Transgenic Epidermal Cultures for Junctional Epidermolysis Bullosa - 5-Year Outcomes.

Inherited junctional epidermolysis bullosa is a severe genetic skin disease that leads to epidermal loss caused by structural and mechanical fragility of the integuments. There is no established cure for junctional epidermolysis bullosa. We previously reported that genetically corrected autologous epidermal cultures regenerated almost an entire, fully functional epidermis on a child who had a devastating form of junctional epidermolysis bullosa. We now report long-term clinical outcomes in this patient. (Funded by POR FESR 2014-2020 - Regione Emilia-Romagna and others.).

One versus two vein anastomoses in breast reconstruction with a profunda artery perforator flap-does it make a difference.

BACKGROUND: The profunda artery perforator (PAP) flap has gained popularity as a reliable alternative in breast reconstruction. Extensive research has focused on its vascular supply, dissection techniques, and broader applications beyond breast reconstruction. This study aims to investigate the correlation between the number of veins anastomosed for the PAP flap and postoperative complications. METHODS: A retrospective study was conducted to evaluate the outcomes of breast reconstructions with PAP flaps at our institution between 2018 and 2022. A total of 103 PAP flaps in 88 patients were included. Statistical analysis was performed to compare outcomes between flaps with one vein anastomosis and those with two vein anastomoses. Patient characteristics, intra and postoperative parameters were analysed. RESULTS: One vein anastomosis was used in 36 flaps (35.0%), whereas two vein anastomoses were used in 67 flaps (65.0%). No significant differences were found in patient characteristics between the one vein and two vein groups. The comparison of ischemia times between flaps with one versus two veins revealed no statistically significant difference, with mean ischemia times of 56.2 ± 36.8 min and 58.7 ± 33.0 min, respectively. Regarding outcomes, there were no statistically significant differences in secondary lipofilling, revision of vein anastomosis, or total flap loss between the two groups. Fat necrosis was observed in 5 (13.9%) one vein flaps and 5 (7.5%) two vein flaps, indicating no statistically significant difference between the two groups (p = .313). In the one vein group, the most frequently employed coupler ring had a diameter of 2.5 mm. In the two vein group, the most prevalent combination consisted of a 2.0 mm diameter with a 2.5 mm diameter. CONCLUSION: Based on our study results, both one vein anastomosis and two vein anastomoses are viable options for breast reconstruction with PAP flap. The utilization of either one or two veins did not significantly affect ischemia time or flap loss. Fat necrosis exhibited a higher incidence in the single-vein group; however, this difference was also not statistically significant. These findings underscore the effectiveness of both approaches, providing surgeons with flexibility in tailoring their surgical techniques based on patient-specific considerations and anatomical factors.

Fully Telemetric Robotic Microsurgery: Clinical Experience With 23 Cases.

BACKGROUND: Recently, there is an ongoing trend in plastic surgery with robotic-assisted microsurgery and supermicrosurgery devices being developed. Combining a telemetrically controlled robotic microscope with an also telemetrically controlled microsurgery robot unlocks synergistic effects with complete disconnection of the operating surgeon from the operating field. Here, we report the first clinical free flap reconstructions using this setup. METHODS: Twenty-three surgeries were performed with the combined remote approach using the Symani Surgical System and the RoboticScope in open microsurgery procedures. Anastomosis time and ischemia time were recorded. The surgical performance for anastomoses was assessed using the modified Structured Assessment of Microsurgical Skills (SAMS) score. Subjective satisfaction was evaluated by the surgeons in comparison with conventional microsurgery. To evaluate the learning curve, the senior authors first four (first group) and last four (last group) procedures were compared. RESULTS: Overall, flap survival was 95.7%. The average arterial anastomosis time was 36.7 ± 10.9 min. Total time of surgery was 277.7 ± 63.8 min, and ischemia time was 100.6 ± 24.9 min. Most SAMS score parameters were significantly higher in the last group of surgical procedures compared with the first operations. Subjective satisfaction was equal or better with the combined robotic-assisted approach in most categories. CONCLUSIONS: Our data demonstrates safety and feasibility of the use of a combined remote approach. Robotic systems for microsurgical procedures may hold promising potential for improvement of surgical quality and open up new frontiers in microsurgery.

