"Extra-anatomical Pedicle Rerouting" An alternative technique to obtain new recipient vessels for microsurgical reconstruction in unfavorable clinical situations.

BACKGROUND: Lack of adequate recipient vessels in certain anatomically unfavorable locations or in complex clinical situations is still a limitation to successful microsurgical transfer. To address such complex cases, advanced microsurgical techniques should be applied. In this paper, the authors describe their experience with the Extra-anatomical Pedicle Rerouting (EPR) technique, an alternative approach that was used in selected cases throughout the body to obtain healthy recipient vessels for microsurgical reconstruction in unfavorable clinical situations where suitable recipient vessels were difficult to find. PATIENTS AND METHODS: Fifteen patients with defects of variable etiology (oncological resection, trauma, previous surgeries) located in the trunk or upper and lower extremities received EPR free flap reconstruction at our Institution. Operative data, postoperative course, and complications were recorded. Clinical and photographic follow-ups were also documented. RESULTS: A total of 15 flaps (6 antero-lateral thigh (ALT), 6 latissimus dorsi/thoracodorsal artery perforator flap (LD/TDAP), 3 deep inferior epigastric artery perforator flap (DIEP)) were transferred adopting the EPR technique for oncological (11) and post-traumatic (4) defects. According to the different clinical scenarios, the rerouted vessels were the thoraco-acromial, posterior circumflex humeral, thoracodorsal, deep inferior epigastric, lateral circumflex femoral, anterior tibial, and medial sural pedicles. Mean length of the rerouted vascular conduits was 6.53 cm. Mean operative time was 420 minutes. No major complications were registered. Minor wound dehiscence was observed and managed conservatively in 3 patients. CONCLUSIONS: The EPR technique proved to be useful in a reliable and reproducible manner in different regions of the body as an alternative solution to obtain healthy recipient vessels in anatomically and surgically unfavorable clinical situations.

Conjoined thoracodorsal perforator-supercharged dorsal intercostal artery perforator propeller flap for reconstruction of a complex upper back defect: Case report and review of the literature on supercharged pedicled perforator flaps.

The reported complications' rate of perforator propeller flaps is variably high, but the etiology of distal flap necrosis, potentially linked to vascular insufficiency, is yet to be clarified. Vascular augmentation procedures have been previously described involving an extra anastomosis of a superficial vein, while a perforator-to-perforator supercharging approach has been only sporadically documented in literature. We present a case of perforator-to-perforator vascular supercharging of an extended dorsal intercostal artery perforator (DICAP) propeller flap to provide a salvage option for pedicled flap complicated by venous congestion. A 71-year-old male patient underwent Dermatofibrosarcoma Protuberans resection in the upper back, leading to a 17 × 17 cm defect with bone exposure. A 30 × 9 cm DICAP propeller flap was planned, with the distal third of the flap designed over the adjacent Thoracodorsal artery perforasome, in a conjoined fashion. Considering the small DICAP pedicle caliber and the flap lateral extension, a thoracodorsal artery perforator vein was dissected and included in the distal flap. Once the flap was raised on its main pedicle, the skin paddle turned blue, showing signs of venous insufficiency. Indocyanine green angiography (ICG) showed a viable proximal half of the flap. Hence, after rotating the skin paddle to reach the upper margin of the defect, an additional anastomosis between the perforating thoracodorsal vein and the perforating vein of the dorsal scapular pedicle was performed according to the perforator-to-perforator approach. Doing so, both clinical and ICG examinations showed a well perfused flap, with normal capillary refill. The postoperative course was uneventful, and the patient obtained a good oncological and reconstructive result 4 months postoperatively. The second Vasconez law ("all of the flap will survive except the part that you need") is often encountered in propeller flaps surgery. Our case shows that it is possible to prevent or overcome this problem by planning appropriate vascular augmentation procedures according to the perforator-to-perforator approach, being guided by advanced vascular imaging tools like ICG.

Thigh reconstruction between form and function: An algorithm for flap selection based on a series of 70 oncological patients.

