Medial Arm Flap: An Unexplored Option for Autologous Breast Reconstruction in the Setting of Morbid Obesity.

Currently, deep inferior epigastric perforator flap is undoubtedly the first choice for autologous breast reconstruction for most surgeons; however, there are instances where lower abdominal tissue is unavailable for microvascular transfer. In these cases, most surgeons choose gluteal or lower-extremity territories as donor sites.In the setting of morbid obesity, there is an increased risk of flap and donor site complications, as well as increased blood loss, surgical time, and risk of deep venous thrombosis, not to mention a more challenging surgical technique. Added to these problems, Tamoxifen intake and delayed or limited ambulation due to pain or surgical wounds increases deep venous thrombosis risk even further.The use of the upper arm as donor site for microvascular transfer avoids most of these problems and allows for immediate, comfortable ambulation. On the other hand, upper arm flaps have smaller caliber vessels for microanastomosis, shorter pedicles, and a limited amount of skin which makes them a viable option for only a select group of patients with redundant upper arm skin. We provide a previously undocumented proof-of-concept case report of a delayed breast reconstruction using the medial arm free flap that resulted in an uneventful postoperatory follow-up with a naturally textured and shaped reconstructed breast.

Buccal Fat Pad Excision: Hydrodissection Technique.

BACKGROUND: Buccal fat pad (BFP) excision is a procedure in which the fat pad is extracted in order to achieve a more youthful appearance. OBJECTIVES: The aim of this study was to describe an alternative technique that utilizes hydrodissection to extract the BFP. METHODS: This is a controlled, prospective, randomized clinical study involving 2 groups. Group A (n = 27) underwent BFP excision with hydrodissection, during which 15 mL of a vasoconstricting anesthetic solution was injected into the BFP. Group B (n = 27) underwent BFP excision, during which 3 mL of lidocaine 2% with epinephrine was injected. All procedures were performed by the same surgeon. Variables analyzed were surgical time, intraoperative bleeding, and postoperative pain directly following surgery 2 hours after the procedure, as well as maximum pain within 72 hours of surgery and complications. Postoperative care was standardized, and patient follow-up extended over a 6-month period. RESULTS: Pain scores for 54 patients were recorded on a visual analog scale (0-10). Mean ± standard deviation transoperative pain scores were 0.5 ± 0.8 for Group A and 1.3 ± 1.3 for Group B (P = 0.01); 2 hours postoperation the scores were 1.2 ± 0.7 for Group A and 2.6 ± 1 for Group B (P < 0.0001). Maximum pain occurred within 72 hours, and scored 1.6 ± 0.6 for Group A and 3.1 ± 1 for Group B (P < 0.0001). Mean operative time was 8:18 ± 0:47 minutes for Group A and 14:08 ± 2:28 minutes for Group B (P < 0.0001). There was a positive correlation between operative time and pain. Overall, 5.5% of patients suffered postoperative complications. CONCLUSIONS: BFP excision by hydrodissection is an effective procedure that decreases surgical times by facilitating extraction of the BFP with less manipulation, thereby resulting in decreased postoperative pain and a more tolerable recovery.

Immediate implant replacement with DIEP flap: a single-stage salvage option in failed implant-based breast reconstruction.

BACKGROUND: Implant-based immediate breast reconstruction after skin-sparing mastectomy has shown a significant improvement in patients' quality of life, making the procedure steadily more popular year after year. However, this technique has a high morbidity rate, including skin necrosis and implant exposure. METHODS: A retrospective review of a prospectively held database for autologous breast reconstruction in our institution of the last 5 years found eight cases with exposed implants after nipple-sparing mastectomy and immediate reconstruction. A single-stage procedure consisting on implant removal and immediate replacement with a deepithelialized DIEP flap was performed in all cases (10 DIEP flaps). RESULTS: All flaps were successful. Patients' mean age was 45 years old. Three patients developed seroma (5, 7, and 14 days after surgery, respectively). No infections were detected in up to 24 months of follow-up. CONCLUSIONS: Nipple-sparing mastectomy with immediate implant-based reconstruction is considered oncologically safe. However, it has a high rate of complications that could require implant removal. Immediate free flap reconstruction is a feasible and safe option to replace the missing volume with low risk of complications that result in a soft and natural-shaped breast.

Superficial Thinning of the DIEP Flap: A Safe Option to Achieve an Aesthetic Reconstructed Breast in the Obese Patient.

BACKGROUND: Abdominal flap-based breast reconstruction is challenging in the overweight and obese population not only because of increased donor-site complications, but also because excessive flap thickness makes inset cumbersome, requiring thinning and remodeling that frequently result in aesthetically poor outcomes. METHODS: The authors started by studying 10 deep inferior epigastric artery perforator flaps with angiographic computed tomography. Then, they prospectively performed 21 breast reconstructions using a superficial thinning technique reliant on a constant suprafascial vessel as the pedicle for the remaining deep fat and compared the rate of complications with their previous experience using traditional flap thinning techniques. RESULTS: All samples studied showed a suprafascial division of the main perforator. Two constant branches were identified, one coursing over the Scarpa fascia and displaying a robust network of linking vessels with the subcutaneous and subdermal plexuses. That anatomical insight was used to develop a flap-thinning technique tested on 21 consecutive high-body mass index patients. A 7-year retrospective analysis (n = 164) showed no significant correlation between body mass index and incidence of complications except for a long-term upper pole step deformity that was associated with increasing body mass index (p = 0.001). No statistically significant difference in complications was found comparing high-body mass index patients from the retrospective group (n = 72) with the superficial thinning group, but a highly suggestive difference (p = 0.061) was found regarding the avoidance of the step deformity using the superficial thinning technique. CONCLUSION: The presence of a constant suprafascial perforator branch makes superficial DIEP thinning a safe technique that facilitates inset and improves the reconstructed breast contour of obese patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Free profunda femoris artery perforator flap as a first-line choice of reconstruction for partial glossectomy defects.

BACKGROUND: Free profunda artery perforator (PAP) flap has recently been brought back for head and neck reconstruction. During the course of 1 year, we performed this procedure for reconstruction of partial glossectomy defects with excellent results. METHODS: From January through December 2015, 21 patients underwent partial glossectomy reconstruction with PAP flaps. Demographics, surgical technique, anatomic variations, success rates, complications, and characteristics are described. Swallowing and speech results after reconstruction are evaluated. RESULTS: No donor-site complications were observed. Two cases presented complications potentially related to the flap (1 hematoma and 1 prolonged intubation) that were treated successfully. Deglutition and speech assessment resulted in fair to excellent swallowing capacity in all patients. Speech score resulted 4/5 to 5/5 in all patients at 3-month follow-up. CONCLUSION: The PAP flap should be considered one of the first-line options for hemiglossectomy reconstruction, receiving special consideration in the high-risk population in which future complex reconstructions could be needed. © 2016 Wiley Periodicals, Inc. Head Neck 39: 737-743, 2017.