Tolerance Induction in Vascularized Composite Allotransplantation-A Brief Review of Preclinical Models.

Pre-clinical studies are an obligatory tool to develop and translate novel therapeutic strategies into clinical practice. Acute and chronic rejection mediated by the recipient's immune system remains an important limiting factor for the (long-term) survival of vascularized composite allografts (VCA). Furthermore, high intensity immunosuppressive (IS) protocols are needed to mitigate the immediate and long-term effects of rejection. These IS regiments can have significant side-effects such as predisposing transplant recipients to infections, organ dysfunction and malignancies. To overcome these problems, tolerance induction has been proposed as one strategy to reduce the intensity of IS protocols and to thereby mitigate long-term effects of allograft rejection. In this review article, we provide an overview about animal models and strategies that have been used to induce tolerance. The induction of donor-specific tolerance was achieved in preclinical animal models and clinical translation may help improve short and long-term outcomes in VCAs in the future.

Regeneration of the entire human epidermis using transgenic stem cells.

Junctional epidermolysis bullosa (JEB) is a severe and often lethal genetic disease caused by mutations in genes encoding the basement membrane component laminin-332. Surviving patients with JEB develop chronic wounds to the skin and mucosa, which impair their quality of life and lead to skin cancer. Here we show that autologous transgenic keratinocyte cultures regenerated an entire, fully functional epidermis on a seven-year-old child suffering from a devastating, life-threatening form of JEB. The proviral integration pattern was maintained in vivo and epidermal renewal did not cause any clonal selection. Clonal tracing showed that the human epidermis is sustained not by equipotent progenitors, but by a limited number of long-lived stem cells, detected as holoclones, that can extensively self-renew in vitro and in vivo and produce progenitors that replenish terminally differentiated keratinocytes. This study provides a blueprint that can be applied to other stem cell-mediated combined ex vivo cell and gene therapies.

Transgenic skin biomechanical properties following first lifesaving epidermal regeneration using combined gene and cell therapy.

BACKGROUND: In 2017, we reported the first life-saving regeneration of virtually an entire epidermis by combined gene and stem cell therapy. Recently, we demonstrated excellent long-term stability of this transgenic epidermis. Skin quality in this experimental approach and its potential application in other conditions were elucidated here regarding long-term outcomes of biomechanical properties. PATIENTS AND METHODS: Analysis of biomechanical properties including skin elasticity, anisotropy and friction was performed on multiple body sites 24, 36 and 60 months following transplantation. Firstly, the sites were matched against and compared to remaining stable non-transgenic areas as well as to a control group of 13 healthy subjects. Parameters for skin elasticity, deformation and friction were assessed non-invasively. RESULTS: Biomechanical properties of the transgenic epidermis showed encouraging results in comparison to both the remaining stable non-transgenic skin as well as healthy controls. Skin elasticity was comparable to the controls. Skin friction showed some decrease in both transgenic and non-transgenic areas as compared to the controls. CONCLUSIONS: The excellent functional outcomes of the transgenic epidermis demonstrate stable long-term results of this novel combined gene and stem cell therapy for epidermal regeneration. Thus, other applications for this technology, such as treatment of specific burns, should be explored.

Software-based video analysis of functional outcomes of face transplantation.