INTRODUCTION: Thigh reconstruction after oncological resection represents a challenge in terms of ideal morphological and functional outcomes to aim for. Very few papers presented a comprehensive approach to this topic, most of them being only small cases series. The purpose of this article was to review our institutional experience in the field of thigh soft-tissue reconstruction, proposing an algorithm to choose the most convenient pedicled or free flap approach according to the different clinical scenarios and the specific morpho-functional requirements of the case. PATIENTS AND METHODS: The authors retrospectively reviewed patients who received flap reconstruction for thigh soft-tissue defects after oncological resection between 2014 and 2021. Demographic and operative data were recorded. Twelve months post-operatively, patients were asked to rate the esthetic and functional outcomes of the reconstructive procedure on a 5-point Likert scale. Additionally, for patients receiving a free functional muscle transfer to restore quadriceps or hamstring function, recovery was evaluated with the Medical Research Council Scale for Muscle Strength. RESULTS: Seventy flap reconstructions of the thigh were, respectively, performed after sarcoma (n = 43), melanoma (n = 13) and non-melanoma skin cancer (n = 14) resection. Pedicled flaps were used in 55 patients: 46 perforator flaps (32 ALT, 4 AMT, 4 PAP, 2 TFL, 2 MSAP, 2 DIEP) and 9 muscle or myocutaneous flaps (4 medial gastrocnemius, 2 gracilis, and 3 VRAM). Microsurgical reconstruction was performed in 15 patients for extensive defects (2 SCIP, 1 latissimus dorsi-LD, 1 thoracodorsal artery perforator-TDAP, 1 ALT, 2 DIEP flaps) or when >50% of the quadriceps or hamstring compartments were resected (eight free functional muscle transfer including five vastus lateralis, two LD, and one rectus femoris). Extensive defect surface, previous irradiation and neoadjuvant chemotherapy appeared to be predictors of free flap reconstruction. Complication (49% vs. 26.6%; p > .05) and readmission rates (32.7% vs. 13.3%; p > .05) were comparable between pedicled and free flap groups, as well as complications severity scores according to Clavien-Dindo classification (1.15 vs. 1.29; p > .05). However, patients with previous irradiation experienced worse outcomes when receiving pedicled rather than free flaps in terms of reintervention (87.5% vs. 28.6%; p = .04) and readmission rates (87.5% vs. 14.29%; p = .01), and severity of surgical complications. Overall patients' satisfaction was high, with esthetic and functional mean score of 4.31 and 4.12, respectively (p > .05). In the FFMT group, M5, M4, M3, and M2 strength was observed in 3, 3, 1, and 1 patients, respectively. CONCLUSION: Oncological thigh defects are usually well addressed with pedicled perforator flaps. Microsurgical reconstruction offers reliable and reproducible results in extensive defects and in previously irradiated fields or when functional restoration is indicated.

Abdominal wall reconstruction with the free functional L-shaped latissimus dorsi flap: A case report.

Extensive tridimensional defects of the abdominal wall are usually addressed with soft tissue flaps combined with meshes. In this scenario, the additional value of dynamic abdominal wall reconstruction with functional flaps has yet to be demonstrated. In this paper the authors describe for the first time a unique case of total abdominal wall reconstruction with the free functional L-shaped latissimus dorsi (LD) flap, designed to increase the surface area of skin flap coverage while minimizing donor site morbidity, highlighting technical tips and long-term outcomes. A 65-year-old patient underwent abdominal wall resection for a dermatofibrosarcoma protuberans, leaving her with a 23 × 15 cm full-thickness defect. After placing a mesh, a myo-cutaneous free LD Flap with an L-shaped configuration was planned. The flap was composed of Paddle A, designed vertically along the anterior margin of the muscle and Paddle B, designed over the inferior aspect of the LD muscle, extending obliquely from the midline and intersecting Paddle A laterally with a 60° angle. End-to-end anastomoses to the deep inferior epigastric artery and vein and thoracodorsal nerve coaptation to a sizeable intercostal nerve were performed. The LD muscle was sutured according to its native tension while the two skin islands allowed an almost complete resurfacing of the abdominal wall defect. Donor site was closed primarily. Post-operative course was uneventful. One year postoperatively, good abdominal contour was observed, with adequate abdominal tone at rest in laying and standing position. Muscle neurotization was confirmed with clinical examination showing voluntary contraction of the transplanted muscle and the patient reported very high functional outcomes at the hernia-related quality-of-life (HerQles) questionnaire. The free L-shaped LD flap represents an innovative solution to reconstruct extensive full-thickness defects of the abdominal wall while reducing donor site morbidity. Flap neurotization should be attempted whenever possible to improve functional outcomes of the procedure.

