with free flaps between January 2013 and June 2018 were examined and cases with primary IVG were included. Data were collected on patient, flap and graft characteristics, indications and outcomes. RESULTS: A total of 76 IVG, specifically 65 vein grafts and 11 arterial grafts, were used for 49 (of 1547) flaps in 48 (of 1346) cases. Of these, 52 grafts were primarily used to lengthen the pedicle and aid flap inset and 24 grafts to augment venous flow; 49 grafts were harvested from the flap harvest site, 7 from the anastomosis recipient site and 20 from a separate site. Of the total, 16.7% (8/49 flaps) required salvage procedures - seven cases for venous congestion and one for ischaemic compromise - in comparison to 4.3% in cases without IVG (65/1498) (p

LV thrombus is a possible complication of anterior wall MI. It is imperative to recognize and understand the difficulty in management in the event of stenosis or requirement of percutaneous intervention in the presence of a LV thrombus. 59 y/o male with history of HTN, CAD, HIV presented to the

BACKGROUND Microvascular free tissue transfer has become the gold standard for breast reconstruction. While safe and reliable, there are operative complications, with hematomas developing under the free flap among the more common. These can compromise flap viability, lead to hemodynamic instability and infection. This study aims to identify predictors of hematomas following free-flap breast reconstruction. METHODS A prospective study was undertaken of patients undergoing autologous free-flap breast reconstruction over a 4-year period. Precise times to hematoma formation, age, arterial and venous anastomosis time, and anastomosis length were recorded and analyzed for association with time to hematoma formation. RESULTS One thousand two hundred twelve flaps were undertaken in 1,070 patients during the period of review. Seventy-one (5.8%) flaps were taken back to theater for hematomas. Immediate reconstruction had a significantly higher hematoma rate compared to delayed reconstruction 7.4% versus 5.2% (p

Summary Introduction We sought to review the current state of robotics in this specialty. Methods A Pubmed and Medline search was performed using key search terms for a comprehensive review of the whole cross-section of plastic and reconstructive practice. Results Overall, 28 publications specific to robotic plastic and reconstructive procedures were suitable for appraisal. Conclusion The current evidence suggests robotics is comparable to standard methods despite its infancy. The possible applications are wide and could translate into superior patient outcomes.

Background Prophylactic mastectomy (PM) has become increasingly common but is not without complications especially if accompanied by reconstructive surgery. In patients with sporadic unilateral breast cancer, contralateral PM offers no survival advantage. Multidisciplinary team (MDT) communication and interaction may facilitate shared decision-making and curtail PM rates. The aim of this study was investigate the effect of a regional MDT meeting on PM decision-making. Methods We conducted an observational study involving retrospective review of prospectively recorded MDT meeting records for a 151 patient requests for PM from 2011 to 2014. Final MDT decisions were recorded as PM ‘accepted’, ‘declined’ or ‘pending’. For MDT sanctioned requests, the factors justifying PM were recorded. Where PM was declined, justification for MDT refusal was sought and recorded. Results Approximately half of all requests for PM have been upheld (53.0%) and 1/3 of requests have been declined (32.5%). Of those declined, low risk of contralateral breast cancer versus relatively high risk of systemic relapse were commonly cited as justification for PM refusal (45.7%). A proportion of patients who initiated PM discussion subsequently changed their minds (19.6%), or failed to attend clinic appointments (6.5%). Some patients were deemed medically unfit for complex reconstructive surgery (13%), or were declined on the basis of an apparent cosmetic drive for surgery (6.5%), concerns regarding depression or anxiety (2.2%) and/or if family history could not be substantiated (6.5%). Discussion MDT meetings facilitate cross-specialty interrogation of requests for PM, minimise unnecessary surgery and restrict PM to those likely to derive maximum benefit.