INTRODUCTION: Assessment of outcomes after face transplantation (FT) is necessary to provide sound evidence on the benefits of this life-giving surgery. Current methods for outcomes assessment, however, are imprecise or prone to subjectivity. Software-based video analysis may allow fast, objective and retrospective assessment of restoration of facial movements and functions after FT. PATIENTS AND METHODS: We recorded videos of 7 subjects before as well as every 3-6 months after facial transplantation. Patients performed the same sequence of facial movements in every video: smile, open mouth, purse lips, wrinkle nose, frown, close eyes, and lift eyebrows. The videos were retrospectively analyzed using EMOTIENT software, which is capable of automatic tracking and detailed measurements of facial movements and expressions. These measurements were subsequently compared to the same patient at different time points, as well as to the normal population. RESULTS: Open mouth, wrinkle nose and smile functions significantly improved in all patients when compared to pre-transplant functions; this improvement was significant at 3, 6, and 12 months after transplant, respectively. Lip purse, eye closure and frown functions improved by 6, 9, and 18 months after transplantation, respectively; however, improvement in these particular functions was not significantly with respect to pre-transplant. Face transplantation did not improve any of the patients' ability to lift their eyebrows. Most remarkably, mouth opening and smiling functions both reached values comparable to the normal population at 3 and 12 months after transplantation, respectively. CONCLUSION: Software-based video analysis provides a valuable assessment tool capable of objective, precise and reproducible analysis of facial movements and functions after FT.

Extracorporeal Perfusion in Vascularized Composite Allotransplantation: Current Concepts and Future Prospects.

Severe injuries of the face and limbs remain a major challenge in today's reconstructive surgery. Vascularized composite allotransplantation (VCA) has emerged as a promising approach to restore these defects. Yet, there are major obstacles preventing VCA from broad clinical application. Two key restrictions are (1) the graft's limited possible ischemia time, keeping the potential donor radius extremely small, and (2) the graft's immunogenicity, making extensive lifelong monitoring and immunosuppressive treatment mandatory. Machine perfusion systems have demonstrated clinical success addressing these issues in solid organ transplantation by extending possible ischemia times and decreasing immunogenicity. Despite many recent promising preclinical trials, machine perfusion has not yet been utilized in clinical VCA. This review presents latest perfusion strategies in clinical solid organ transplantation and experimental VCA in light of the specific requirements by the vascularized composite allograft's unique tissue composition. It discusses optimal settings for temperature, oxygenation, and flow types, as well as perfusion solutions and the most promising additives. Moreover, it highlights the implications for the utility of VCA as therapeutic measure in plastic surgery, if machine perfusion can be successfully introduced in a clinical setting.

Vascularized composite allotransplantation: current standards and novel approaches to prevent acute rejection and chronic allograft deterioration.

The advent of more potent immunosuppressants led to the first successful human upper extremity transplantation in 1998. At this time, >100 upper extremity transplants, 30 face transplants, and a variety of other vascularized composite allotransplantation (VCA) procedures have been performed around the world. VCA recipients present unique challenges for transplantation. The incidence of acute rejection exceeds 80% in hand and face transplantation and is well documented, whereas reports about antibody-mediated rejection and chronic rejection remain scarce. Immunosuppression protocols commonly used at US centers are derived from solid organ transplantation protocols. Novel approaches to minimize rejections in VCA may include improved HLA matching and considerations toward cytomegalovirus infection status. New graft preservation techniques may decrease immunogenicity prior to transplant. Novel monitoring methods such as valid biomarkers, ultrasound biomicroscopy, and sentinel flaps may enable earlier diagnosis of rejection. Cell-based therapies are being explored to achieve immunosuppressive regimen minimization or even tolerance induction. The efficacy of local immunosuppression in clinical VCA remains controversial. In conclusion, although immunosuppressive strategies adapted from SOT have demonstrated good midterm results, focusing on the unique features of VCA grafts may enable additional, more specific treatment strategies in the future and improved long-term graft outcomes.

A Mobile Extracorporeal Extremity Salvage System for Replantation and Transplantation.