Prepectoral Versus Subpectoral Direct-to-Implant Breast Reconstruction: Evaluation of Patient's Quality of Life and Satisfaction with BREAST-Q.

BACKGROUND: Over the years, plastic surgery has acquired a central role in the integrated treatment of breast cancer. Direct-to-implant (DTI) reconstruction using the prepectoral approach has emerged as an alternative to reconstruction using the subpectoral technique to overcome the complications arising from this type of surgery resulting as a consequence of muscle elevation. The satisfaction and quality of life of patients undergoing DTI breast reconstruction were evaluated using the BREAST-Q questionnaire, comparing the prepectoral and the subpectoral technique. METHODS: A single-center cross-sectional study on patients who underwent mastectomy and DTI breast reconstruction at our institution between 2013 and 2021 was conducted. Eighty-one patients were included and mainly divided into two groups based on the surgical procedure: 52 patients undergoing a subpectoral breast reconstruction approach and 29 patients receiving a prepectoral breast reconstruction. In order to assess the quality of life, the postoperative BREAST-Q module was administered electronically to the enrolled patients. RESULTS: Higher scores in BREAST-Q domains were recorded from patients who underwent mastectomy and breast reconstruction with prepectoral technique: psychosocial well-being (P<0.0085), sexual well-being (P<0.0120), physical well-being: lymphoedema (P<0.0001) and satisfaction with information received (P<0.0045). There were further statistically significant differences between the two groups with regard to postoperative complications (p<0.0465) and the need for reoperation (p<0.0275). CONCLUSIONS: Patients who underwent DTI breast reconstruction with prepectoral technique were more satisfied in terms of psychosocial, sexual and also physical well-being. These patients also had statistically lower complications and reoperations compared to patients who received breast reconstruction with the subpectoral technique. LEVEL OF EVIDENCE IV: This journal requires that authors 38 assign a level of evidence to each article. For a full 39 description of these Evidence-Based Medicine ratings, 40 please refer to the Table of Contents or the online 41 Instructions to Authors www.springer.com/00266 .

Histologic and Immunohistochemical Evaluation of Human Breast Capsules Formed around Five Different Expander Surfaces.

BACKGROUND: Polyurethane (PU) coating and implant texturization were designed to reduce the incidence of capsular contracture (CC), even if the link between surface type and CC remains unclear. To date, the etiopathogenetic aspects have not been fully clarified. The aim of this study was to evaluate capsules formed around five different breast expanders. METHODS: Thirty patients were divided into randomized groups implanted with five different expanders: smooth, coated with PU foam (poly), with a low-microtextured, high-microtextured, and macrotextured surface (L-micro, H-micro, macro). Specimens of the capsules were removed at implant reconstruction and evaluated for morphology and immunohistochemistry expression of α-smooth muscle actin (α-SMA), collagen type I and III, CD68, CD34, and CD3. Remodeling Combined Index was also evaluated. RESULTS: Expression of α-SMA was significantly increased in smooth capsules versus poly, low-microtextured, and high-microtextured groups ( P = 0.007; P = 0.010; P = 0.028), whereas the prevalence of collagen type I in smooth capsules and collagen type III in poly capsules identified a stable versus an unstable tissue. Remodeling Combined Index and α-SMA showed an inverted correlation. CD68 and CD34 cellular expression increased significantly in poly capsules with respect to smooth ( P < 0.001; P < 0.001) and macrotextured groups ( P < 0.001; P < 0.001). CD3 showed no significant difference among the groups. CONCLUSION: In this human study, the authors observed that increased tissue remodeling and reduced myofibroblast activation, along with the inflammatory infiltration and neoangiogenesis, especially in the poly and low-microtextured groups, might promote the formation of an unstable and less fibrotic capsule, lowering the risk of CC. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Direct-to-Implant Breast Reconstruction After Unilateral and Bilateral Mastectomy: Cross-Sectional Study of Patient Satisfaction and Quality of Life with BREAST-Q.

