Canadian Expert Opinion on Breast Reconstruction Access: Strategies to Optimize Care during COVID-19.

BACKGROUND: Breast reconstructive services are medically necessary, time-sensitive procedures with meaningful health-related quality of life benefits for breast cancer survivors. The COVID-19 global pandemic has resulted in unprecedented restrictions in surgical access, including access to breast reconstructive services. A national approach is needed to guide the strategic use of resources during times of fluctuating restrictions on surgical access due to COVID-19 demands on hospital capacity. METHODS: A national team of experts were convened for critical review of healthcare needs and development of recommendations and strategies for patients seeking breast reconstruction during the pandemic. Following critical review of literature, expert discussion by teleconference meetings, and evidenced-based consensus, best practice recommendations were developed to guide national provision of breast reconstructive services. RESULTS: Recommendations include strategic use of multidisciplinary teams for patient selection and triage with centralized coordinated use of alternate treatment plans during times of resource restrictions. With shared decision-making, patient-centered shifting and consolidation of resources facilitate efficient allocation. Targeted application of perioperative management strategies and surgical treatment plans maximize the provision of breast reconstructive services. CONCLUSIONS: A unified national approach to strategically reorganize healthcare delivery is feasible to uphold standards of patient-centered care for patients interested in breast reconstruction.

The Best of Chest Wall Reconstruction: Principles and Clinical Application for Complex Oncologic and Sternal Defects.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Appraise and evaluate risk factors for respiratory compromise following oncologic resection. 2. Outline and apply an algorithmic approach to reconstruction of the chest wall based on defect composition, size, and characteristics of surrounding tissue. 3. Recognize and evaluate indications for and types of skeletal stabilization of the chest wall. 4. Critically consider, compare, and select pedicled and free flaps for chest wall reconstruction that do not impair residual respiratory function or skeletal stability. SUMMARY: Chest wall reconstruction restores respiratory function, provides protection for underlying viscera, and supports the shoulder girdle. Common indications for chest wall reconstruction include neoplasms, trauma, infectious processes, and congenital defects. Loss of chest wall integrity can result in respiratory and cardiac compromise and upper extremity instability. Advances in reconstructive techniques have expanded the resectability of large complex oncologic tumors by safely and reliably restoring chest wall integrity in an immediate fashion with minimal or no secondary deficits. The purpose of this article is to provide the reader with current evidenced-based knowledge to optimize care of patients requiring chest wall reconstruction. This article discusses the evaluation and management of oncologic chest wall defects, reviews controversial considerations in chest wall reconstruction, and provides an algorithm for the reconstruction of complex chest wall defects. Respiratory preservation, semirigid stabilization, and longevity are key when reconstructing chest wall defects.

Truncal-based perforator flaps for autologous breast reconstruction: A review of 975 flaps and their clinical application.

BACKGROUND: When autologous breast reconstruction is desired and deep inferior epigastric artery perforator (DIEP) flap is inadequate or unavailable, other perforator flaps in the truncal region should not be disregarded. This study aimed to review all truncal-based perforator flaps used for autologous breast reconstruction to identify clinical indications and outcomes of alternate perforator flaps. METHODS: From 2013 to 2018, patients undergoing truncal-based perforator flap breast reconstruction were reviewed and data recorded for; indications, pre-operative and intra-operative treatment decisions, flap failures, take-backs, and revisions. Compared to the gold standard of the DIEP flap, alternate truncal-based flaps were evaluated for their reconstructive merit and application. RESULTS: A total of 975 perforator flaps were harvested circumferentially around the lower trunk. As an alternative or adjunct to the DIEP flap (n = 633, 65%), perforator flaps were harvested based on the superficial inferior epigastric, the deep and superficial circumflex iliac arteries, the intercostal, and lumbar arteries (n = 342, 35%). Overlapping vascular territories facilitate the safe harvest of these alternate flaps with 0.8% of flaps requiring take back (n = 8) and 0.2% flap failure rate (n = 2). There was no difference in peri-operative outcomes between anterior abdominal and alternate truncal-based flaps (p > .05). CONCLUSIONS: Circumferential harvest of alternate truncal flaps is an appropriate option for autologous reconstruction with comparable peri-operative and long-term outcomes as compared to flaps from the anterior abdomen.