Process mapping has been identified as a strategy to improve surgical efficiency but has been inconsistently applied in the literature and underutilised in surgical practice. In this journal, we recently described our utilisation of these approaches when applied to breast reconstruction. We showed that in surgery as complex as autologous breast reconstruction, process mapping can improve efficiency, and may improve surgical teaching, education and audit. The intraoperative period specifically is an area that can be applied not only to breast reconstruction, but to a much broader range of surgical procedures. A systematic review was undertaken of the databases Ovid MEDLINE, Allied and Complementary Medicine Database, Embase and PsychINFO. Manual searching of the references from articles identified was also conducted. Data items relating to the review aims were extracted from articles' methods, applications, and outcomes. A descriptive analysis was carried out to synthesise the information on the current usage of process mapping in the intraoperative period. Seventeen of 1,488 studies were eligible for review, with all of non-randomised study design. Studies had overlap in components of the intraoperative period to which process mapping was applied. Common areas of improvement were identified. Outcome measures were assessed in ten studies that implemented interventions based on the improvement areas to increase surgical efficiency. As such, process mapping has been used as part of larger quality improvement methods, albeit with inconsistent nomenclature, to improve surgical efficiency. While it has been applied to a range of surgical specialties, there is a lack of application to the surgical component of the intraoperative period. Greater consistency in the reporting and description of process mapping will enable further research for evidence of its benefits.

Background: An increasing number of women undergo mastectomy for breast cancer and postmastectomy autologous breast reconstruction has been shown to significantly improve the psychosexual wellbeing of the patients. A goal of treatment is to achieve symmetry and projection to match the native breast, and/or the contralateral breast in the case of a unilateral reconstruction. Autologous reconstruction, particularly with the deep inferior epigastric artery perforator (DIEP) flap, is particularly advantageous as it can be manipulated to mimic the shape and turgor of the native breast. However, very few techniques of shaping the breast conus when insetting the DIEP flap to enhance aesthetic outcome have been reported to date. With the aide of three-dimension (3D) photography and 3D-printed mirrored image of the contralateral breast as a guide intraoperatively, we describe our St Andrew’s coning technique to create a personalized flap projection. Method: We report a prospective case series of 3 delayed unilateral breast reconstructions where symmetrization procedure to the contralateral breast was not indicated. Using a commercial 3D scanner (VECTRA XR, Canfield Scientific), the breast region was imaged. The mirrored image was 3D-printed inhouse using a desktop 3D printer. Results: In all cases, projection of the breast mound was able to be safely achieved, with a demonstrated central volume (or ‘cone’) able to be highlighted on imaging and a 3D printed breast. A 3D print of the contralateral breast was able to be used intraoperatively to guide the operative approach. Conclusions: The St Andrew’s coning technique is a useful aesthetic maneouver for achieving breast projection during DIEP flap breast reconstruction, with 3D imaging techniques able to assist in perioperative assessment of breast volume.

Summary Since the first description of "The free abdominoplasty flap for breast reconstruction" by Hans Holmstrom in 1979, [see Ref. 1] the use of lower abdominal tissue has revolutionised reconstruction of the breast. DIEP (deep inferior epigastric perforator) free flap offers an abundance of reconstructive material, aesthetically-pleasing results and limited donor site morbidity. We report our first case of breast reconstruction with what presently is known as DIEP flap, performed in 1991 at St. Andrew's Centre for Plastic Surgery and Burns in Essex, The United Kingdom and the recent follow up results. We also discuss the historical events surrounding the evolution of this unpublished case and other documented cases.

Summary Introduction PI as an independent indicator of resistance to flow is a widely-accepted alternative index to measurement of flow volume in vessels. This study aimed to determine the normal values and chronological trend of PI of abdominal wall free flaps in breast reconstruction and to revalidate its clinical relevance in post-operative monitoring of these flaps. Materials and methods 47 patients with breast reconstruction using DIEP, MS-TRAM and bi-pedicled DIEP flaps were assessed for PI of the supplying perforator vessels using a hand-held colour Doppler ultrasound device over 6 post-operative days. Triplicate measurements were obtained by one operator once daily concurrently with haemodynamic parameters. Results DIEP flaps demonstrate a descending trend of PI and resistance to blood flow post-operatively ( p = 0.005) similar to non-perforator free flaps. MS-TRAM flaps show higher initial PI values and vascular resistance compared to DIEP flaps ( p = 0.038). PI values show no correlation with haemodynamic parameters ( r = 0.2, n = 38). Flaps with venous insufficiency demonstrate significantly higher values of PI ( p = 0.03). Conclusions PI is an objective, non-invasive, efficient, easy-to-measure, reproducible and quickly-responsive indicator of perfusion of DIEP flaps.

