Mesenchymal stem cell therapy in hypertrophic and keloid scars.

Scars are the normal outcome of wound repair and involve a co-ordinated inflammatory and fibrotic process. When a scar does not resolve, uncontrolled chronic inflammation can persist and elicits excessive scarring that leads to a range of abnormal phenotypes such as hypertrophic and keloid scars. These pathologies result in significant impairment of quality of life over a long period of time. Existing treatment options are generally unsatisfactory, and there is mounting interest in innovative cell-based therapies. Despite the interest in mesenchymal stem cells (MSCs), there is yet to be a human clinical trial that investigates the potential of MSCs in treating abnormal scarring. A synthesis of existing evidence of animal studies may therefore provide insight into the barriers to human application. The aim of this PRISMA systematic review was to evaluate the effectiveness of MSC transplantation in the treatment of hypertrophic and keloid scars in in vivo models. A total of 11 case-control studies were identified that treated a total of 156 subjects with MSCs or MSC-conditioned media. Ten studies assessed hypertrophic scars, and one looked at keloid scars. All studies evaluated scars in terms of macroscopic and histological appearances and most incorporated immunohistochemistry. The included studies all found improvements in the above outcomes with MSC or MSC-conditioned media without complications. The studies reviewed support a role for MSC therapy in treating scars that needs further exploration. The transferability of these findings to humans is limited by factors such as the reliability and validity of the disease model, the need to identify the optimal MSC cell source, and the outcome measures employed.

Epstein-Barr Virus-associated Diffuse Large B-cell Lymphoma Identified in a Breast Implant Capsule: A New Breast Implant-Associated Lymphoma?

BACKGROUND: Breast implant-associated anaplastic large cell lymphoma is a relatively uncommon T-cell lymphoma with about 900 reported cases worldwide to April 2020 according to the American Society of Plastic Surgeons Breast Implant-Associated Anaplastic Large Cell Lymphoma Physician Resources information. CASE PRESENTATION: A 51-year old woman was found to have an Epstein-Barr virus-related diffuse large B-cell lymphoma (EBV-DLCBCL) in her left breast periimplant capsule at the time of a second revision breast implant surgery for recurrent severe capsular contractures following cosmetic breast augmentation 21 years previously. The first revision operation, 15 years earlier, had comprised simple implant exchange from smooth-saline to textured-silicone gel prostheses. RESULTS: Histopathological and immunohistochemical analyses of the periimplant capsulectomy specimen confirmed a B cell lymphoma which was, in addition, positive for EBV-encoded RNA on in-situ hybridization. Staging investigations including positron emission tomography-computed tomography did not reveal any metastatic disease. DISCUSSION AND CONCLUSION: Despite recommendations to the contrary (by 2 independent hematological malignancy multidisciplinary teams), the patient has declined explantation of her new breast implants choosing instead to be observed under a watch-and-wait protocol. She remains disease-free 2 years postdiagnosis. To date, a diffuse B-cell lymphoma has never been documented as arising in a breast implant capsule or in association with breast augmentation whether associated with EBV or not. This is the first such report in the world.

The Role of CT Angiography in Assessing Deep Inferior Epigastric Perforator Flap Patency in Patients With Pre-existing Abdominal Scars.

BACKGROUND: Abdominal scars can affect the patency of deep inferior epigastric artery (DIEA) perforators and are a concern when planning free flap breast reconstruction (FFBR). Computed tomography angiography (CTA) is routinely used for preoperative DIEA flap imaging. We investigated CTA utility in predicting the most clinically useful DIEA perforators in scarred abdomens. METHODS: A single surgeon's CTA FFBR patients were studied. All were imaged by one radiologist. CTA reports, abdominal scars, and flap intraoperative details were analyzed. The operative findings were then correlated with the CTA "predictions." RESULTS: A hundred and six patients with preoperative CTAs underwent 132 FFBRs, 44% (58) from scarred and 56% (74) from virgin abdomens. All flap transfers were successful. Concordance between perforators identified by CTA preoperatively and those selected by the surgeon intraoperatively was 95% (scarred 93%; non-scarred 96%, P = 0.470). There was a significant difference in the proportion of single-perforator flaps between the two groups (scarred 46%; non-scarred 28%, P = 0.041). "Scarred" flaps were heavier (789 vs 676 g, P = 0.0244) than those harvested from virgin abdomens. CONCLUSIONS: CTA accurately predicted perforator choice in flaps from scarred and virgin abdomens. "Scarred" flaps are more likely to be heavier and based on one perforator suggesting that scarring may have an effect on intraflap vascular anatomy. Further investigations are needed to delineate the mechanism by which this occurs.