Intraoperative Autoderm Decontamination for Use in Immediate Single-stage Direct-to-implant Breast Reconstruction.

Acellular dermal matrix (ADM) in direct-to-implant breast cancer reconstruction is the standard of care due to superior cosmetic results and decreased capsular contracture, but can be cost prohibitive. Although more economical, using patient's own dermis ("Autoderm") instead of ADM has undescribed sterility. Sterility is essential, as bacterial contamination may cause infection and capsular contraction. This study aimed to determine the sterility and optimal decontamination protocol of Autoderm. METHODS: A prospective controlled study of 140 samples from 20 DIEP (deep inferior epigastric perforator) breast cancer reconstruction patients was performed. Seven de-epithelialized dermal samples (2 × 1 cm) per patient were collected from excess abdominal tissue (6 decontamination protocols and one control). Samples were submerged in povidone-iodine, chlorhexidine, or cefazolin/tobramycin/bacitracin for 15 minutes; half of the samples were agitated (150 rpm) for 15 minutes, and half were not. The control was normal saline without agitation. The solution was removed, and the tissue was sent for aerobic colony count cultures. Patient's demographic data and complications were also collected. RESULTS: Of 140 samples, 3 of 20 non-agitated povidone-iodine and 1 of 20 control samples had aerobic bacterial growth. All of the other 100 samples from 5 experimental groups (povidone-iodine + agitation, chlorhexidine ± agitation, and cefazolin/tobramycin/bacitracin ± agitation) had no aerobic bacterial growth. CONCLUSIONS: This study suggests povidone-iodine + agitation, chlorhexidine ± agitation, and cefazolin/tobramycin/bacitracin ± agitation are effective at sterilizing de-epithelialized dermis, whereas povidone-iodine without agitation and saline are ineffective. Autoderm with the appropriate decontamination protocol may be a potential sterile alternative to ADM.

Patient Reported Outcomes Following Lower Extremity Soft Tissue Sarcoma Resection with Microsurgical Preservation of Ambulation.

BACKGROUND: Lower extremity soft tissue sarcoma treatment has evolved from primarily amputation procedures toward limb salvage. This series assesses whether soft tissue sarcoma tissue defects, extensive enough to require microsurgical reconstruction, can reliably result in preservation of ambulation, as well as objectively evaluate functional outcomes utilizing a patient-reported validated scale. It will also look at whether immediate functional muscle reconstructions and tendon transfers can be successful at restoring ambulation, potentially expanding the indications for limb salvage procedures. METHODS: A retrospective review of all microsurgical reconstructions for limb salvage in lower extremity sarcoma patients was completed at our institution (2009-2013). Patients were additionally asked to complete the Toronto Extremity Salvage Score(TESS) quality of life survey. RESULTS: Over a 5-year period, 23 patients (mean age: 53 years) underwent free flap reconstructions for 23 sarcomas (mean follow-up: 14 months). Seventy-eight percent of patients received neoadjuvant radiation. The thigh was the most common tumor site (61%) and three muscles were resected on average. Perforator flaps were most frequently used (61%), and functional muscle transfers or immediate tendon transfers were used in four patients. There were no flap take-backs or failures, and 22 patients achieved independent ambulation. Three patients in the series died, two from metastatic disease found postoperatively and one from local recurrence. A 74% response rate was achieved for the TESS survey, with a mean score of 83. CONCLUSION: Microsurgical reconstruction of lower extremity sarcoma defects enables preservation of independent ambulation. Restoration of function utilizing immediate functional microsurgical reconstructions and tendon transfers should be considered.

Computed Tomographic Angiography Used for Localization of the Cutaneous Perforators and Selection of Anterolateral Thigh Flap "Bail-Out" Branches.