BACKGROUND: Traumatic amputation is the second leading cause of limb loss in the United States. The preferred treatment is salvage and replantation of the amputated limb, whenever possible, and allotransplantation is a novel procedure whereby healthy limbs are procured from deceased organ donors and transplanted into the amputee recipient. A major restriction for both procedures is the irrecoverable muscle damage occurring due to ischemia. We investigated the feasibility of using a novel lightweight, mobile perfusion device specifically designed to perfuse amputated porcine limbs with an acellular perfusion solution to delay ischemic muscle damage prior to transplantation or replantation. METHODS: Bilateral hind limbs of Yorkshire pigs were amputated; one of the limbs was preserved by perfusion in the mobile perfusion device, and the other by storage in ice slurry for 12 hours. RESULTS: Five sets of bilateral limbs were preserved as described previously. A defined pressure of 30 mm Hg was reliably maintained in the arterial system without loss of flow. Comparison of the perfusate composition before and after limb passage revealed significant differences. Muscle biopsies showed a consistent progression of clusters of hypoxic cells in the control limbs with time. Similar changes could not be observed in the perfused tissue. CONCLUSIONS: We have designed and built a small, mobile perfusion device that is operational and that more closely mimics the normal physiological environment when compared with the current standard of preservation in ice slurry. This project may have far-reaching implications for the treatment of limb loss through replantation and transplantation.

Surgical Optimization of Motor Recovery in Face Transplantation.

BACKGROUND: Face transplantation (FT) has emerged as a viable option for treating devastating facial injuries. Most reported outcomes have demonstrated satisfactory motor and sensory restoration despite differences in technique. The authors have developed an algorithm of facial nerve management in these challenging patients. Our principles of management are illustrated by 2 specific patients. METHODS: A retrospective analysis of prospectively collected data on 2 full face transplants was performed. Both patients required nerve grafting during full FT. Patient 1 due to short donor facial nerve stumps and patient 2 due to intraoperative soft tissue swelling. Patient 2 required a nerve transfer 11 months after full FT due to impaired motor recovery opposite the side of nerve grafting. Follow-up examinations consisting of manual muscle testing and Sunnybrook Facial Grading System 6 to 42 months after full FT with selected video examinations were critically reviewed. RESULTS: Patient 1 had symmetrical motor recovery with gradual improvements noted throughout. At 6 months, Patient 2 had asymmetrically improving motor function. After nerve transfer, the patient showed gradual improvement in motor recovery, symmetry, and tone. Videos for each patient demonstrate the evolution of the patients' ability to smile from 6 to 42 months. DISCUSSION: The authors describe their assessment of motor recovery and management of facial nerve reconstruction as it pertains to FT. Finally, the authors illustrate the principles of nerve transfer are applicable to FT recipients.

Surgical treatment of primary gynecomastia in children and adolescents.

PURPOSE: Idiopathic gynecomastia is a common diagnosis in children and adolescents. Though medical treatments reveal potentially harmful side effects, surgical interventions are performable in numerous techniques. In children and adolescents, only minimal evidence exists. This retrospective study presents our experiences with two common surgical techniques, namely subcutaneous mastectomy and combination with liposuction. PATIENTS AND METHODS: This retrospective study included all patients <18 years who underwent surgery due to idiopathic gynecomastia. Height, weight and grade of gynecomastia according to Simon's classification before surgery were reviewed in all patients' files. Additionally, duration of surgery, inpatient stay and postoperative complications were documented. Follow-up examinations were performed with assessment of scar formation, numbness and retraction of the nipple region. Furthermore, patients were asked to report on general satisfaction with surgery (satisfactory/not satisfactory) and esthetic outcome on a numeric scale (1 = good, 6 = bad). RESULTS: 37 patients underwent surgery for verified idiopathic gynecomastia. Grade of gynecomastia was I° in 13.5% (n = 5), II° in 40.5% (n = 15) and III° in 46% (n = 17) of cases. Subcutaneous mastectomy was applied in 11 patients (group I, 30%) and both subcutaneous mastectomy and liposuction in 26 patients (group II, 70.3%). Postoperative complications occurred in two patients. Long-term follow-up was performed in 32 patients after a median of 34 months (range 6-96 months). Hypertrophic scar formation was seen in one patient (3%) and nipple retraction in two patients (5%). Recurrence of gynecomastia occurred in two patients (5%). Patient rating was satisfactory in 9% of cases and esthetic outcome was received with a median of 2.0 (1-5). In comparing both surgical techniques, combination of mastectomy and liposuction revealed better results in every measure except for surgical duration (median 73 vs. 90 min). CONCLUSION: Surgical correction of gynecomastia remains a purely elective intervention. In contrast to adults, skin in children and adolescents provides high retractability. Therefore, open reduction combined with minimally invasive liposuction was proven useful.