Initial Management of Traumatic Digit Amputations: A Retrospective Study of Functional Outcomes.

BACKGROUND: Traumatic amputation of one or more digits can have a serious detrimental effect on social and economic standings which can be mitigated by successful replantation. Little has been recorded on preoperative management before replantation and how this affects the outcomes of the replanted digit. METHODS: A retrospective cohort study was conducted and data collected over an 18-month period. Three protocols for preoperative management were examined: minimal (basic wound management), complete Buncke (anticoagulation, dry dressing on amputate placed on indirect ice and absence of a digital block), and incomplete (any two or three criteria from complete Buncke in addition to the minimal) protocols. Data was collected on survival rate, secondary operations, and complication rate. Function was defined by sensation, range of movement, and strength. RESULTS: Seventy four of 177 digits were replanted with an overall survival rate of 86.5%. The rates for minimal, incomplete, and complete protocols were 95%, 87%, and 91%, respectively, and not significantly different. The complication rate was significantly different between the complete (20%) and minimal (60%) protocols (p = 0.0484). Differences in sensation and grip strength were statistically significant between protocols (p = 0.0465 and p = 0.0430, respectively). Anticoagulation, no digital block and dry gauze all showed reduced complication rates in comparison to their counterparts. CONCLUSIONS: The Buncke protocol, which includes anticoagulation, no digital block, and dry gauze, was found to significantly reduce the complication rate which suggests that it prevents compromise of tissue integrity. Significant differences were found between protocols for sensation and grip strength. A higher-powered study is needed to investigate the effects of preoperative management on complication rates and functional outcomes.

Reconstruction of complex orbital exenteration defects: a single center's experience with a five-year follow-up.

BACKGROUND: Orbital exenteration presents a challenge to the reconstructive surgeon. Defects may be treated with split skin grafts, local advancement flaps, or free flap coverage. There are few published series showing the long-term outcomes of reconstruction. Our results, with at least a 5-year follow-up, are presented. METHODS: A retrospective review of 15 immediate reconstructions after orbital exenterations for malignancies in 12 patients at a tertiary referral center over a 5-year period, was done. All flaps were followed up for at least 5 years (mean, 75 months; range, 3-118 months). RESULTS: Malignancies included squamous cell carcinoma, basal cell carcinoma, meningioma, sebaceous gland carcinoma, and rhabdomyosarcoma. Eight cervicofacial rotation-advancement flaps and 4 anterolateral thigh, 1 rectus abdominis, and 1 radial forearm free tissue transfers were used. Aggressive postoperative radiotherapy (9/15) was well tolerated by both regional and free flaps. Both cervicofacial flaps in previously irradiated patients had wound dehiscence or fistula formation. Six (50%) patients died during follow-up, 4 of whom (33%) died of tumor recurrence. CONCLUSIONS: Flap reconstruction after complex orbital exenteration is associated with low morbidity. Cervicofacial rotation-advancement flaps offer reliable, single-stage, aesthetically pleasing reconstructions. They should be avoided in the previously irradiated. Free tissue transfer is indicated for volume replacement, after previous radiotherapy, after tumor recurrence and previous use of locoregional flaps. Reconstruction of complex orbital exenteration defects for malignancies should be undertaken in centers with experience in the management of these procedures.