BACKGROUND: The purpose of this study was to evaluate the territory supplied by the lateral circumflex femoral artery for the consistency of a proximal perforator that could be used as an alternative pedicle for the anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of the perforator used to develop the initial surgical plan. It is hypothesized that a consistent "bail-out" perforator supplying the proximal thigh would facilitate a simpler anterolateral thigh flap harvest, with minimal modification to flap design. METHODS: Computed tomographic images of 9 fresh cadavers were imported using Materialize's Interactive Medical Imaging Control System software to create surface-rendered 3-dimensional reconstructions of 15 lower limbs. Perforators emerging proximally and laterally to a 3-cm radius circle drawn at the midpoint of the anterior superior iliac spine and superolateral patella were considered potential bail-out perforators and evaluated for their number emerging diameter, length, course, and location relative to the anterior superior iliac spine. RESULTS: An average of 2.9 ± 1.8 perforators per limb were identified. Mean pedicle length was 111 ± 20 mm, measured from the origin in the lateral circumflex femoral artery to where the perforators emerged through the deep fascia directly overlying the thigh muscles. Average diameter at origin in the lateral circumflex femoral artery was 2.8 ± 0.8 mm, and that at emergence through the deep fascia was 1.1 ± 0.3 mm. Vessel course was predominantly musculocutaneous (90%). CONCLUSIONS: A significant bail-out perforator routinely supplies the proximal anterolateral thigh and may be used as an alternative vascular pedicle for an anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of a perforator identified within the conventional landmarks (3-cm radius circle at the midpoint of the anterior superior iliac spine and superolateral patella).

Canadian Plastic Surgery Resident Work Hour Restrictions: Practices and Perceptions of Residents and Program Directors.

BACKGROUND: The impact of resident work hour restrictions on training and patient care remains a highly controversial topic, and to date, there lacks a formal assessment as it pertains to Canadian plastic surgery residents. OBJECTIVE: To characterize the work hour profile of Canadian plastic surgery residents and assess the perspectives of residents and program directors regarding work hour restrictions related to surgical competency, resident wellness, and patient safety. METHODS: An anonymous online survey developed by the authors was sent to all Canadian plastic surgery residents and program directors. Basic summary statistics were calculated. RESULTS: Eighty (53%) residents and 10 (77%) program directors responded. Residents reported working an average of 73 hours in hospital per week with 8 call shifts per month and sleep 4.7 hours/night while on call. Most residents (88%) reported averaging 0 post-call days off per month and 61% will work post-call without any sleep. The majority want the option of working post-call (63%) and oppose an 80-hour weekly maximum (77%). Surgical and medical errors attributed to post-call fatigue were self-reported by 26% and 49% of residents, respectively. Residents and program directors expressed concern about the ability to master surgical skills without working post-call. CONCLUSIONS: The majority of respondents oppose duty hour restrictions. The reason is likely multifactorial, including the desire of residents to meet perceived expectations and to master their surgical skills while supervised. If duty hour restrictions are aggressively implemented, many respondents feel that an increased duration of training may be necessary.

HISTORIQUE: L'effet des restrictions des heures de travail des résidents sur la formation et les soins aux patients est un sujet très controversé. Jusqu'à présent, il n'y a pas d'évaluations officielles de cette réalité chez les résidents canadiens en chirurgie plastique. OBJECTIF: Caractériser le profil des heures de travail des résidents canadiens en chirurgie plastique et évaluer les points de vue des résidents et des directeurs de programme à l'égard de l'effet des restrictions des heures de travail sur la compétence chirurgicale, le bien-être des résidents et la sécurité des patients. MÉTHODOLOGIE: Les auteurs ont préparé un sondage anonyme en ligne qu'ils ont transmis à tous les résidents et les directeurs de programme en chirurgie plastique au Canada. Ils ont synthétisé les statistiques de base. RÉSULTATS: Au total, 80 résidents (53 %) et dix directeurs de programme (77 %) ont répondu au sondage. Les résidents ont déclaré faire une moyenne de 73 heures de travail hospitalier par semaine, faire huit quarts de garde par mois et dormir 4,7 heures par nuit lorsqu'ils sont sur appel. La plupart d'entre eux (88 %) déclarent une moyenne de 0 journée de congé après une garde, et 61 % travaillent ensuite sans avoir dormi. La majorité désire pouvoir travailler après une garde (63 %) et s'oppose à un maximum hebdomadaire de 80 heures (77 %). Par ailleurs, 26 % des résidents précisent avoir fait des erreurs chirurgicales et 49 %, des erreurs médicales qu'ils attribuent à la fatigue accumulée après une garde. Les résidents et les directeurs de programme s'inquiètent de la capacité des résidents à maîtriser les habiletés chirurgicales s'ils ne travaillent pas après les gardes. CONCLUSIONS: La majorité des répondants s'opposent aux restrictions des heures de garde. La raison est probablement multifactorielle, y compris le fait que les résidents souhaitent répondre aux attentes perçues et maîtriser leurs habiletés chirurgicales pendant qu'ils sont sous supervision. Si les restrictions des heures de garde étaient vigoureusement adoptées, de nombreux répondants croient qu'il faudrait allonger la formation.

