Bilateral breast reconstruction with deep inferior epigastric perforator flaps in slim patients.

BACKGROUND: Slim women are not always considered candidates for bilateral autologous breast reconstruction. The study aims to assess the volume considerations and complications of deep inferior epigastric perforator (DIEP) flap in bilateral breast reconstruction among slim patients. METHODS: All patients undergoing bilateral DIEP breast reconstruction at the Royal Marsden Hospital, London, September 2007-March 2015, were reviewed. Flap weight was compared to mastectomy weight (weight ratio) and complications were recorded. Subgroup analyses according to Body Mass Index (BMI) were performed. RESULTS: One-hundred seventy patients (340 flaps) were included. There were 42 in the slim-group (BMI <25) (84 flaps), 70 in the traditional (BMI = 25.0-29.9) (140 flaps), and 58 in the obese (BMI >30) (116 flaps). There were no significant differences in reconstruction weight ratio between the slim and the traditional groups (1.04 ± 0.31 versus 0.95 ± 0.38, p = .267). When comparing the slim to obese group the ratio was lower for the obese group, inferring that a larger reconstruction was performed (p = .016). Complications was less frequent in the slim group compared to the traditional and the obese groups (31% compared to 50% and to 53% (p = .060 and p = .021, respectively). Donor-site specific complications did not differ between groups (29% 26% and 29%; p = .823 and .830, respectively). CONCLUSION: The DIEP flaps may be a safe option for bilateral breast reconstruction among patients with BMI <25 without sacrifice in volume or increase in donor-site complications; low BMI does not in itself contraindicate bilateral DIEP breast reconstruction.

HoloLens in Breast Reconstruction: What Is the Future?

SUMMARY: Autologous breast reconstruction using the deep inferior epigastric perforator flap has been established as the standard for perforator-based free-flap breast reconstruction. This technique relies on the surgeon's ability to identify the patient's relevant abdominal vasculature to facilitate accurate dissection, optimize surgical outcomes, and minimize morbidity. A technique is described in which the authors incorporate augmented reality using HoloLens technology in their surgical planning to identify epigastric arteries and perforators. This technology allows the surgeon to superimpose computed tomography angiography images directly onto the patient, facilitating an in vivo appreciation of underlying anatomy before incision and dissection. This allows real-time surgical planning, increasing the value and tangibility of preoperative computed tomography angiography with the potential to enhance the accuracy and efficiency of the operative technique. Although the authors did not use the HoloLens technology to make clinical decisions, they provide evidence of its accuracy and ease of use, offering a proof of concept. The potential of this technology is demonstrated, and the authors encourage future application in free-flap breast reconstruction and beyond.

Isolated post laparoscopic DIEA injury in bilateral DIEP breast reconstruction.

Scarring from previous open abdominal surgery in patients undergoing autologous deep inferior epigastric perforator (DIEP) breast reconstruction has been reported to increase overall flap and donor site complication rates. The evidence to date demonstrates that it can be performed safely although with significantly higher postoperative donor site morbidity. It would seem logical that minimal access laparoscopic surgery is less likely to be associated with increased risks to flap vascularity or donor-site complications; however, there is little evidence available in the literature about the impact of previous laparoscopic surgery to the DIEP harvest site. The typical positions for port placement in standard laparoscopic procedures are usually distant from ideal perforator locations reducing the risk of perforator damage. We present a case of unilateral isolated injury to the proximal deep inferior epigastric artery (DIEA) following previous laparoscopic abdominal surgery in a patient undergoing bilateral mastectomy and breast reconstruction with bilateral free DIEP flaps.

Microsurgical refinements with the use of internal mammary (IM) perforators as recipient vessels in transverse upper gracilis (TUG) autologous breast reconstruction.

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.

Microsurgery simulation training system and set up: An essential system to complement every training programme.