Acute rejection in vascularized composite allotransplantation.

PURPOSE OF REVIEW: Acute rejection is the most common complication after vascularized composite allotransplantation (VCA). This review provides a state-of-the-art analysis of prevention, diagnosis and treatment of acute rejection episodes and highlights recent findings with the potential to improve patient care and enhance understanding of the underlying biologic processes. RECENT FINDINGS: Recent reports suggest that maintenance immunosuppression dose reduction and steroid withdrawal are realistic goals in VCA, despite the known high immunogenicity of the skin component. It appears that utilization of sentinel flaps, in-depth histological analyses and application of novel biomarkers have facilitated early diagnosis and characterization of acute rejection episodes, leading to timely institution of appropriate therapy. The successful management of the first highly sensitized face transplant recipient suggests the possibility of carefully considering these high-risk VCA candidates for transplantation. SUMMARY: Acute rejection is higher in VCA than in any other organ in the field of transplantation, although most episodes are controlled by high-dose steroids and optimization of maintenance immunosuppression. Because of limitations in patient number and the duration of follow-up, the long-term safety and effectiveness of VCA remain unclear. Moreover, the tests currently used to diagnose acute rejection are of limited value. Better diagnostic tools and a better understanding of the immunologic events during acute rejection are therefore needed to improve diagnosis, treatment and outcomes of this life-changing restorative surgery.

Minimally Invasive Robotic-assisted Perforator-to-Perforator DIEP Flap Breast Reconstruction.

Reducing morbidity has been the goal of many reconstructive microsurgery efforts. Several techniques have been described for deep inferior epigastric perforator flap breast reconstruction to minimize abdominal donor-site morbidity. Although these techniques have certain tradeoffs, we designed a minimally invasive robot-assisted perforator-to-perforator approach to achieve minimal donor- and recipient-site morbidity. Simultaneous identification of the deep inferior epigastric artery (DIEA) and internal mammary artery (IMA) perforator was performed, followed by a small fascial incision around the dominant DIEA perforator. The IMA perforator was prepared for a prepectoral anastomosis. The short DIEA pedicle was dissected without further longitudinal fascial incision until an adequate diameter compared with the IMA perforator was reached, and a robot-assisted perforator-to-perforator anastomosis was performed prepectorally. All patients underwent reconstruction performed by a single surgeon. The smallest abdominal incision was 2.5 cm with a DIEP pedicle length of 6 cm. The average IMA perforator diameter was 1.14 mm (1.0 mm-1.2 mm). The average vein diameter was 2.0 mm (1.5-3.0 mm). The incision to closure lasted 330 minutes (313-348 minutes). Flap ischemia was 105 minutes (82-118 minutes), whereas the time for robot-assisted anastomosis was 25 minutes (22-30 minutes). All anastomoses were performed successfully. Our initial experience with robot-assisted perforator-to-perforator anastomosis for DIEP flap breast reconstruction demonstrates promise in achieving minimal patient morbidity. Raising only a very short pedicle can be compensated by adding the prepectoral IMA perforator length and enabling a good size match for small-caliber anastomosis. This technique combines important aspects of most minimally invasive DIEP flap harvests and insets.