The Best of Abdominal Wall Reconstruction.

LEARNING OBJECTIVES: After reviewing this article, the participant should be able to: 1. List major risk factors for hernia formation and for failure of primary repair. 2. Outline an algorithmic approach to anterior abdominal wall reconstruction based on the degree of contamination, components involved in the deficit, and width of the hernia defect. 3. Describe appropriate indications for synthetic and biological mesh products. 4. List common flaps used in anterior abdominal wall reconstruction, including functional restoration strategies. 5. Describe the current state of the art of vascularized composite tissue allotransplantation strategies for abdominal wall reconstruction. SUMMARY: Plastic surgeons have an increasingly important role in abdominal wall reconstruction-from recalcitrant, large incisional hernias to complete loss of abdominal wall domain. A review of current algorithms is warranted to match evolving surgical techniques and a growing number of available implant materials. The purpose of this article is to provide an updated review of treatment strategies to provide an approach to the full spectrum of abdominal wall deficits encountered in the modern plastic surgery practice.

Evidence-Based Medicine: Autologous Breast Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Gain an understanding of the different methods of autologous reconstruction available. 2. Understand the timing of autologous breast reconstruction and the impact of adjuvant and neoadjuvant treatments. 3 Understand the factors necessary for a comprehensive patient assessment. 4. Gain knowledge of patient factors that will affect autologous reconstruction and potential contraindications. 5. Summarize the patient-reported and clinical outcomes of autologous breast reconstruction. SUMMARY: This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

Reverse Radial Artery Flap Perforator Anatomy and Clinical Applications.

The pedicled reverse radial forearm flap is a well-known option for the treatment of a variety of soft tissue wounds including dorsal hand wounds. We document the number, emerging diameter, length from origin, course, and location of all perforators of the radial artery in a series of 6 fresh human cadavers after whole body lead oxide and gelatin injection to confirm and comprehensively document the anatomy of the radial artery perforators. This data provide an anatomic basis for a modification to the reversed radial forearm flap used to decrease venous congestion in the postoperative period. Two case reports are presented to provide clinical demonstration of the importance of this modification.

Goal-directed fluid therapy for microvascular free flap reconstruction following mastectomy: A pilot study.

BACKGROUND: Fluid management of the surgical patient has undergone a paradigm shift over the past decade. A change from 'wet' to 'dry' to a 'goal-directed' approach has been witnessed. The fluid management of patients undergoing free flap reconstruction is particularly challenging. This is typically a long operation with minimal surgical stimulation, and hypotension often ensues. The use of vasopressors in these cases is contraindicated to maintain adequate flow to the flap. Hypotension is often treated with intravenous fluid boluses. However, aggressive fluid administration to maintain adequate blood pressure can result in flap edema, venous engorgement and, ultimately, flap loss. OBJECTIVE: The primary objective of the present study was to determine whether goal-directed fluid therapy, titrated to maintain stroke volume variation ≤13%, with the use of an arterial pulse contour device results in improved postoperative cardiac index (CI) and stroke volume index (SVI) with reduced amounts of intravenous fluid. The primary end points studied were CI, SVI and cumulative crystalloid/colloid administration. METHODS: Twenty female patients undergoing simultaneous microvascular free flap reconstruction immediately following mastectomy were studied. Preoperative and intraoperative care were standardized. Each patient received intra-arterial blood pressure monitoring. In all patients, cardiac output measurement occurred throughout the intraoperative period using the arterial pulse contour device. Control patients had their fluid administered at the discretion of the anesthesiologist (blinded to results from the cardiac output device). Patients in the intervention group had a baseline crystalloid infusion of 5 mL/kg/h, with intravenous colloid boluses to maintain a stroke volume variation ≤13%. RESULTS: There was no difference in heart rate or mean arterial pressure between groups at the end of the operation. However, at the end of the operation, the intervention group had significantly higher mean (± SD) CI (3.8±0.8 L/min/m(2) versus 3.0±0.5 L/min/m(2); P=0.02) and SVI (51.4±2.4 mL/m(2) versus 43.3±2.3 mL/m(2); P=0.03). This improved CI and SVI was achieved with similar amounts of administered intraoperative fluid (5.8±0.5 mL/kg/h versus 5.0±0.7 mL/kg/h, control versus intervention). The intervention group required less postoperative fluid resuscitation during the early postoperative period (total fluid administered from end of operation to midnight of the operative day, 6.4±1.9 mL/kg/h versus 10.2±3.3 mL/kg/h, intervention versus control, respectively, P<0.01). DISCUSSION: Goal-directed fluid therapy using minimally invasive cardiac output monitoring resulted in improved end-operative hemodynamics, with less 'rescue' fluid administration during the perioperative period.

