Rippling Following Breast Augmentation or Reconstruction: Aetiology, Emerging Treatment Options and a Novel Classification of Severity.

BACKGROUND: Implant rippling is a frequent complication following breast augmentation or implant-based reconstruction and results in significant patient dissatisfaction. Traditionally, the treatment has been to replace the implant, often placing it in a subpectoral pocket to reduce the risk of recurrence. Other techniques, such as increasing the implant size or tightening the capsule, can also be used. Recently, however, there has been much interest in alternative treatments, including fat grafting or insertion of an acellular dermal matrix. METHODS: We review the evidence base for emerging treatments and propose a classification to grade severity, based on the typical clinical presentation of rippling: Grade 1-MILD-rippling is palpable but not visible: (1a) palpable in the lower outer quadrant, (1b) palpable in the upper inner quadrant (cleavage area); Grade 2-MODERATE-rippling is visible only when the patient bends forward; Grade 3-SEVERE-rippling is visible with the patient upright. CONCLUSION: Our proposed classification aims to standardise the clinical description of rippling, which will be valuable in determining the efficacy of new treatments and better characterising long-term complications from breast augmentations or reconstructions. LEVEL OF EVIDENCE V: 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 .

The 'round-the-clock' training model for assessment and warm up of microsurgical skills: a validation study.

Microsurgery is an essential technique in free flap reconstructions today. The technical skills involved require a learning curve, which may be affected by the current issues of limited training resources and patient safety. We describe a study on the value of a microsurgery training device as an assessment and warm up tool in basic microsurgery skills. Forty volunteers with different levels of microsurgery experience performed a microsurgical 'round-the-clock' exercise on the training device three consecutive times. Video-recordings of these performances were rated by two blinded independent assessors using a modified Global Rating Scale to assess basic microsurgery skills on the following parameters: steadiness, instruments handling and speed. Time to complete a round was also recorded objectively. The Kruskal-Wallis test was used to analyse the construct validity of the parameters assessed between the groups of level of microsurgery experience. Crohnbach's coefficient alpha was used to determine the reliability index of the independent assessors. All participants improved their time on consecutive rounds of the exercise. A median of 82 s (range 6-583 s) improvement in time between the first and third round was observed. Different mean performance time could be identified between the groups, but individual speed did not correlate significantly with microsurgery experience. Assessment of microsurgery skills using the modified Global Rating Scale demonstrated statistically significant differences for instruments handling (p=0.03) and speed (p=0.01) between the groups with regard to microsurgery experience, and improvement in the parameters assessed for all groups. Difference in steadiness (p=0.07) was not significant amongst the juniors. Consultants performed better than juniors but, at all levels of experience, significant improvement in skills was demonstrated after practice. The 'round-the-clock' microsurgery training device is an inexpensive and readily available valid tool that provides a useful warm up exercise and instant assessment of basic microsurgical skills.

The pectoralis minor pedicled muscle flap in axillary reconstruction.

We report on the case of a patient undergoing resection of a large axillary and chest wall tumor, resulting in exposure of the brachial plexus and axillary vessels. Our experience of the use of the pectoralis minor pedicled flap for the reconstruction of such a defect is described, providing for excellent postoperative mobility of the axilla and minimal donor-site morbidity.