Stack, PAP and Bury: Technical refinements from a case series of 56 profunda artery perforator flaps for breast reconstruction.

AIMS: To share experiences and learning curve of the introduction of profunda artery perforator (PAP) flaps in breast reconstruction. The secondary aim was to share techniques to improve outcomes. METHODS: Case series reviewing outcomes of 56 consecutive PAP flaps performed by a single surgeon across five institutions between March 2021 and May 2023 were reported. The senior author's preference is to routinely stack and bury the flaps to optimise cosmetic outcomes. RESULTS: Fifty-six PAP flaps were performed in 30 patients. The majority of the PAPs were stacked (n = 43, 77%). The mean age at surgery was 46 years (SD 8.44 years) and mean body mass index was 23.86 (SD 3.59). The mean flap weight was 198.83 g (SD 82.86 g) and the mean combined weight for stacked flaps was 369.57 g (SD 98.65 g). Mean ischaemia time was 56.59 min (SD 17.83 min). There was one flap loss (2%). Of the immediate flaps, 90% were buried and monitored using flow couplers. CONCLUSION: The routine use of PAPs, in particular stacked PAPs, allows for adequate volume and height for breast reconstruction in patients who may have otherwise been deemed unsuitable for autologous breast reconstruction. The PAP flap has replaced the transverse upper gracilis and superior gluteal artery perforator flaps as the second line flap choice in our practice.

Opportunistic use of naturally expanded neck skin for a buccal mucosa defect.

A 77-year-old female presented with an ulceroproliferative lesion of the left buccal mucosa extending to the commissure, diagnosed with squamous cell carcinoma on biopsy. She also had a large thyroid swelling, with expanded skin, diagnosed with a multinodular goiter. The patient underwent buccal mucosa wide local excision with left-sided selective neck dissection and total thyroidectomy. The naturally expanded skin over the anterior neck overlying the goiter was used for the reconstruction of the buccal mucosa defect based on the perforator unexpectedly arising directly from the external carotid artery instead of superior thyroid artery. The venous drainage was to an internal jugular vein tributary, multiple dilated veins on the flap were draining into this vein. We describe the innovative use of locally expanded skin for buccal mucosa reconstruction and thereby avoiding the morbidity of a free flap transfer and associated donor site morbidity.

Characteristics and outcomes of primary interposition vascular grafts in free flap breast reconstruction.

INTRODUCTION: There is paucity of data on primary interposition vascular grafts (IVG) use in microsurgery. Our study examines the characteristics, indications and outcomes of IVG in free flap breast reconstruction. METHODS: All cases of breast reconstruction with free flaps between January 2013 and June 2018 were examined and cases with primary IVG were included. Data were collected on patient, flap and graft characteristics, indications and outcomes. RESULTS: A total of 76 IVG, specifically 65 vein grafts and 11 arterial grafts, were used for 49 (of 1547) flaps in 48 (of 1346) cases. Of these, 52 grafts were primarily used to lengthen the pedicle and aid flap inset and 24 grafts to augment venous flow; 49 grafts were harvested from the flap harvest site, 7 from the anastomosis recipient site and 20 from a separate site. Of the total, 16.7% (8/49 flaps) required salvage procedures - seven cases for venous congestion and one for ischaemic compromise - in comparison to 4.3% in cases without IVG (65/1498) (p<0.0001). Out of 49 IVG flaps, three (6.1%) failed in comparison to 1.7% (26/1498), where IVG flaps were not used (p<0.05). Two were transverse upper gracilis flaps with vessel calibre mismatch, and one lumbar artery perforator (LAP) flap with past infected implant and failed deep inferior epigastric artery (DIEP). CONCLUSION: We present the largest number of primary vascular grafts for free flap breast reconstruction in the literature. Primary IVG were used for at-risk flaps and had a success rate of 93.9%. This shows that IVG are a viable option to prevent venous congestion and lengthen the pedicle to aid inset and shaping; they are associated with higher complication rates bearing in mind the high-risk profile of the flaps these are used for.

Thoracodorsal Artery Perforator and Superior Epigastric Artery Perforator Flaps for Volume Replacement Oncoplastic Breast Surgery.

Introduction Breast conservation therapy (BCT) and oncoplastic breast surgery (OBS) are now established modalities of treatment for breast cancer, with proven oncological safety. Traditionally, latissimus dorsi (LD) flaps have been the one-stop solution workhorse when volume replacement is needed. We present our experience with thoracodorsal artery perforator (TDAP) and superior epigastric artery perforator (SEAP) flaps. These flaps allow the preservation of muscle structure and function. Material and Methods Data were collected prospectively of patients in whom pedicled perforator flaps after BCT were used. A handheld 8-MHz audio Doppler was used to locate the perforators. TDAP flaps were used in four patients, whereas SEAP flaps were used in two patients. Skin paddle sizes ranged from 10 × 3 cm to 21 × 7 cm. Results TDAP flaps were used in four patients, whereas SEAP flaps were used in two patients All flaps survived. No flap had partial necrosis or fat necrosis. All donor sites were closed primarily and healed uneventfully, and none had a seroma requiring aspiration. Conclusion TDAP flaps can be selectively employed when the LD muscle function needs to be preserved. SEAP flaps can also be employed as a rare option in case of lower inner quadrant defects. Pedicled perforator flaps are a useful and reliable option for volume replacement OBS in select patients for reconstructing partial mastectomy defects.