HISTORIQUE: La prise en charge des liquides du patient opéré a connu un changement de paradigme depuis dix ans. On a constaté un passage de « mouillé ¼ à « sec ¼, puis à une démarche « axée sur des objectifs ¼. La prise en charge des liquides des patients qui subissent une reconstruction par lambeau libre est particulièrement difficile. C'est habituellement une longue opération associée à une stimulation chirurgicale minimale, qui entraîne souvent une hypotension. Le recours aux vasopresseurs est contre-indiqué dans ces situations, pour maintenir un débit suffisant dans le lambeau. L'hypotension est souvent traitée au moyen de bolus de liquide intraveineux. Cependant, l'administration énergique de liquides pour maintenir une tension artérielle suffisante peut provoquer un oedème du lambeau, un engorgement veineux et, au bout du compte, la perte du lambeau. OBJECTIF: L'objectif primaire de la présente étude visait à déterminer si la perfusion de liquides axée sur des objectifs, titrée pour maintenir la variation du volume de débit systolique à un maximum de 13 % au moyen d'un dispositif de contour de l'onde de pouls artériel, assure une amélioration de l'indice cardiaque postopératoire (IC) et de l'indice de débit systolique (IDS) et une moins grande utilisation de liquide intraveineux. Les paramètres primaires étudiés étaient l'IC, l'IDS et l'administration cumulative de crystalloïdes et de colloïdes. MÉTHODOLOGIE: Les chercheurs ont étudié 20 patientes subissant une reconstruction simultanée par lambeau libre microvasculaire suivant immédiatement une mastectomie. Les soins préopératoires et peropératoires ont été standardisés. Chaque patiente était soumise à une surveillance de la tension intra-artérielle. Le débit cardiaque de toutes les patientes a été mesuré pendant la période peropératoire au moyen du dispositif de contour de l'onde de pouls artériel. Les patientes témoins se sont fait administrer le liquide au moment déterminé par l'anesthésiste (non informé de résultats du dispositif de débit cardiaque). Les patientes du groupe d'intervention ont reçu une infusion crystalloïde initiale de 5 mL/kg/h, de même que des bolus de colloïde intraveineux pour maintenir une variation du débit systolique à un maximum de 13 %. RÉSULTATS: Il n'y avait pas de différence de fréquence cardiaque ou de tension artérielle moyenne entre les groupes à la fin de l'opération. Cependant, le groupe d'intervention présentait alors un IC moyen (± ÉT, 3,8±0,8 L/min/m2 par rapport à 3,0±0,5 L/min/m2; P=0,02) et un IDS (51,4±2,4 mL/m2 par rapport à 43,3±2,3 mL/m2; P=0,03) considérablement plus élevés. Cette amélioration de l'IC et de l'IDS se produisait au moyen de quantités similaires de liquide peropératoire (5,8±0,5 mL/kg/h par rapport à 5,0±0,7 mL/kg/h, groupe témoin par rapport au groupe d'intervention). Le groupe d'intervention avait besoin de moins de réanimation par liquide postopératoire au début de la période postopératoire (quantité totale de liquide administrée entre la fin de l'opération et minuit le jour de l'opération, 6,4±1,9 mL/kg/h par rapport à 10,2±3,3 mL/kg/h, groupe d'intervention par rapport au groupe témoin, respectivement, P<0,01). EXPOSÉ: La perfusion de liquides axée sur des objectifs faisant appel à une surveillance minimalement invasive du débit cardiaque assurait une amélioration de l'hémodynamique en fin d'opération, et l'administration d'un moins grand volume de liquide de « rattrapage ¼ pendant la période périopératoire.

