Perforator-based chimeric anterolateral thigh flap U-shaped insetting for total pharyngoesophageal reconstruction: Surgical technique and functional outcomes.

BACKGROUND: Pharyngoesophageal reconstruction with the tubed anterolateral thigh (ALT) flap is burdened by possible strictures and pharyngocutaneous fistulae (PCF). We present our experience with the U-shaped insetting of perforator-based chimeric ALT flap focusing on surgical technique, complications and functional outcomes. METHODS: We retrospectively included 10 patients with a total circumferential defect of the hypopharynx undergoing reconstruction with ALT flap. A perforator-based chimeric ALT flap with two independent skin paddles was harvested: the trapezoid paddle with the greater base cranially and the height oriented vertically was used for pharyngoesophageal reconstruction while the second paddle was exteriorized and used for flap monitoring and reducing tension on skin closure. Mean age was 56.4 years. Eight patients were affected by squamous cell carcinoma. Modified barium swallow radiogram and fiberoptic laryngoscopy were performed to assess strictures and PCFs. Swallowing and speech outcomes were evaluated through the Deglutition Handicap Index (DHI), M.D. Anderson Dysphagia Inventory (MDADI) and Voice Handicap Index (VHI) questionnaires. RESULTS: Mean flap dimension was 7.9 × 6 × 9.2 cm. Mean ischemia time was 58.2 min (range 42-80). No flap loss nor flap-related complications were reported. Two PCFs were observed. Fiberoptic laryngoscopy documented a complete integration of the flap with no strictures or stenosis. Mean follow-up was 13.6 months (range 1-45 months). Mean DHI score was 33.8, mean MDADI score was 62.5, mean VHI score was 32.2. CONCLUSIONS: The ALT flap U-shaped insetting is a reliable option for pharyngoesophageal reconstruction yielding a high success rate, low number of strictures and fistulae and good swallowing and voice outcomes.

Breast augmentation using a free lateral thoracic artery perforator flap from the contralateral breast: A case report.

When performing breast reconstruction, reduction of the contralateral breast is often required to achieve symmetry. The tissue that would otherwise be discarded from the reduced breast has been utilized as a free flap. This has the benefit of minimizing donor site morbidity, and combining the principles of "spare-part-surgery" and replacing "like-with-like." The purpose of this paper is to report the procedure, outcome, and potential controversies of using a free lateral thoracic artery perforator flap for contralateral breast reconstruction. We present a 32-year-old with congenital breast asymmetry previously corrected with an implant. The patient required tertiary breast reconstruction for capsular contracture, and a simultaneous left breast reduction. There was no history of breast cancer. The reconstruction proceeded as follows; the right sided breast implant was removed. On the left breast, a wise pattern reduction with a superomedial pedicle was instigated. Intraoperatively, four perforating arteriovenous pedicles perfusing the reduced tissue were identified; of which the lateral thoracic artery perforator was selected. The flap weight was 296 g. The lateral thoracic pedicle was anastomosed to the right internal mammary vessels. The flap survived completely. The post-operative course was uneventful and without complication. The patient was followed up for 1 year and was pleased with the final result. The application of the LTAP free flap may cautiously be extended to oncological breast reconstruction. For patients to be suitable, they would need a large remaining breast to provide adequate tissue for reconstruction, up-to-date breast screening and a low risk of developing breast cancer in the future.

Unilateral immediate deep inferior epigastric artery perforator flap breast reconstruction following skin sparing mastectomy: A comparative study on revision surgeries to improve breast symmetry.

BACKGROUND: The number of revision surgeries to improve breast asymmetry after deep inferior epigastric perforator (DIEP) flap breast reconstruction is still high worldwide with impact on both patients and healthcare systems. These procedures include fat grafting, contralateral breast symmetrization, scar revision, flap repositioning and remodeling. A previously published DIEP flap insetting algorithm has proven to be effective in selecting patient-tailored strategies to achieve excellent aesthetic outcomes. This study investigated whether this insetting algorithm was effective in reducing revision surgeries in patients undergoing SSM and immediate DIEP flap breast reconstruction to achieve the goal of a one-stage reconstruction. METHODS: This retrospective case-control study included 60 patients (group A) treated without the DIEP flap standardized insetting algorithm and 60 patients (group B) treated with the standardized insetting algorithm, which considers among its variables the type of breast to be reconstructed, abdominal tissue thickness, rotation due to harvesting side. Demographic data, operative data, complications and number of revision surgeries were recorded. RESULTS: One hundred and twenty primary and 106 revision surgeries were performed. Groups were homogenous for age (p = .32), body mass index (p = .77), flap weight (p = .7), operative time (p = .87) and early complications (p = .78). When excluding isolated nipple reconstruction from the revision surgeries, one-stage reconstruction was successfully performed in 26 patients in group A (43.3%) and 39 patients (65.0%) in group B, with a statistically significant difference between the groups (p = .003). CONCLUSIONS: The introduction of a standardized insetting algorithm for immediate unilateral DIEP flap breast reconstruction can be effective in reducing the number of revision surgeries for breast asymmetry, making a one-stage reconstruction an achievable and reliable target.