Developmental breast asymmetry (DBA) can affect psychosocial well-being in the young female. Correction of breast asymmetry may present a reconstructive challenge, especially in tuberous breasts. Fifty-two cases of DBA treated between January 2002 and January 2006 were reviewed. Preoperative clinical assessment of the specific anatomical deformity, subsequent surgical treatment modalities, esthetic outcome, and patient's satisfaction were evaluated. Surgical modalities used in our series include augmentation mammaplasty with or without tissue expansion, parenchymal scoring, nipple areola complex reduction, glanduloplasty techniques, mastopexy and reduction mammaplasty. The mean age of DBA presentation was 21 years; 69% (36/52) patients had tuberous breasts, of which 67% (24/36) were unilateral and 33% (12/36) were bilateral deformities. Patients with tuberous breast deformity presented consistently under the age of 25 years. Esthetic outcome was rated "good" in 75% (39/52), and symmetry rated as "good" in 58% (30/52) by professional evaluation. Surgical treatment is tailored to the affected esthetic units of the individual breast. In our experience, symmetry is the hardest parameter to achieve, particularly in tuberous breasts. Operative treatment is of great value to the psychosocial well-being of the patient. A conceptual approach in the assessment and treatment of DBA is emphasized by this series.

Summary Microsurgery is an essential component in plastic surgery training. Competence has become an important issue in current surgical practice and training. The complexity of microsurgery requires detailed assessment and feedback on skills components. This article proposes a method of Structured Assessment of Microsurgery Skills (SAMS) in a clinical setting. Three types of assessment (i.e., modified Global Rating Score, errors list and summative rating) were incorporated to develop the SAMS method. Clinical anastomoses were recorded on videos using a digital microscope system and were rated by three consultants independently and in a blinded fashion. Fifteen clinical cases of microvascular anastomoses performed by trainees and a consultant microsurgeon were assessed using SAMS. The consultant had consistently the highest scores. Construct validity was also demonstrated by improvement of SAMS scores of microsurgery trainees. The overall inter-rater reliability was strong ( α =0.78). The SAMS method provides both formative and summative assessment of microsurgery skills. It is demonstrated to be a valid, reliable and feasible assessment tool of operating room performance to provide systematic and comprehensive feedback as part of the learning cycle.

Inguinal lymphadenectomy is associated with considerable morbidity, and several attempts have been made to minimize the morbidity by well-vascularized flaps of adequate bulk to obliterate the dead space and promote wound healing. In the case of recurrence, the overlying skin is usually involved and the reconstructive surgeon is confronted with exposed femoral vessels and complex groin defects. We report a series of 40 patients that underwent inguinal lymphadenectomy and immediate sartorius transposition for skin malignancies, and 4 patients with recurrence that was treated with radical surgical excision and pedicled anterolateral thigh flap (ATL). We examined complications such as infection, skin necrosis, lymphorea, lymphoedema, and wound healing time. The immediate sartorius transposition was associated with 7.5% infection rate, 5% superficial skin edge necrosis, 0% of persistent lymph, and 27.5% of mild lymphoedema. All ALT flaps survived completely and wounds healed uneventfully within 2 weeks without any signs of infection, seroma, or wound dehiscence.Sartorius and ALT flap are reliable methods to reconstruct the groin following inguinal lymphadenectomy. They ensure low complication rate with no donor site morbidity, and should be the first line treatment of immediate and secondary groin reconstruction, respectively.