A reliable frozen section technique for basal cell carcinomas of the head and neck.

Basal cell carcinomas (BCCs) of the head and neck treated by conventional techniques of surgical excision, curettage, cryotherapy and radiation therapy have recurrence rates of up to 42%. Mohs micrographic surgery (MMS) decreases the recurrence rate but can be expensive, delay definitive reconstruction and is limited in its availability. The authors report a series of 50 patients with head and neck BCCs treated by a surgeon-directed 'en face' frozen section technique that immediately evaluates the entire peripheral and deep margins during BCC resection, and potentially offers a more efficient and equally effective alternative to MMS. Patient demographics, pathology results, operative time, technique and outcomes are all reported. With a mean follow-up of three years, there was only one recurrence (1.7%). Mean total operative time was 1 h 47 min. The authors conclude that this surgeon-directed 'en face' frozen section technique does not require any specialized training, enables more rapid and reliable results than standard frozen section techniques that are currently used, and provides outcomes equivalent to MMS in the surgical treatment of head and neck BCCs.

Les carcinomes basocellulaires (CBC) de la tête et du cou traités par les techniques classiques d'excision clinique, de curetage, de cryothérapie et de radiothérapie ont un taux de récurrence pouvant atteindre 42 %. La chirurgie micrographique de Mohs (CMM) réduit le taux de récurrences, mais elle peut être coûteuse, peut retarder la reconstruction définitive et n'est pas très utilisée.Les auteurs présentent une série de 50 patients ayant un CBC de la tête et du cou, traités par une technique d'examen extemporané dirigée par un chirurgien sur place, qui permet d'évaluer immédiatement l'ensemble des bords périphérique et profond pendant la résection du CBC, ce qui pourrait se révéler plus fonctionnel et tout aussi efficace que la CMM.La démographie des patients, les résultats pathologiques, la durée de l'opération, la technique et les résultats sont tous présentés. Après un suivi moyen de trois ans, une seule récurrence a été observée (1,7 %). L'opération durait en moyenne 1 h 47. Les auteurs concluent que la technique d'examen extemporané dirigée par le chirurgien sur place ne nécessite pas de formation spécialisée, permet d'obtenir des résultats plus rapides et plus fiables que les techniques d'examen extemporané standards actuellement en usage et donnent des résultats équivalents à ceux de la CMM pour le traitement chirurgical du CBC de la tête et du cou.

Rethinking the superficial inferior epigastric artery flap in breast reconstruction: Video demonstration of a rapid, reliable harvest technique.

Abdominal-based autologous free tissue breast reconstruction has undergone significant changes over the past decade. The evolution has focused on limiting morbidity of the donor site. The transition from the transverse rectus abdominus muscle free flap to the muscle-sparing transverse rectus abdominus muscle free flap to the deep inferior epigastric artery perforator free flap has markedly improved abdominal-based autologous breast reconstruction. However, all of these flaps involve an incision through the anterior rectus fascia and potential damage of intercostal motor and sensory nerves. The superficial inferior epigastric artery flap (SIEA) reliably perfuses the ipsilateral hemiabdomen, yet does not violate the fascia or any motor nerves. As a result, the incidence of hernia, abdominal wall weakness and bulging is essentially eliminated. Nevertheless, use of the SIEA flap remains marginal. Vessel size, dissection difficulties and lack of understanding of the relevant anatomy have limited its acceptance. The present article describes a rapid, reliable and safe dissection technique with an algorithm for harvesting the SIEA flap in autologous breast reconstruction.