Psychological well-being as a motive for and result of post-bariatric body contouring procedures.

Objective: This study investigates whether psychological well-being in post-bariatric patients seeking body contouring procedures differs from those who do not seek body contouring procedures, those who have already undergone body contouring procedures, and those who are unsure about body contouring procedures. Methods: An anonymous, nonrandomized, cross-sectional survey study was designed. Psychological well-being of four groups of post-bariatric-patients (undergone body contouring procedures, seeking body contouring procedures, not seeking body contouring procedures, unsure about body contouring procedures) were compared. Results: A total of 345 patients were included in this study. No significant difference between patients seeking body contouring procedures and those not seeking body contouring procedures was found with regard to depressive symptoms, self-esteem, and body image. Patients who had already undergone body contouring procedures scored lower on depressive symptoms (p = 0.035) and reported feeling more attractive (p < 0.001) and less insecure (p = 0.030) than patients who had not yet undergone body contouring procedures but sought it. Satisfaction with the result of the body contouring procedures was associated with lower depression levels (p < 0.001), higher self-esteem (p < 0.001) and a more positive body-image (p < 0.001). Conclusions: Depressive symptoms or low self-esteem are not motivational factors for post-bariatric patients to seek body contouring procedures. Body contouring procedures are associated with improvement in psychological well-being in post-bariatric patients. Patients' satisfaction with the result of the body contouring procedures is significantly associated with positive psychological well-being.

Preclinical Performance of the Combined Application of Two Robotic Systems in Microsurgery: A Two-center Study.

Background: Recent advancements in the development of robotic devices increasingly draw the attention toward the concept of robotic microsurgery, as several systems tailored to open microsurgery are being introduced. This study describes the combined application of a novel microsurgical robot, the Symani, with a novel robotic microscope, the RoboticScope, for the performance of microvascular anastomoses in a two-center preclinical trial. Methods: Six novices, residents, and experienced microsurgeons (n = 18) performed five anastomoses on 1.0-mm-diameter silicone vessels with a conventional versus combined robotic approach, resulting in 180 anastomoses. Microsurgical performance was evaluated, analyzing surgical time, subjective satisfaction with the anastomosis and robotic setup, anastomosis quality using the anastomosis lapse index score, microsurgical skills using the Structured Assessment of Microsurgery Skills score, and surgical ergonomics using the Rapid Entire Body Assessment score. Results: All participants significantly improved their performance during the trial and quickly adapted to the novel systems. Surgical time significantly decreased, whereas satisfaction with the anastomosis and setup improved over time. The use of robotic systems was associated with fewer microsurgical errors and enhanced anastomosis quality. Especially novices demonstrated accelerated skill acquisition upon robotic assistance compared with conventional microsurgery. Moreover, upper extremity positioning was significantly improved. Overall, the robotic approach was subjectively preferred by participants. Conclusions: The concept of robotic microsurgery holds great potential to improve precision and ergonomics in microsurgery. This two-center trial provides promising evidence for a steep learning curve upon introduction of robotic microsurgery systems, suggesting further pursuit of their clinical integration.

Ideal suturing technique for robot-assisted microsurgical anastomoses.