The relationship between the intercostal distance, patient height and outcome in microsurgical breast reconstruction using the second interspace rib-sparing internal mammary vessel exposure.

PURPOSE OF THE STUDY: Rib-sparing internal mammary vessel (IMV) exposure in breast reconstruction is becoming common, with a smaller space in which to perform the microanastomoses. The objectives were to determine whether patient height could be used as a proxy measurement for intercostal distance (ICD), assess whether the complication rate or the flap ischemia time are affected in such surgery, and provide anatomical data about ICDs. METHODS: Data were collected from 95 consecutive patients (109 breasts) undergoing free flap breast reconstruction using rib-sparing vessel exposure over a 3-year period by one surgeon. Pearson's product moment correlation coefficient was used to assess the relation between height and ICD, body mass index (BMI), operative times, and flap outcomes. RESULTS: There was no correlation between patient height and ICD (r = 0.087), age, BMI, recipient vessel preparation time, and flap ischemia time. CONCLUSION: Being able to predict patients with a small ICD in whom microsurgery may be more challenging can influence surgical planning. The anatomy of the intercostal spaces is variable and was not predictable in relation to height, BMI, or age. Height was not a reliable proxy for ICD and where there is a concern about the available ICD it is suggested that it is measured directly through preoperative imaging. This study found no increase in the complication rate and flap ischemia time using the rib-sparing IMV exposure technique.

An algorithmic approach to perineal reconstruction after cancer resection--experience from two international centers.

AIM: This paper aims to simplify the approach to reconstruction of the perineum after resection of malignancies of the anal canal, lower rectum, vulva, and vagina. MATERIALS AND METHODS: The data were collected from 2 centers, namely, Addenbrooke's Hospital, University of Cambridge, United Kingdom and Christchurch Hospital, University of Otago, New Zealand. All patients who underwent perineal reconstruction from 1997 to 2009 at Christchurch Hospital (13 years) and 2001 to 2009 at Addenbrooke's Hospital (9 years) were included. The diagnosis (indication), primary surgery, reconstructive surgery, complications, tumor outcomes (recurrence and survival), and follow-up were entered into a database (Microsoft Excel; Redmond, Wash). The incidence of previous radiotherapy, requirement for adjuvant radiotherapy, and length of inpatient stay were also recorded. RESULTS: Forty-six patients were identified for this study--13 in New Zealand and 33 in Cambridge. Indications for perineal reconstruction included resection of anal and rectal malignancies (24), vulval and vaginal malignancy (19), perineal sarcoma (1), and perineal squamous cell carcinoma arising in an enterocutaneous fistula (Table 1). The reconstructive strategies adopted included rectus abdominis myocutaneous flaps (26), gluteal fold flaps (9), gracilis V-Y or advancement flaps (7) and others (4), gluteal rotation flaps (1), local flap (2), and free latissimus dorsi flaps (1). CONCLUSIONS: Although various surgeons performed the reconstructive surgeries at 2 different centers, the essential approach remained the same. Smaller defects were best treated by local flaps, whereas the rectus abdominis flap remained the standard option for larger defects that additionally required closure of dead space. On the basis of our 2 center experience, we propose a simple algorithm to facilitate the planning of reconstructive surgery for the perineum.

Oncoplastic and reconstructive breast surgery.

This article provides an overview of the principles and techniques of oncoplastic and reconstructive breast surgery for patients with early-stage breast cancer. Oncoplastic breast surgery (OPBS) with partial breast reconstruction is a natural evolution in the application of breast conserving surgery and permits wide surgical resection of tumours that might otherwise mandate mastectomy and whole breast reconstruction. These reconstructive techniques must be optimally selected and integrated with ablative breast surgery together with non-surgical treatments such as radiotherapy and chemotherapy that may be variably sequenced with each other. A multidisciplinary approach with shared decision-making is essential to ensure optimal clinical and patient-reported outcomes that address oncological, aesthetic, functional and psychosocial domains. Future practice of OPBS must incorporate routine audit and comprehensive evaluation of outcomes.