INTRODUCTION: Microsurgical techniques are essential in plastic surgery; however, inconsistent training practices, acquiring these skills can be difficult. To address this, we designed a standardised laboratory-based microsurgical training programme, which allows trainees to develop their dexterity, visuospatial ability, operative flow and judgement as separate components. METHOD: Thirty trainees completed an initial microsurgical anastomosis on a chicken femoral artery, assessed using the structured assessment of microsurgical skills (SAMS) method. The study group (n = 18) then completed a 3-month training programme, while the control group (n = 19) did not. A final anastomosis was completed by all trainees (n = 30). RESULTS: The study group had a significant improvement in the microsurgical technique, assessed using the SAMS score, when the initial and final scores were compared (Mean: 24 SAMS initial versus 49 SAMS final) (p < 0.05, Wilcoxon's rank test). The control group had a significantly lower rate of improvement (Mean: 23 SAMS initial versus 25 SAMS final). There was a significant difference between the final SAMS score of the study group and that of senior surgeons (Mean: 49 study final SAMS versus 58 senior SAMS). CONCLUSION: This validated programme is a safe, cost-effective and flexible method of allowing trainees to develop microsurgical skills in a non-pressurized environment. In addition, the objectified skills allow trainers to assess the trainees' level of proficiency before operating on patients.

Overview of gynaecological and colorectal reconstruction.

Plastic surgeons are often required to reconstruct defects following radical pelvic surgery for advanced or recurrent anorectal and gynaecological malignancies. This article describes the most commonly used flaps for reconstruction following radical pelvic surgery and provides a treatment algorithm to facilitate decision making.

Prospective randomized controlled trial: fibrin sealant reduces split skin graft donor-site pain.

BACKGROUND: Pain at split skin graft donor sites is common. Fibrin sealant has been demonstrated to reduce time to hemostasis at wound sites, and patients receiving this treatment were incidentally noted to report less pain. This study aimed to evaluate pain and incapacity in split skin graft donor sites treated with and without fibrin sealant. METHODS: Fifty patients requiring thigh donor-site split skin grafts were prospectively randomized to receive either a self-adhesive fabric dressing alone or fibrin sealant plus the self-adhesive fabric dressing as primary donor-site dressings. External secondary dressings were the same. Patients were blinded with regard to treatment group. Using visual analogue scales (scored 0 to 5), patients rated their donor-site pain and incapacity for 14 days postoperatively. Secondary endpoints were length of hospital stay and duration of requirement for dressings. RESULTS: Forty patients were included in the study analysis and completed self-reported pain and incapacity scores. Twenty received the fibrin sealant plus self-adhesive fabric dressing and 20 received the fabric dressing only (controls). Patients using the fibrin sealant plus the dressing reported significantly less pain (mean score, 0.42 versus 1.60, p < 0.001) and significantly less incapacity (mean score, 0.48 versus 1.71, p < 0.001). Patients allocated to the fibrin sealant group recorded shorter lengths of stay and faster time to discontinuation of dressing, though statistical significance was not achieved. CONCLUSION: Patients whose split skin graft donor sites were dressed with fibrin sealant plus self-adhesive fabric dressing experienced significantly less pain and incapacity than patients with self-adhesive fabric dressings alone, allowing a more rapid return to normal activity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Technical tip: coverage of the wrist arthroscopy tower using a sterile concentrical endoscopy camera drape.

Wrist arthroscopy allows complete visualization under magnification and is essentially a diagnostic and therapeutic tool. The first wrist arthroscopy was described by Chen in 1979. Since then, the indications and applications for wrist arthroscopy continue to expand as new techniques and instrumentation evolve.

Customised silicone prostheses for the reconstruction of chest wall defects: technique of manufacture and final outcome.

Chest wall reconstruction with a customised silicone prosthesis in 13 patients (five patients with pectus excavatum, six Poland's syndrome and two with post-surgical chest wall deformity) is presented. An alginate impression or CT scan with three-dimensional reconstruction was used to produce the final mould from which the silicone prosthesis was fabricated. The surface of the silicone implant was roughened to reduce capsular contracture and holes were incorporated to allow for tissue integration. Twelve patients had aesthetically acceptable results after a mean of 5 years follow up. This series indicates that accurate assessment of the defect, modifications on manufacture and proper placement of the implant result in a more satisfactory final outcome.