Shaping the breast in secondary microsurgical breast reconstruction: single- vs. two-esthetic unit reconstruction.

The esthetic outcome is dictated essentially not only by the position, size, and shape of the reconstructed breast, but also by the extra scaring involved. In the present study, we conducted a visual analog scale survey to compare the esthetic outcome in delayed autologous breast reconstruction following two different abdominal flaps inset. Twenty-five patients had their reconstruction using the Single-esthetic Unit principle and were compared with 25 patients that their breast was reconstructed using the Two-Esthetic Unit principle. Photographic images were formulated to a PowerPoint presentation and cosmetic outcomes were assessed from 30 physicians, by means of a Questionnaire and a visual analog scale. Our data showed that the single-esthetic unit breast reconstruction presents significant advantages over the traditional two-esthetic units, due to inconspicuous flap reconstruction, better position of the inframammary fold, and more natural transition from native and reconstructed tissues. Moreover, patient self-evaluation of esthetic outcome and quality of life showed that single-esthetic unit reconstruction is associated with higher patient satisfaction, therefore should be considered the method of choice.

Paramuscular and paraneural perforators in DIEAP flaps: radiographic findings and clinical application.

The computed tomography microangiography revolutionized the planning of abdominal flaps, and enabled us to identify perforators from the deep inferior epigastric system with a medial extramuscular or minimal medial intramuscular trajectory. We define these perforators as paramuscular and paraneural, since their main course is retromuscular and they emerge medial to the medial border of rectus muscle or medial to its motor nerve supply, respectively. Studying the different perforator distributions in the abdomen of 58 patients who underwent breast reconstruction with deep inferior epigastric artery perforator flap, we have recorded that 46.4% of the abdominal walls have a dominant paramuscular/paraneural perforator (25.8% paramuscular and 20.6% paraneural) with an average diameter 1.56 +/- 0.2 mm. Although, the comparison of the rectus muscle morbidity following deep inferior epigastric artery perforator flap dissection based on paramuscular/paraneural and based on other perforator patterns, did not reveal significant differences, paraneural/paramuscular type perforators are not related anatomically to the motor nerves, and the donor site morbidity should be negligible in any operator's hands.

A cohort study of acute plastic surgery trauma and burn referrals using telemedicine.

A store-and-forward telemedicine system was used to supplement normal telephone referrals to the plastic surgery unit at the Queen Victoria Hospital (QVH). During a 12-week prospective study, 11 units (8 hospitals and 3 minor injury units) with the telemedicine system and 10 units (8 hospitals and 2 minor injury units) without it regularly made referrals (at least 10) to the QVH. There were 389 referrals from the telemedicine-equipped units and 607 telephone referrals from the non-telemedicine units. The telemedicine system was used for 246 of the 389 referrals (63%) made from telemedicine-equipped units. There was a significant difference in the management of patients when the telemedicine system was available, with more patients booked directly into day surgery and fewer attending for assessment. The burns unit and the day surgery unit demonstrated a significantly improved accuracy of triage. Telemedicine could have a valuable role to play in the triage and planning of acute plastic surgery referrals.

Free tissue breast reconstruction in older patients.

We present the case of a 72-year-old woman who underwent mastectomy with immediate breast reconstruction using a free transverse rectus abdominis myocutaneous (TRAM) flap, to illustrate that age is not necessarily a barrier to microvascular reconstructive techniques for breast reconstruction.

Incidence of 'Incidentalomas' in over 100 consecutive CT angiograms for preoperative DIEP flap planning.

The gold standard in breast reconstruction is the deep inferior epigastric perforator (DIEP) flaps, although muscle-sparing tranverse rectus abdominis myocutaneous (TRAM) flaps are still being performed due to variations in the abdominal vasculature and to reduce flap complications. Recently, there has been a rise in interest in preoperative imaging, in particular, by means of computer tomography angiogram (CTA). CTA has been shown to delineate the vascular anatomy, improve preoperative decision making and possibly reduce operating time and constitutes a routine preoperative investigation in our unit. Of the 104 consecutive patients who had undergone CTA prior to breast reconstruction, we have found a 13% incidence of unexpected findings or 'incidentalomas' in otherwise asymptomatic women. None were malignant, but changes to the initial operative plan included deferring immediate breast reconstruction, further surgery and further investigations for these incidentalomas. We recommend that all women are counselled of the possibilities of incidentalomas prior to CTA. Furthermore, clinicians need to be receptive to the possibility of a delayed or alternative reconstruction, and closely liaise with other specialties to avoid damage to the deep inferior epigastric vasculature.