Increased Production of Abdominal Donor Site Fluid Following Microsurgical Breast Reconstruction With Superficial Inferior Epigastric Artery Versus Deep Inferior Epigastric Artery Perforator Flaps.

Introduction and aims Donor site seroma following abdominal flap harvest for breast reconstruction is common in both deep inferior epigastric artery perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps. We tested the hypothesis that there is increased donor site fluid following SIEA dissection compared to DIEP. Materials and methods Of60 SIEA breast reconstructions performed by one surgeon in 50 patients (2004-2019), complete data were available for 31 patients. Eighteen unilateral SIEAs were matched with 18 unilateral DIEPs. Thirteen bilateral flap harvests involving an SIEA were matched with 13 bilateral DIEP controls. Their cumulative abdominal drain outputs, times to drain removal, hospital stay, and number and volume of seroma aspirations were compared. Results Patients who underwent an SIEA flap harvest had significantly increased drain output compared to only a DIEP flap harvest (SIEA=1,078 mL, DIEP=500 mL, p<0.001), which remained significant after controlling for confounding variables (p=0.002). There was increased time until drain removal (SIEA=11 days, DIEP=6 days, p=0.010), and patients who underwent an SIEA harvest were 14 times more likely to be discharged with a drain in situ (odds ratio (OR)=14.6, 95% confidence interval (CI)=2.8203-75.9565, p=0.0014). There was no significant difference in the number or volume of outpatient aspirations, length of hospital admission, or total seroma volume. Conclusion This study demonstrated that SIEA harvest is a significant predictor of increased abdominal drain output postoperatively. This accounted for longer periods before drain removal and more patients discharged with an abdominal drain in situ and should be an important consideration for reconstructive surgeons. There was no demonstrable difference in the number or volume of seroma aspirations after drain removal for either group.

A comparison of presentations and outcomes of salvage versus non-salvage abdominal free flap breast reconstructions-Results of a 15-year tertiary referral centre review.

INTRODUCTION: Salvage breast reconstruction with autologous tissue is becoming more prevalent due to a resurgence in implant-based procedures. The latter has caused a commensurate rise in failed or treatment-resistant prosthetic cases requiring conversion to free tissue transfers. Salvage reconstruction is often considered more challenging, owing to patient presentation, prior treatments and intraoperative difficulties. The aim of the study was to test this hypothesis by comparing outcomes of salvage versus non-salvage autologous microsurgical breast reconstructions in a retrospective matched cohort study. METHODS: The demographics, risk factors, operative details and outcomes of patients who underwent free flap salvage of implant-based reconstructions by a single operator (2005-2019) were retrospectively evaluated. For each salvage reconstruction, the consecutive non-salvage abdominal free flap reconstruction was selected for comparison. The clinical outcomes including intraoperative blood loss, operative time, flap survival and complication rates were compared. RESULTS: Of 442 microsurgical patients, 35 (8.0%) had salvage reconstruction comprising 41 flap transfers (29 unilateral, 6 bilateral) and 42 flaps (28 unilateral, 7 bilateral) in nonsalvage reconstruction. Deep inferior epigastric perforator (DIEP) flaps comprised the commonest autologous tissue used in both groups at 74% and 71% respectively. Most patients (83%) underwent salvage reconstruction for severe capsular contractures. There was a significant difference in radiation exposure between groups (salvage reconstruction 89%, non-salvage reconstruction 26%; p<0.00001). All 83 flaps were successful with similar reoperation rates and intraoperative blood losses. Unilateral salvage reconstruction took on average two hours longer than non-salvage reconstruction (p = 0.008). Overall complication rates were similar (p>0.05). CONCLUSION: This 15-year study shows that despite salvage autologous free flap breast reconstruction requiring longer operation times, its intra and postoperative outcomes are generally comparable to non-salvage cases. Therefore, salvage breast reconstruction with free flaps provides a reliable option for failed or suboptimal implant-based reconstructions.