INTRODUCTION: Immediate single stage breast reconstruction is a challenging procedure with the goal of improving the quality of life of patients with breast cancer. The aim of this study is to evaluate using the BREAST-Q patient satisfaction, body perception and quality of life after direct-to-implant breast reconstruction comparing unilateral and bilateral reconstructions. METHODS: In this study we enrolled 56 women who underwent mastectomy and immediate single-stage direct-to-implant (DTI) breast reconstruction at Campus Bio-Medico University of Rome between 2013 and 2020. One year after surgery they were administered electronically the BREAST-Q post-operative module. RESULTS: Our two cohorts of patients consisted in 34 women who received unilateral nipple-sparing mastectomy and DTI breast reconstruction and 22 women who underwent bilateral nipple-sparing mastectomy and DTI breast reconstruction. Twenty-four of the 34 patients belonging to the unilateral group responded to the questionnaire (70.5%), while in the bilateral group responders were 16 out of 22 (72.7%). The BREAST-Q scores were compared between the two groups: patients undergoing bilateral mastectomy and breast reconstruction showed higher scores in every BREAST-Q domain compared to patients undergoing unilateral mastectomy and breast reconstruction with a statistically significant difference in the Satisfaction with breast (P = 0.01), Sexual well-being (P = 0.03), and Satisfaction with implants (P = 0.01) domains. CONCLUSIONS: Patients undergoing bilateral DTI breast reconstruction have a favorable postoperative surgical cosmetic outcome with a better patient's body image perception and a higher post-operative level of satisfaction compared to unilateral DTI reconstruction after nipple-sparing mastectomy. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Total autologous breast reconstruction with the Kiss Latissimus Dorsi Flap.

INTRODUCTION: Patients presenting breast actinic damage or implant-related complications require an autologous approach to breast reconstruction. However, when they are not good candidates for microsurgical procedures, alternative solutions must be sought. Latissimus dorsi (LD) is a workhorse flap in breast reconstruction, but often the amount of skin and volume achievable are insufficient. Taking inspiration from the Kiss flap concept, the authors hereby describe the "Kiss" LD flap to achieve totally autologous breast reconstruction. PATIENTS AND METHODS: A prospective service evaluation of all patients who underwent breast reconstruction with Kiss LD flap between 2018 and 2020 was performed. Patient demographics and operative variables were recorded, together with early and late complications. Patient satisfaction and quality of life were registered using the latest BREAST-Q reconstruction module, which includes specific LD scales. The questionnaire was administered to patients preoperatively and six months postoperatively. RESULTS: Thirty patients underwent total autologous breast reconstruction with Kiss LD flap. Breast cancer and breast sarcoma resection were followed by reconstruction. The timing of reconstruction was immediate in 3 cases and delayed in 27 cases. No major complications nor total flap loss were registered. BREAST-Q scores postoperatively were significantly higher than the preoperative ones in every domain (p<0.0001) except for the physical well-being of back and shoulder, where the scores differed slightly and non-significantly (p=0.05). CONCLUSIONS: The Kiss LD flap allows to harvest a large amount of skin to restore the breast envelope and a considerable volume to reconstruct the breast mound in a completely autologous procedure.

"Thou Shalt Not Throw Away a Living Thing": Innovative Use of Perforator Flaps in Abdominal Wall Reconstruction.

SUMMARY: Abdominal wall reconstruction represents a complex challenge for plastic surgeons, given the variable range of clinical situations requiring restoration of abdominal wall integrity. When significant myofascial defects are encountered, repair with either a synthetic or biological mesh is indicated, both of which have advantages and drawbacks. Taking inspiration from Gillies' fourth commandment of plastic surgery- Thou shalt not throw away a living thing -an innovative technique to obtain a vascularized autologous mesh from the tissues usually discarded during abdominal contouring procedures was conceived. The authors describe how to maximize the use of perforator flaps derived from abdominoplasty excision patterns in abdominal wall reconstruction to simultaneously obtain restoration of abdominal wall integrity and improvement of the abdominal contour.