A free intercostal artery perforator flap as a salvage operation for a planned lumbar artery perforator flap with aberrant anatomy in breast reconstruction: A case report.

When autologous breast reconstruction is planned but abdominal tissue is not available, the lumbar artery perforator flap provides an alternative choice with minimal donor site morbidity. The lumbar and posterior intercostal arteries supply adjacent perforasomes on the posterolateral flank. The purpose of this report is to highlight the salvage of an autologous breast reconstruction free flap using a dorsal perforator of the posterior intercostal artery, when the planned lumbar artery perforators were not suitable. The patient was a 74-year-old with recurrent left-sided breast cancer requiring immediate breast reconstruction. A lumbar perforator flap was planned as an oblique ellipse 19 × 10 cm. Intraoperatively, the two identified perforators traveled superiorly up to the 12th rib and therefore originated from the intercostal rather than lumbar arteries. The internal mammary artery and the vena comitants were used as recipient vessels, anastomosed to an interposition graft. Postoperatively, the patient was discharged home after 7 days without complication. Six months later, the patient was pleased with the reconstruction and had negligible donor site morbidity. The dorsal intercostal artery perforator flap therefore provides a salvage option when presumed lumbar artery perforators are dissected and found to be intercostal in origin.

Tear drop-free anterolateral thigh flap, a versatile design for lower limb reconstruction after trauma.

BACKGROUND: In lower limb reconstruction the cosmetic outcome is influenced by the contouring of the flap at the recipient site as well as by the donor site closure. It is also important to minimise compression of the flap pedicle. We discuss the outcomes of a versatile ALT flap design that allows freedom in skin paddle tailoring without elongating the scar, reduction of the tension over the pedicle and improved cosmetic results of both donor and recipient sites. METHODS: Between January 2009 and October 2015, 27 patients underwent reconstruction using tear drop ALTs. The age ranged between 20 and 89 years. Seventeen were elective procedures and 10 were urgent. The locations of the defects were: knee (1 case), achilles tendon (2 cases), os calcis (1 case), lateral malleolus (1 case), fibula (3 cases), tibia (6 cases), tibia/fibula (5 cases), and ankle (8 cases). The sizes of the defects ranged from 4 × 3 cm to 9 × 7 cm. RESULTS: The size of the flap ranged from 6 × 4 cm to 11 × 7 cm. One venous congestion and a wound dehiscence occurred, no flap loss. Two defatting procedures were performed. The mean follow-up was 16.44 months. Final outcomes showed good functional and cosmetic results in both the donor and recipient sites. CONCLUSIONS: The tear drop ALT is a useful tool in lower limb reconstruction allowing to improve skin paddle tailoring without elongating the donor site scar. It allows minimal tension over the pedicle while optimizing the contour of both the donor and recipient sites.

Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral Versus Bilateral Reconstructions.

BACKGROUND: The demand for bilateral breast reconstructions is rising worldwide. In the UK, approximately 30% of breast cancer patients undergoing mastectomy choose autologous tissue breast reconstruction. Although the deep inferior epigastric perforator (DIEP) flap is gaining popularity, bilateral DIEP flap breast reconstruction remains a complex procedure and reliable outcome data are lacking. In the absence of clinical trials, evidence from cohort studies is needed to better inform clinicians and patients. METHODS: Over a 6-year period, all consecutive patients undergoing DIEP flap breast reconstruction were prospectively included and categorized as unilateral or bilateral reconstruction for comparative analyses of outcomes and complications, with the patient as the unit of analysis. RESULTS: Overall, 565 DIEP flaps were performed on 468 women (371 unilateral and 97 bilateral reconstructions [194 flaps]). Postoperative complications requiring reoperation were twice as likely for bilateral reconstructions (risk ratio [RR] 2.1, 95% CI 1.4-3.4, p = 0.002) and were mainly due to venous congestion (RR 3.1, 95% CI 1.2-7.5, p = 0.011). The risk of total flap loss was six times greater in bilateral reconstruction (RR 6.4, 95% CI 1.6-26, p = 0.011). The rates of revision breast and abdominal surgery were similar between groups. CONCLUSIONS: Both unilateral and bilateral DIEP flap breast reconstructions are safe, with a low risk of complications; however, bilateral reconstruction was associated with a higher risk of complications and total flap loss. This information should be highlighted to patients requesting bilateral breast reconstruction, particularly those requesting risk-reducing mastectomy and reconstruction.

Correction to: Reply to ''Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral Versus Bilateral Reconstructions".