The development of novel robotic devices specifically designed for open microsurgery leads to increasing applications in reconstructive procedures. While initial studies revealed improved precision and surgical ergonomics upon robotic assistance, surgical time was consistently observed to be increased. This study compares two robotic suturing techniques using the Symani Surgical System and RoboticScope in a preclinical setting, to further leverage the benefits of novel robotic devices in microsurgery. Six experienced microsurgeons performed three microvascular anastomoses with a "steady-thread" suturing technique and a "switch-thread" technique on 1.0-mm-diameter artificial silicone vessels. Time for anastomosis and participant's satisfaction with the techniques and robotic setup were recorded. Anastomosis quality and microsurgical skills were assessed using the Anastomosis Lapse Index and Structured Assessment of Microsurgery Skills. Lastly, technical error messages and thread ruptures were quantified. Knot tying was significantly faster and evaluated significantly better by participants using the steady-thread technique (4.11 ± 0.85 vs. 6.40 ± 1.83 min per anastomosis). Moreover, microsurgical skills were rated significantly better using this technique, while both techniques consistently led to high levels of anastomosis quality (2.61 ± 1.21 vs. 3.0 ± 1.29 errors per anastomosis). In contrast, the switch-thread technique was associated with more technical error messages in total (14 vs. 12) and twice as many unintended thread ruptures per anastomosis (1.0 ± 0.88 vs. 0.5 ± 0.69). This study provides evidence for the enhanced performance of a steady-thread suturing technique, which is suggested to be applied upon robot-assisted microsurgical procedures for optimized efficiency.

Mastopexy Strategies for Ptotic Breasts in Patients Choosing Autologous Reconstruction Following Prophylactic Mastectomy.

BACKGROUND: Autologous breast reconstruction is a reliable solution for many patients after mastectomy. While this technique represents a standardized approach in many patients, patients with ptotic breasts may require a combination of procedures to achieve an aesthetically pleasing result. METHODS: We reviewed the mastectomy and free-flap breast reconstruction procedures performed at our institution from 2018 to 2022 in patients with ptotic breasts. The technique used to address the ptosis was put in focus as we present the four strategies used by our reconstructive surgeons. We performed two different one-stage and two different two-stage procedures. The difference between the two-stage procedures was the way the nipple areola complex was treated (inferior dermal pedicle or free skin graft). The difference between the one-stage procedures was the time of execution of the mastopexy/breast reduction (before or after the mastectomy and autologous breast reconstruction). RESULTS: The one-stage procedure was performed with a free NAC in three patients and with a pedicled NAC in five patients. The two-stage procedure was performed in seven patients, with six of them undergoing mastopexy before and one patient undergoing mastopexy after the bilateral mastectomy and autologous reconstruction. No flap loss or total loss of the nipple areola complex occurred. Partial NAC loss was observed in five breasts in the single-stage group without any occurrence in the double-stage group. CONCLUSIONS: While both one- and two-stage procedures were performed in a safe fashion with satisfactory results at our institution, larger trials are required to determine which procedure may yield the best possible outcomes. These outcomes should also include oncological safety and patient-reported outcomes.

Breast Reconstruction with DIEP Flap: The Learning Curve at a Breast Reconstruction Center and a Single-Surgeon Study.

Although microsurgical breast reconstruction represents a very interesting and rewarding field of plastic surgery, appropriate microsurgical training is not possible in every plastic surgery department. In this retrospective study, we present the learning curve of our plastic surgery department as a whole and of a single microsurgeon assessing breast reconstruction procedures with a deep inferior epigastric artery perforator (DIEP) flap between July 2018 and June 2021. The present study included 115 patients and 161 flaps. Cases were stratified into single DIEP/double DIEP groups and into early and late groups based on the flap order. Surgery times and postoperative complications were analyzed. Regarding the institution, the length of hospital stay was lower in the late group than in the early group (single 7.1 ± 1.8 vs. 6.3 ± 1.5 days, p = 0.019; double 8.5 ± 3.8 vs. 6.6 ± 1.4 days, p = 0.043). Apart from that, no statistically significant differences were found between the start and end of our study. In terms of the single surgeon, there was a significant improvement in the total surgery time (single 296.0 ± 78.7 vs. 227.5 ± 54.7 min, p = 0.018; double 448.0 ± 85.6 vs. 341.2 ± 43.1 min, p = 0.008), flap ischemia time (53.6 ± 15.1 vs. 40.9 ± 9.5 min, p = 0.007) and length of stay among the compared groups. There was no significant difference in flap loss rate or other complications between the early and late groups. Further performance of surgeries seemed to improve the surgeon's skills as well as the overall experience of the medical institution.