Five recipient vessels for metachronous chest wall reconstruction: Case report and literature review.

Selecting potential recipient vessel options for free flap anastomosis is an important consideration in microsurgical breast and chest wall reconstruction. In these settings, the most common comprise the internal mammary and thoracodorsal vessels, although alternative anastomotic sites have also been described. On occasion, consideration of these alternatives becomes a necessity. The use of five separate recipient vessels is highlighted in a unique case of recurrent locally advanced breast cancer requiring multiple complex reconstructions using free tissue transfer. A 56-year-old lady presented for delayed breast reconstruction one year after radical mastectomy for locally advanced lobular breast cancer. Despite wide resections, local chest-wall recurrence five times necessitated five microsurgical reconstructions, using separate recipient pedicles: internal mammary vessels, thoracodorsal vessels, serratus branch of thoracodorsal vessels, intercostal vessels and thoracoacromial vessels. All flaps survived completely, without donor or recipient complications. There has not been a subsequent recurrence at 6 months since last reconstruction. The purpose of this report is to present the first reported case of microsurgical chest wall reconstruction using five separate free flaps requiring anastomosis to multiple recipient vessels for anterior chest wall coverage, to present a literature-based and clinical review of the regional vascular anatomy of the anterior chest wall, and to present an operative approach algorithm. In such complex cases, this understanding can facilitate a streamlined approach to management. © 2014 Wiley Periodicals, Inc. Microsurgery 37:66-70, 2017.

Microsurgical Reconstruction of Large Oncologic Chest Wall Defects for Locally Advanced Breast Cancer or Osteoradionecrosis: A Retrospective Review of 26 Cases over a 5-Year Period.

BACKGROUND: Locally advanced breast cancer (LABC) and chest wall osteoradionecrosis (ORN) often require extensive and composite tissue resection, including muscles, ribs, pleura, and lung parenchyma. As such, these cases necessitate complex reconstructive procedures for skeletal chest wall reconstruction and soft tissue resurfacing of extensive defects. Traditional local and regional flaps are often inadequate, and many such cases are prospectively labeled "unresectable." METHODS: We report a single-center experience with the microsurgical reconstruction of such defects over a 5-year period. Between 2007 and 2011, 1,077 microvascular reconstructive cases following breast cancer resection were performed, of which 26 cases comprised LABC or ORN requiring reconstruction. Surgical indications, defect parameters, choice of reconstruction, and outcomes were assessed. RESULTS: Thirty free flap microsurgical reconstructions were undertaken in 26 cases, with a 96.2% flap survival rate. Complications were low, and mean hospital stay was 8.7 days. An algorithmic approach to management is presented. CONCLUSION: Wide resection and microvascular free tissue transfer provide versatile solutions for the reconstruction of extensive chest wall defects. With good reported perioperative outcomes even in advanced cases, surgical resection of LABC may offer a useful approach in difficult and/or palliative cases.

The use of plasmakinetic cautery compared to conventional electrocautery for dissection of abdominal free flap for breast reconstruction: single-centre, randomized controlled study.

BACKGROUND: The plasmakinetic cautery is a surgical dissection instrument that combines scalpel-like cutting precision with electrocautery-like haemostasis properties, and operates at lower temperatures (40-170 °C) than conventional electrocautery (200-350 °C). The aim of this study is to evaluate the clinical benefits of using plasmakinetic cautery in abdominal free flap dissection for breast reconstruction. METHODS: Forty women undergoing abdominal-based microsurgical breast reconstruction (DIEP/MS-TRAM) were randomized to plasmakinetic cautery (n=20) or conventional electrocautery (n=20) for dissection of the abdominal free flap. Total abdominal wound drainage volume/duration, operation time and complications such as seroma and haematoma were examined. RESULTS: Age, body mass index, type of reconstruction and abdominal flap weight were similar in both groups. Mean abdominal drainage volume was (279±262) mL in conventional electrocautery group and (294±265) mL in plasmakinetic cautery group (P=0.853). Plasmakinetic cautery group mean drainage duration (4.3±2.2 days) was no difference compared to conventional diathermy group (3.8±2.0 days, P=0.501). Mean operation time in the conventional electrocautery group and plasmakinetic cautery group was 157±50 vs. 174±70 min respectively (P=0.195). There was more seroma detected in the conventional electrocautery group compared to plasmakinetic cautery group at days 7, 14 and 42 post-operation, but this was not statically significant. 2 haematomas in conventional diathermy group and 1 haematoms in the plasmakinetic cautery group required evacuation. CONCLUSIONS: This study demonstrates that there are no significant differences between the use of plasmakinetic cautery and conventional electrocautery for abdominal free flap dissection.

The microvascular anastomotic coupler for venous anastomoses in free flap breast reconstruction improves outcomes.