In the original article Justin C. R. Wormald's middle initials were incorrect. They are correct as reflected in this erratum. The original article has also been corrected.

Superficial outside-flap shunt (SOS) is associated with a low incidence of postoperative DIEP flap venous congestion: A single-institution retrospective cross-sectional study.

INTRODUCTION: Venous congestion burdens up to 15% of deep inferior epigastric artery perforator (DIEP) flap breast reconstructions. For these cases, venous augmentation by superficial outside shunt (SOS) is associated with 100% success in secondary salvage surgeries. Intraoperative venous augmentation using other techniques yields a 0.3% rate of return to theater due to venous congestion, but there is no evidence assessing the effectiveness of the SOS technique applied preventively. Comparing this preventive approach to data prior to its implementation, we expect to find a reduced number of venous congested flaps with reduced flap losses and revision surgeries. PATIENTS AND METHODS: This retrospective cross-sectional study involved DIEP flap breast reconstructions performed between 2011 and 2020. The control group included patients receiving additional venous anastomosis as a secondary salvage procedure. The "preventive SOS group" included patients who received preventive SOS during the main surgery. Age, body mass index (BMI), pregnancies, perioperative treatments (neoadjuvant or adjuvant chemo or radiotherapy), follow-up complications (arterial ischemia, venous congestion, hematomas, partial/total flap loss), and revision surgeries (breast debridement, flap remodeling) were recorded and compared. RESULTS: Within 695 flaps performed, 397 flaps were included in the control group, and 298 flaps were included in the preventive SOS group. The groups were homogeneous for age (p = 0.418), BMI (p = 0.747), and flap weight (p = 0.064). Fifty-one flaps (12.8%) in the control group compared to zero (0.0%) in the preventive SOS group required return to theater (p < 0.001). CONCLUSIONS: We reported encouraging preliminary results for SOS to prevent DIEP flap venous congestion. These results must be validated prospectively.

Inferior gluteal artery perforator (IGAP) flap versus profunda artery perforator (PAP) flap as an alternative option for free autologous breast reconstruction.

BACKGROUND: When patients are unsuitable for deep inferior epigastric perforator (DIEP) flap breast reconstruction, the inferior gluteal artery perforator (IGAP) flap has been used as an alternative option. However, the profunda artery perforator (PAP) flap is also gaining popularity as an alternative to the DIEP flap for several reasons. This retrospective cohort study compares baseline characteristics, peri- and post-operative outcomes following IGAP flap and PAP flap breast reconstructions after mastectomy for cancer. METHODS: In a single center in the UK, from September 2008 through December 2016, 43 women underwent IGAP Flap(s) breast reconstruction and 51 received PAP flap(s) breast reconstructions. Statistical analysis was performed to compare baseline, peri-operative and post-operative variables between the two reconstruction methods. RESULTS: Perioperative complications requiring reoperation were experienced in women undergoing IGAP flap breast reconstructions only (21% versus 0%, p = 0.001), principally due to the risk of total flap failure (12% versus 0%, p = 0.01). Women undergoing IGAP flap breast reconstructions were at significantly higher odds of revision surgery (OR 17 [95% CI: 5.5-53], p < 0.001), which was unchanged after adjusting for bilateral reconstructions (adjusted OR 18 [95% CI: 5.3-58], p < 0.001). CONCLUSIONS: PAP flaps appear to be associated with significantly fewer complications and revision surgeries than IGAP flaps for breast reconstruction in women undergoing mastectomy for cancer and who are unsuitable for a DIEP flap breast reconstruction.

Microsurgical autologous breast reconstruction in the midst of a pandemic: A single-unit COVID-19 experience.

INTRODUCTION: COVID-19 has disrupted the provision of breast reconstructive services throughout the UK. Autologous free flap breast reconstruction was restarted in our unit on 3 June 2020. We aimed to compare the unit's performance of microsurgical autologous breast reconstruction in the "post-COVID" period compared with the exact time period in the preceding year. METHODS: We retrospectively reviewed prospectively collected data in the "pre-COVID" (from 3 June 2019 to 31 December 2019) and "post-COVID" period (from 3 June 2020 to 31 December 2020). Patient demographics included age, body mass index, co-morbidities, Anaesthesiologists (ASA) grade and smoking status. Surgical factors included neoadjuvant chemotherapy, previous chest wall radiotherapy, unilateral or bilateral reconstruction, reconstruction timing, number of pedicles, contralateral symmetrisation and other procedures. dependant variables were ischaemic time, operative time, mastectomy weight, flap weight, length of stay, return to theatre and complication rates. The number of trainers and trainees present in theatre was recorded and analysed. RESULTS: Fewer DIEP flaps were performed in the "post-COVID" period (45 vs. 29). No significant difference was observed in mastectomy resection weight, but flap weight was significantly increased. No significant difference was found in ischaemic time as well. The postoperative length of stay was significantly reduced. No significant difference was found in rates of return to theatre, unplanned admission, infection, haematoma, seroma or wound dehiscence. No cases of venous thromboembolism or flap failures were recorded. The mean number of trainers and trainees, and the trainee-to-trainer ratio was not found to be significantly different between cohorts. CONCLUSION: Although fewer cases were performed, autologous breast reconstruction was safely delivered throughout the COVID-19 pandemic in the first wave without affecting training.