Postmastectomy Radiation Therapy in the Setting of Two-Stage Retropectoral Implant-Based Breast Reconstruction: Should It be Delivered Before or After Implant Exchange? A Retrospective Analysis on 183 Patients.

INTRODUCTION: Postmastectomy radiation therapy (PMRT) has a primary role in the treatment of locally advanced breast cancer; however, the most appropriate timing of irradiation in immediate tissue expander breast reconstruction (ITEBR) still remains unknown. METHODS: A retrospective review was performed on all women undergoing mastectomy and retropectoral ITEBR at Campus Bio-Medico University Hospital in Rome, Italy, between 2010 and 2019. The patients were categorized into three cohorts: patients undergoing PMRT with the tissue expander (TE) in situ, patients with PMRT delivered to the permanent implant (PI), patients who were not administered RT. Complications and failure rates were analysed and compared. Potential predictors of adverse outcomes were analysed. RESULTS: Over 10 years, 183 patients underwent retropectoral ITEBR (55 PMRT-TE, 50 PMRT-PI, 78 no-PMRT). The three groups were well matched with respect to patient- and treatment-related factors (p > 0.05), with the exception of neoadjuvant chemotherapy and irradiation. The mean follow-up was, respectively, 4.58, 7 and 5.75 years. Radiotherapy either to the TE or to the PI was independently associated with failure and conversion to autologous procedures (p < 0.0001). Failure rate was significantly higher when TE was irradiated (p = 0.03). PMRT was associated with severe capsular contracture development (p < 0.00001), the odds being higher when irradiation was delivered after implant exchange (p = 0.04). Increased BMI was significantly associated with failure. CONCLUSIONS: When PMRT is delivered to the TE, the risk of failure is higher (OR 2.77); when the PI is irradiated, reconstruction will more likely be affected by severe capsular contracture (OR 2.7). However, considering that the overall risk of severe capsular contracture correlated to PMRT is higher than failure, we believe that irradiation should be delivered to the TE. Performing a proper capsuloplasty at the time of implant exchange, indeed, allows to correct the deformities related to radiation-induced capsular contracture. Patients with unfavourable outcomes after TE placement and RT, instead, can be directly switched to autologous reconstruction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Impact on Patient's Appearance Perception of Autologous and Implant Based Breast Reconstruction Following Mastectomy Using BREAST-Q.

INTRODUCTION: The purpose of this study is to determine if there is a better quality of life with one of the two techniques and if the results are in line with those already present in the literature. The hypothesis from which we started is to demonstrate that cancer patients who undergo a deep inferior epigastric perforator flap (DIEP) breast reconstruction surgery are more satisfied and have a higher level of quality of life compared to those subjected to an intervention of reconstruction with prosthesis. MATERIALS AND METHODS: All patients undergoing reconstruction from January 2010 to July 2018 were eligible for inclusion. This is a retrospective cohort study carried out using the patients of two plastic surgery departments who have undergone monolateral or bilateral implant-based or DIEP flap breast reconstruction. We administered BREAST-Q questionnaire electronically almost 2 year after surgery. Patients were divided into two groups: implant-based and autologous breast reconstruction with DIEP flaps. Baseline demographics and patient characteristics were analyzed using a Students t-test (continuous variables) or Chi-square/Fisher's exact test (categorical variables). Mean standard deviation BREAST-Q scores were reported for the overall cohort and by modality for the postoperative period. The linear regression model was applied to all BREAST-Q score with all predictor factors. RESULTS: Of the 1125 patients involved, only 325 met the inclusion criteria and were enrolled in this study; specifically, 133 (41%) DIEP and 192 (59%) prosthetic reconstructions. We summarized the results of the principal scales of BREAST-Q module: satisfaction with breast, psychosocial well-being, satisfaction with outcome, and sexual well-being in which the autologous group was always more satisfied. We reported results of all linear regression models with higher values for the DIEP group independently from predictors. CONCLUSION: This is the first study performed on the Italian population that compares autologous surgical techniques with the implantation of breast implants. In this population, DIEP is considered the technique that leads to the highest satisfaction in all BREAST-Q scores. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Delayed Mastopexy Following Breast-Conserving Surgery and Radiation Therapy: A Case-Control Study to Evaluate Safety and Versatility of the Central Mound Technique.