BACKGROUND: Venous couplers are ubiquitous around the world and are a useful tool for the reconstructive microsurgeon. A systematic review of coupler performance studies demonstrated a thrombosis rate range of 0% to 3%, whilst the average time of using the device is 5 minutes. There is sparse published data on cost analysis and the impact of operator experience on the anastomotic coupler device success. Improvements in outcomes other than time benefits have also not been shown. This study aims to address these deficiencies in the literature. METHODS: A retrospective clinical study was undertaken, aiming to compare equivalent groups of patients that had free flap surgery with venous micro-anastomoses with those that had sutured anastomoses. The cohort comprised all patients undergoing microsurgical breast reconstruction at the St Andrew's Centre for Plastic Surgery & Burns from January 2009 to December 2014. RESULTS: Between January 2010 to December 2014, 1,064 patients underwent 1,206 free flap breast reconstructions. The average age of patients was 50 years. Seventy percent of patients underwent mastectomy and immediate reconstruction during this period with the remaining 30% having a delayed reconstruction. The 1,206 free flaps comprised of 83 transverse myocutaneous gracilis (TMG) flaps, and 1,123 deep inferior epigastric artery perforator (DIEP) flaps. In total the coupler was used in 319 flaps, 26% of the cohort. There was a statistically significant clinical benefit in using the anastomotic coupler for venous anastomosis. Overall, the return to theatre rate was 12.69% whilst the overall flap loss rate was 0.75%. The overall coupler failure rate was significantly less at 1.4% whilst sutured vein failure rate was 3.57% (P=0.001). CONCLUSIONS: The anastomotic coupler for venous anastomosis in free flap surgery is associated with reduced operating times, reduced take-backs to theatre and cost benefits. This is the first study to demonstrate clear clinical benefits to anastomotic couplers, and suggests that these may be the gold standard for venous microanastomosis. With increasing experience with their use and technological advances, these outcomes may continue to improve.

Stacked and bipedicled abdominal free flaps for breast reconstruction: considerations for shaping.

BACKGROUND: Stacked and bipedicled abdominal flaps are useful in women who require a large breast reconstruction but have relative paucity of abdominal tissue. A new classification system is described to assist the surgeon in achieving the best possible aesthetic outcome. METHODS: A retrospective review of 25 consecutive stacked and/or bipedicled deep inferior epigastric perforator (DIEP) flap reconstructions was assessed from 2009 to 2014. Demographic data and key variables were prospectively collected in our breast reconstruction database and an aesthetic classification devised. There are four main subtypes, (I) folded; (II) divided; (III) coned; and (IV) divided and folded. Each of these subtypes can be moulded in a symmetrically or asymmetrically fashion depending on the contralateral breast shape together with distribution and consistency of fat within the abdominal flap. RESULTS: Of the 25 patients, three-quarter were immediate reconstruction, with an average age of 48 years and a median follow-up of 2 years 10 months. Just over half the patients (57%) had bipedicle flaps with two recipient donor vessels with the remaining 43% had stacked flaps. The most common recipient sites are the thoracodorsal vessels (62%) and intercostal perforators (26%). The average abdominal pannus weight was 610 grams (SD: 320 grams), with a hemi-abdominal weight of 305 grams. Two patients had haematomas, of which one lost their reconstruction. Another patient had a venous congestion flap which was salvaged. CONCLUSIONS: Bipedicled or stacked abdominal flaps allow the all four zones of the abdominal tissue to be used in unilateral breast reconstruction. The approach of tailoring the abdominal flaps to match the contralateral breast reconstruction is largely an art form. The paper aims to bring some meaningful system to aid the surgeon to achieve the best possible outcome with the components presented to them.

Modern use of smartphone applications in the perioperative management in microsurgical breast reconstruction.

BACKGROUND: Advances in mobile telecommunication, improved mobile internet and affordability have led to a significant increase in smartphone use within medicine. The capability of instant messaging, photography, videography, word processing, drawing and internet access allow significant potential in this small portable device. Smartphone use within medicine has grown tremendously worldwide given its affordability, improved internet and capabilities. METHODS: We have searched for apps specifically helpful in the perioperative care of microsurgical breast reconstructive patients. RESULTS: The useful apps have been subdivided: (I) communication apps-multimedia messaging, WhatsApp, PicSafeMedi: allow efficient communication via text, picture and video messages leading to earlier assessment and definitive management of free flaps; (II) storage apps-Notability, Elogbook: electronic storage of patient notes and logbooks of case which can be shared with others if required; (III) educational apps-FlapApp, Touch Surgery, PubMed on tap: step by step guides to surgical procedures to aid learning and medical journal database; (IV) flap monitoring app-SilpaRamanitor: free flap monitoring app based on photographic analysis for earlier detection of compromised flaps. CONCLUSIONS: There has been remarkable growth in smartphones use among surgeons. Apps are being developed for every conceivable use. The future will be in wearable smart devices that allow continuous monitoring with the potential to instigate change should deviations from the norm occur. The smart watch is the start of this digital revolution.