Free tissue transfer after unsatisfactorily implant-based breast reconstruction, a cohort study.

Breast reconstruction can be performed using implants or autologous tissue, either alone or in combination. Implants typically require re-operation during the patient's lifetime, often for adverse capsular contracture. Conversion from implants to autologous tissue may improve symptoms and deliver a definitive reconstruction. This is known as salvage breast reconstruction. In this paper we evaluate the indications, outcomes, complications and cost implications of salvage breast reconstruction in our regional centre and report these in line with the STROBE guidelines. Retrospective casenote analysis of all salvage breast reconstruction patients from January 2018 to January 2020 was performed. Nineteen patients were identified, with a median age of 52 years. Indications were all capsular contracture other than two each of implant rupture and patient request. Thirty-two perforator free flaps; 29 deep inferior epigastric, two profunda artery and one lateral thoracic artery flap were performed. Median time from first implant to free flap reconstruction was nine years. Median hospital stay was five days. No total flap losses and one partial flap loss occurred. Three patients underwent secondary procedures to the breast to improve the aesthetic outcome. All patients reported improvement in symptoms and appearance. For implant-intolerant patients adequately counselled and accepting of the post-operative downtime, salvage reconstruction with autogenous tissue offers a lasting solution. The upfront healthcare costs are higher with a free tissue transfer, but may become comparable longer term given the multiple exchange of implant procedures required over a patient's lifetime.

DIEP flap rescue by venesection of the superficial epigastric vein.

Microsurgical breast reconstruction with the deep inferior epigastric perforator flap is a technically challenging procedure, where flap survival depends on sufficient arterial input and venous outflow. Rarely, these flaps can become congested because of insufficient venous pathways and dominance of the superficial venous system. We describe a simple technique to allow the rescue of congested flaps by intermittent venesection of the superficial inferior epigastric vein. This relieves the venous congestion in the immediate postoperative period, allowing the flap to develop venous drainage through alternate channels.

Contralateral breast symmetrisation in unilateral DIEP flap breast reconstruction.

INTRODUCTION: Women undergoing unilateral deep inferior epigastric artery perforator (DIEP) flap breast reconstruction may be offered a contralateral symmetrisation either at the time of reconstruction (simultaneous/immediate) or at a later stage (delayed). Simultaneous contralateral breast symmetrisation may be more beneficial to patients and healthcare institutions by avoiding staged surgery, although there is limited evidence on which to base practice. This deficit formed the rationale for our study. The primary outcome was the overall rate of revision surgery. METHODS: Over a 6-year period, this prospective cohort study recorded the demographics, cancer treatments and operative outcomes of all consecutive unilateral DIEP flap breast reconstructions with or without contralateral symmetrising surgery. Patients were categorised into three groups: (1) simultaneous symmetrisation, 2) delayed symmetrisation and (3) no symmetrisation for comparative analysis. RESULTS: During the study period, 371 women underwent unilateral DIEP flap breast reconstruction 194 (52.3%) were not symmetrised, 155 (41.8%) were simultaneously symmetrised and 22 (5.9%) underwent delayed symmetrisation. Simultaneous symmetrisation of the contralateral breast and unilateral DIEP flap breast reconstruction increased the mean total operative time by 28 min. There were no differences in the rates of peri-operative complications. There were significantly higher rates of all-cause revision surgery (OR 3.97 [1.58, 9.94], p = 0.003) in women undergoing delayed symmetrisation, because of higher rates of revision lipomodelling, scar revision and revision contralateral symmetrisation. CONCLUSION: Simultaneous contralateral breast symmetrisation was associated with a lower risk of all-cause revision surgery. It is safe, beneficial and likely to be more cost-effective for women undergoing unilateral free DIEP flap breast reconstruction.

Inadvertent free intercostal artery perforator flaps.

Two cases of free lateral intercostal artery perforator flaps are presented in this article. Both flaps were raised instead of thoracodorsal artery perforator flaps, which had been the initial operative plan. The free intercostal artery perforator flap can be technically difficult, the pedicle is relatively short and the vessel diameters can be small. The pedicle may need to be dissected along the intercostal groove to obtain sufficient vessel length and diameter. Despite all these issues, we describe a relatively straightforward salvage operation if a perforator flap raised on a presumed thoracodorsal artery axis is found to be an intercostal artery perforator flap.