La reconstruction mammaire à l'aide de tissu libre autologue prélevé sur l'abdomen a connu d'importants changements depuis dix ans. L'évolution a visé à limiter la morbidité au foyer du donneur. La transition du lambeau libre prélevé sur le muscle grand droit abdominal transverse au lambeau libre épargnant ce muscle, puis au lambeau perforateur libre de l'artère épigastrique inférieure a considérablement amélioré la reconstruction mammaire autologue à l'aide de tissu prélevé sur l'abdomen. Cependant, tous ces lambeaux exigent une incision traversant le fascia droit antérieur, qui risque d'endommager les nerfs moteurs et sensoriels intercostaux. Le lambeau de l'artère épigastrique inférieure superficielle (AÉIS) assure une perfusion fiable de l'hémiabdomen ipsilatéral, sans toucher le fascia ou d'autres nerfs moteurs. Par conséquent, on prévoit une incidence nulle de hernie, de faiblesse ou de bombement de la paroi abdominale. Néanmoins, le recours au lambeau de l'AÉIS demeure marginal. La dimension des vaisseaux, les problèmes de dissection et la mauvaise compréhension de l'anatomie perti-nente en ont limité l'acceptation. Le présent article décrit une technique de dissection rapide et fiable à l'aide d'un algorithme pour prélever le lambeau de l'AÉIS en cas de reconstruction mammaire autologue.

The transverse upper gracilis flap: Efficiencies and design tips.

The transverse upper gracilis free flap is a well-described option for breast reconstruction. The technique is a secondary choice for autologous breast reconstruction because the abdomen remains the primary donor site for breast reconstruction. However, in appropriately selected patients, the authors believe that the transverse upper gracilis flap remains a reliable flap for breast reconstruction. Its consistent anatomy, potentially reasonable donor site scar, limited functional morbidity and simultaneous two-team surgical approach make this flap a viable option for many patients. The technique, however, is not without drawbacks - known numbness of the medial thigh and the potential for chronic lymphedema of the lower leg, contour deformities of the medial thigh, and widening of the medial thigh scar need to be considered. The current article presents a harvest technique that is reliable, rapid and addresses each of the above-mentioned limitations with specific changes in the traditional technique. The article provides video documentation of the modified harvest technique using only monopolar cautery for the dissection.

Le lambeau supérieur transverse du muscle gracile est une méthode bien connue de reconstruction mammaire. Cette technique est un choix secondaire en cas de reconstruction mammaire autologue, car l'abdomen demeure le principal foyer de prélèvement en vue de ce type de reconstruction. Cependant, chez certains patients bien choisis, les auteurs sont d'avis que le lambeau supérieur transverse du muscle gracile demeure fiable pour procéder à cette reconstruction. Son anatomie uniforme, la cicatrice raisonnable potentielle au foyer du prélèvement, la morbidité fonctionnelle limitée et l'approche chirurgicale à deux équipes font de ce prélèvement de lambeau une option viable pour de nombreux patients. La technique n'est toutefois pas sans défauts : il faut tenir compte de l'engourdissement connu de la cuisse, du potentiel de lymphœdème chronique de la jambe inférieure, de la déformation du contour de la cuisse et de l'élargissement de la cicatrice de la cuisse de la partie médiale.Le présent article propose une technique de prélèvement à la fois fiable et rapide et remplace chacune des limites susmentionnées par des changements particuliers à la technique traditionnelle. Il présente une vidéo de cette technique, faisant seulement appel à la cautérisation monopolaire de la dissection.

Free tissue transfers and replantation.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the indications and contraindications for free flap reconstruction. 2. Describe the indications, anatomy, harvest technique, and advantages and disadvantages of the workhorse free flaps. 3. Describe the indications and contraindications for extremity replantation. 4. Describe the techniques and management for extremity replantation. SUMMARY: Microsurgical free flap reconstruction uses a multitude of surgical flaps available to meet the needs of the recipient site. These include cutaneous, muscle, bone, fascia, or some combination of these as available options. Furthermore, sophisticated reconstruction has been enhanced by the development of perforator flaps, enabling multicomponent reconstruction to be performed with reduced donor-site morbidity. It is mandatory that proper débridement of the defect be performed before reconstruction, and that the anastomosis is performed without tension or twisting outside of the zone of injury. There are indications for both musculocutaneous and perforator flaps, and selection is dependent on recipient-site characteristics in addition to function and aesthetics of both the recipient and donor sites. Muscle flaps provide well-vascularized pliable tissue and are used for deep space obliteration, whereas fasciocutaneous flaps are used for flatter, more superficial wounds. Microsurgical replantation of an amputated extremity offers a result that is usually superior to any other type of reconstruction. However, replantation of extremities involves more than microsurgery, as repair of bony and tendon injury must be undertaken as well. This article focuses on the indications, technique, and results of free flap reconstruction and replantation.