INTRODUCTION: Breast remodeling following breast-conserving surgery (BCS) and radiation therapy (RT) is challenging and often burdened by complications due to irradiated tissue atrophy. The authors present a case-control study to compare the central mound mastopexy (CMM) to more conventional techniques, applying it to different patterns of skin excision. METHODS: A variation of the original central mound technique is presented separately addressing glandular and cutaneous deformities. Between 2012 and 2018, 17 consecutive patients presenting defects following unilateral BCS and RT underwent breast remodeling with CMM technique. Immediate and long-term complications together with patient-reported outcomes were evaluated and compared to a matched control group of sixteen patients who underwent superior pedicle mammoplasty. Two independent plastic surgeons reviewed pre- and postoperative photographs and rated the cosmetic outcomes on a visual analog scale from 1 to 5. RESULTS: In the study group, different patterns of skin excision, i.e., inverted-T pattern (41.2%), circumareolar (23.5%), skin-sparing type V (17.65%), omega (11.77%), and J (5.88%), were used to correct various breast deformities, and a decisional algorithm was developed. No major complications were registered. Retraction recurrence rate was higher in the control group (p = 0.037). Cosmetic results were considered more satisfying in the CMM group by both patients (4.18 vs 3.00, p<0.001) and surgeons (4.06 vs 2.69, p=0.001). CONCLUSIONS: The CMM technique is an advanced approach that addresses breast remodeling after BCS-RT surgery yielding reliable results. Following our algorithm, several patterns of skin excision, tailored to pre-existing scars, can be considered and safely performed. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Versatility of the lateral circumflex femoral artery sparing perforator-based anterolateral thigh flaps in loco-regional thigh reconstruction after skin cancer, melanoma, and sarcoma resection.

BACKGROUND: The anterolateral thigh (ALT) flap represents a workhorse in reconstructive microsurgery but its use in a free style fashion as perforator-based flap has yet to be popularized. We describe our experience with lateral circumflex femoral artery (LCFA) sparing perforator-based ALT flaps for thigh reconstruction after oncological resection in a case series of 24 consecutive patients. METHODS: Twenty-four patients underwent thigh reconstruction with 25 perforator-based ALT flaps between 2014 and 2020. Defect etiology was related to skin cancer, melanoma, and sarcoma resection in 3, 7, and 14 cases respectively. Mean defect size was 15 × 8 cm. Six months postoperatively, patients were asked to rate on a 5-point Likert scale the aesthetic and functional outcomes of the reconstructive procedure. RESULTS: Eight flaps were advanced in a V-Y fashion (33.3%), whether 16 flaps (66.7%) were rotated in a propeller fashion. The average flap size was 19 × 8 cm, while mean operative time was 197.2 min. Donor sites were always closed by primary intention. Minor complications were registered in 5 cases and managed conservatively. Overall patients' satisfaction was high, with mean aesthetic and functional ratings of 4.46 and 4.21 respectively. CONCLUSIONS: LCFA sparing perforator-based ALT flaps proved to be a versatile and reproducible solution to address thigh reconstruction after oncological resection according to the different topographical sub-units involved.

Perforator-Based Flap Reconstruction after Melanoma Resection: Evaluation of Oncological, Aesthetic, and Functional Outcomes.