Recent advances in breast reconstruction allow for high expectations regarding long-term symmetry and aesthetic appearance. The DIEP flap is currently considered as an ideal autologous reconstruction. However, there are situations in which the amount of tissue from a DIEP flap is not enough to achieve adequate symmetry. Indications and outcomes for a combined use of DIEP flap and implants are discussed in order to describe and examine a further scenario in optimising breast reconstruction. Between January 2004 and January 2006, all patients who underwent combined DIEP/implant breast reconstruction have been collected and followed prospectively. When clinical assessment demonstrated inadequate amount of tissue in the abdominal region to achieve a suitable unilateral or bilateral reconstruction with DIEP flaps, the patients were counselled about the opportunity of primary augmentation of the DIEP flaps. In cases where DIEP breast reconstruction has been done previously and there is a considerable asymmetry, delayed flap augmentation was considered. Patient's age, indication for surgery, preoperative and postoperative radiotherapy (RT), operative procedure, implant size, location and timing of insertion, complications, outcomes, and follow-up have been gathered. In all cases, textured round silicone gel implants have been used. After 12 months, four-point scales were used to analyse patients' satisfaction and aesthetic outcome. During the study period, 156 patients underwent breast reconstruction with 174 DIEP flaps. Fourteen patients (8.9%) had breast reconstruction with 19 DIEP flaps and 18 implants. The mean follow-up was 20.6 months (range 12-32 months). Fourteen implants were placed primarily at the time of DIEP reconstruction. The average implant weight was 167.2g with range between 100 and 230 g. Implant/flap weight ratio is about 1:5 corresponding to 20%. In six flaps, the patients had RT before the reconstruction, whilst in three cases of delayed DIEP flap augmentation the patients had RT after the DIEP post-mastectomy reconstruction. One infection and one haematoma, both followed by flap partial necrosis, occurred. After 12 months following the completion of reconstruction, aesthetic scores were all between good and excellent. Surgical indications and outcomes available from this series demonstrate that primary and delayed DIEP/implant augmentation can be a safe and effective option in optimising breast reconstruction with autologous tissue.

The authors describe the history of breast reconstruction and the anatomy of the DIEP flap including the arterial system of the anterior abdominal wall, DIEA musculocutaneous perforators, DIEA perfusion zones and the venous system of the anterior abdominal wall. There is a discussion of the extended DIEP Flap, extended DIEP by vasculature (stacked flap) and extended DIEP by volume (shelving flap).

Background: Nipple-preserving mastectomy and immediate reconstruction has further improved the aesthetic outcome of skin-sparing mastectomy. To investigate the effect of the type of reconstruction technique on aesthetic outcome, three different methods of reconstruction were compared using four evaluation modalities. Methods: Sixty-one cases of nipple-sparing envelope mastectomy with immediate reconstruction were studied, with a mean follow-up of 48 months. The methods of reconstruction used were implant-only reconstruction, pedicled latissimus dorsi muscle with implant, and deep inferior epigastric perforator flap. Evaluation methods were objective applanation tonometry, clinical evaluation, photography-based assessment, and patient satisfaction survey. Results: All three reconstruction methods achieved good evaluation scores in the four modalities. However, in patients who had postoperative radiotherapy, objective tonometry showed that the breast remained softer in deep inferior epigastric perforator flap reconstruction. Conclusion: In patients who are undergoing nipple-preserving envelope mastectomy with immediate reconstruction and who are likely to have postoperative radiotherapy, deep inferior epigastric perforator flap reconstruction achieved a better aesthetic outcome.

Background Locally advanced breast cancer (LABC) and chest wall osteoradionecrosis (ORN) often require extensive and composite tissue resection, including muscles, ribs, pleura, and lung parenchyma. As such, these cases necessitate complex reconstructive procedures for skeletal chest wall reconstruction and soft tissue resurfacing of extensive defects. Traditional local and regional flaps are often inadequate, and many such cases are prospectively labeled “unresectable.” Methods We report a single-center experience with the microsurgical reconstruction of such defects over a 5-year period. Between 2007 and 2011, 1,077 microvascular reconstructive cases following breast cancer resection were performed, of which 26 cases comprised LABC or ORN requiring reconstruction. Surgical indications, defect parameters, choice of reconstruction, and outcomes were assessed. Results Thirty free flap microsurgical reconstructions were undertaken in 26 cases, with a 96.2% flap survival rate. Complications were low, and mean hospital stay was 8.7 days. An algorithmic approach to management is presented. Conclusion Wide resection and microvascular free tissue transfer provide versatile solutions for the reconstruction of extensive chest wall defects. With good reported perioperative outcomes even in advanced cases, surgical resection of LABC may offer a useful approach in difficult and/or palliative cases.