BACKGROUND: Evidence in literature about the best reconstructive approach after melanoma resection is controversial, with some authors advocating that tissue rearrangement flap techniques might hinder the early detection of local relapses. The aim of the present study is to evaluate oncological, aesthetic, and functional outcomes following melanoma reconstruction using pedicled perforator-based flaps. METHODS: The authors reviewed all patients affected by melanoma treated during a 6-year period. Demographic data, tumor characteristics, and operative variables were evaluated. Locoregional recurrence was assessed with clinical and radiological follow-up. One-year postoperatively patients rated on a 5-point Likert scale the aesthetic and functional outcomes of the procedure. Three blind observers examined preoperative and 1-year postoperative photographs and rated the aesthetic outcome of the reconstructive procedure. RESULTS: One-hundred sixty-five patients were treated with wide excision and delayed reconstruction, including pedicled perforator-based flaps in 70 patients (group A) and primary closure in 95 patients (group B). Mean Breslow thickness was 2.972 and 2.189 mm in group A and B, respectively. There was no statistically significant difference in locoregional recurrence (chi-squared test, p = 0.8333; Fisher's exact test, p > 0.9999) between the two groups. Group A reported a higher satisfaction with both the aesthetic (mean rating 4.390 in group A and 4.094 in group B) and functional (mean rating 4.732 in group A and 4.170 in group B) outcomes of the procedure, the latter being statistically significant (p = 0.0006). CONCLUSION: This series suggests that pedicled perforator-based flaps provide optimal aesthetic and functional outcomes in melanoma reconstruction without impairing the locoregional control of the disease.

Extended latissimus dorsi flap with propeller ascending design for reconstruction of a complex lateral lumbar defect: A case report and review of the literature.

Lateral lumbar defects are rarely encountered and difficult to manage because of the limited reach of loco-regional flaps and the unfavorable position of recipient vessels for microsurgical transfer. The purpose of this report is to describe the innovative application of an extended latissimus dorsi (LD) flap with propeller ascending design in the field of lumbar reconstruction, reviewing current reconstructive options accepted for lateral lumbar defect. A 68-year-old male patient underwent wide full thickness resection for a solitary hepatocellular carcinoma metastatic lesion arising in the left lumbar region, resulting in an extensive soft-tissue defect (20 x 13 cm) with deep structures exposure. An extended LD flap with propeller ascending orientation was obliquely designed, with the distal third of the skin island laying over the trapezius muscle. The skin paddle measured 34 x 9 cm. The flap, including a cuff of proximal LD muscle spared by the oncological resection and a fasciocutaneous superior extension, underwent 90°clockwise rotation on the main thoracodorsal artery perforator and further caudal advancement allowed by section of the LD cranial tendinous insertion. The rotation-advancement movement allowed tension-free flap insetting, while donor site was closed by primary intention. The post-operative course was uneventful without any complications registered. At 12-months follow-up, a satisfactory result and a stable coverage were achieved. Due to the surgical complexity traditionally associated with the repair of defects located in the lumbar region, the case reported may help to provide a new alternative solution to extend the indications of local flaps in similar cases and simplify such reconstructions.

Predictive Factors of Satisfaction Following Breast Reconstruction: Do they Influence Patients?

INTRODUCTION: This study aims to analyze whether there is any patient- or treatment-related factor that can influence patients' body perception after mastectomy and autologous or implant-based breast reconstruction. MATERIALS AND METHODS: This retrospective cohort study included patients who underwent immediate implant-based or DIEP flap breast reconstruction. Predictive factors analyzed included chemotherapy, radiotherapy, hormone therapy, body mass index, age, type of mastectomy, and follow-up length. The BREAST-Q was administered postoperatively almost 2 years from the last surgical procedure. Mean BREAST-Q scores were reported for the overall cohort and by modality for the postoperative period. A linear regression model was applied to all BREAST-Q scores with all predictor factors. RESULTS: In total, 325 patients were enrolled in this study (133 DIEP flap and 192 implant-based reconstructions). The DIEP flap reconstruction group with a previous nipple sparing mastectomy showed the highest scores. Patients with a longer follow-up were less satisfied than the ones with a shorter follow-up, which could be considered as an assessment of the outcome. No significant difference was reported between patients who underwent radiotherapy, chemotherapy or hormone therapy and those who did not. Furthermore, age and BMI had no influence on patient satisfaction. CONCLUSION: This study is the first that groups a large number of patients and analyzes predictive factors of long-term satisfaction of patients undergoing breast reconstruction. This can be regarded as a pilot study to raise the awareness of everyone's clinical practice to predict the attitude that patients have after surgery and to prepare them in the best possible way. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com .