Summary Aim To determine the long term oncological safety and aesthetic acceptability of envelope mastectomy and immediate reconstruction (EMIR). Patients and methods A retrospective review of 71 cases was carried out. Oncological assessment was by clinical examination, mammography, ultrasound, and, where indicated, MRI scan. Aesthetic assessment was based on detailed clinical examination as well as subjective self-assessment of the outcome. Results During follow-up (mean 48 months), there were three local recurrences, only one involving the nipple-areolar complex. The mean aesthetic score was 0.75 (out of 1), representing a good aesthetic outcome and patient satisfaction. Conclusion Nipple-areolar complex preservation is a safe option and EMIR produced a good aesthetic outcome, which is oncologically safe. Furthermore, it does not preclude post-operative radiotherapy.

The deep inferior epigastric perforator (DIEP) flap is ideally suited for breast reconstruction. The DIEP flap reduces abdominal wall morbidity when compared to a transverse rectus abdominis (TRAM) flap, however, there maybe a compromise of the flap vascularity. Early venous problems and late fat necrosis in DIEP flaps can occur. There is a limited literature on the haemodynamic and microcirculation of the DIEP flap. Sixteen consecutive patients who underwent immediate breast reconstruction with DIEP flap were prospectively monitored during the post-operative time for a minimum period of 48h using laser Doppler flowmetry (LDF) and lightguide reflectance spectrophotometry (LRS) to analyse blood flow and oxygenated haemoglobin percentage in the cutaneous microcirculation of the flap. LDF demonstrated an increase of capillary flow in comparison to the pre-operative levels. LRS showed an initial decrease of the values and a varying pattern of increase in relation to time, to reach the pre-operative levels. A correlation between lower values of post-operative LDF and LRS measurements and late fat necrosis and early venous congestion was demonstrable in this series. This study demonstrates a change in the cutaneous microcirculation of the lower anterior abdominal wall following its elevation as a DIEP flap. These findings could explain the clinical phenomenon occurring in this flap in the early post-operative period. Significant correlation between longer harvesting time and re-exploration and between longer ischaemia time and localised fat necrosis was found.

Since the first reported use of lower abdominal tissue from the lower abdominal skin and fat by Hans Holmstrom in 1979, there have been over 300 publications on this subject. The refinements have been aimed at the limitation of donor morbidity and to allow a predictable success of the transfer. This article analyses the landmarks and highlights the key developments in this area. The more recent development in this area - the Deep Inferior Epigastric Perforator flap is discussed.

Background: In cases of bilateral breast reconstruction when the deep inferior epigastric perforator (DIEP) free flap alone does not provide sufficient volume for body-specific reconstruction, stacking each DIEP flap with a second free flap will deliver added volume and maintain a purely autologous reconstruction. Stacking the profunda artery perforator (PAP) flap with the DIEP flap offers favorable aesthetics and ideal operative efficiency. We present the indications, technique, and outcomes of our experience with 4-flap breast reconstruction using stacked DIEP/PAP flaps. Methods: The authors performed 4-flap DIEP/PAP breast reconstruction in 20 patients who required bilateral reconstruction without adequate single donor flap volume. The timing of reconstruction, average mastectomy/flap weights, and operative time are reported. Complications reviewed include fat necrosis, dehiscence, hematoma, seroma, mastectomy flap necrosis, and flap loss. Results: Twenty patients underwent 4-flap DIEP/PAP breast reconstruction. Surgical time averaged 7 hours and 20 minutes. The primary recipient vessels were the antegrade and retrograde internal mammary vessels. No flap losses occurred. Complications included 1 hematoma, 1 incidence of arterial and venous thrombosis successfully treated with anastomotic revision, 1 incidence of thigh donor site dehiscence, and 3 episodes of minor mastectomy skin flap necrosis. Conclusions: Four-flap breast reconstruction is a favorable autologous reconstructive option for patients requiring bilateral reconstruction without adequate single donor flap volume. Stacking DIEP/PAP flaps as described is both safe and efficient. Furthermore, this combination provides superior aesthetics mirroring the natural geometry of the breast. Bilateral stacked DIEP/PAP flaps represent our first choice for breast reconstruction in this patient population.

A one-stage procedure combining a V-Y advancement flap with a composite graft for the reconstruction of alar-lobule and alar-groove defects is described. After tumour resection, a V-Y flap is advanced and retained at the level of the piriform margin to fill the dead space. To provide vascular support to the composite graft and to recreate the alar groove the advancing edge of the flap is de-epithelialised. In the same stage the composite graft is harvested and placed into the alar defect. A series of 12 patients underwent this procedure, with good results.