Bilateral risk-reducing mastectomy and reconstruction-A 12-year review of methodological trends and outcomes at a tertiary referral centre.

INTRODUCTION: Bilateral risk-reducing mastectomy (BRRM) involves removal of healthy breast tissue to substantially decrease the risk of developing breast cancer in individuals with greater susceptibility due to a strong family history or genetic mutation. This retrospective study evaluates cases of BRRM and associated reconstruction performed at a tertiary centre, with emphasis on mastectomy and reconstructive trends. METHODS: A retrospective review of all BRRM cases performed between January 2010 and May 2022 was conducted, with two separate cohorts corresponding to the earlier (group 1) and later (group 2) portion of the time-period. Data collected included demographics, genetic test results, family history of breast/ovarian cancer, co-morbidities, mastectomy type, reconstruction type, surgical histopathology findings and post-operative complications. RESULTS: A total of 82 patients (group 1 = 41, group 2 = 41) underwent BRRM. The proportion of nipple-sparing mastectomy increased from 14.6% to 56.1% between the two time periods with a reduction in skin-sparing mastectomies from 75.6% to 20.3% (p<0.001). Of the 80 patients who opted to undergo reconstruction, there was a significant decrease in combined flap-implant reconstructions (19.51% to 0%, p<0.01). Importantly, for implant-only reconstruction, there were significant increases in prepectoral approaches (p = 0.0267) and use of acellular dermal matrix (ADM) (48.15% to 90.63%, p<0.001). CONCLUSION: This study documents recent increases in nipple-sparing techniques for BRRM compared to more traditional skin-sparing methods. Concurrently, reconstruction following RRM has become predominantly implant-based without a flap, coinciding with more widespread usage of ADM. This is consistent with national trends towards fewer complex autologous procedures.

Pleural damage during capsulectomy and exchange of long-standing breast implants in Poland syndrome: a cautionary tale.

We present 3 patients undergoing revisional implant surgery more than 20 years after congenital breast asymmetry correction. All of them had Poland syndrome. In 2 patients, the parietal pleura was inadvertently damaged during capsulectomy, resulting in a pneumothorax in one patient and implant loss in the other. The loss followed a copious accumulation of fluid around the implant, possibly due to a (persistent) communication with the pleural cavity. In the first case the pneumothorax was successfully treated intraoperatively. The third patient suffered no complications during surgery. Predisposing factors for pleural damage during revisional implant surgery for congenital breast asymmetry are discussed, in addition to the merits of total capsulectomy during implant exchange. It is concluded that surgeons should aim to minimize the possibility of pleural damage during this surgery and should proceed with caution when performing total capsulectomy in at-risk patients.

The use of Mitek bone anchors for synthetic mesh fixation to repair recalcitrant abdominal hernias.

INTRODUCTION: Repair of recurrent abdominal hernias is a surgical challenge. These patients usually present to the plastic surgeon as a last resort for treatment. Such recalcitrant hernias cause enormous morbidity and constitute a financial burden to any health service. It is important to explore novel and potentially effective repair methods. We report on a technique using overlay prolene mesh fixed to bone by Mitek anchors. METHODS: All patients who had Mitek bone anchor fixation of synthetic mesh, to repair recurrent iatrogenic abdominal hernias between 2003 and 2010 by one surgeon (C.M.M.), were retrospectively reviewed. The indications, operative details, and clinical outcomes were documented. RESULTS: A total of 7 patients (6 females, 1 male) aged 35 to 60 (average 53) years were included in the study. The causes of herniation were previous surgical incisions (3) and abdominal flap harvests (4). They had had a median of 3 hernia repairs before referral to plastic surgery. The operations lasted for a mean of 6 hours (range, 3-10½ hr). There were no major intra- and postoperative problems although 1 patient requested removal of 2 of his 8 Mitek anchors because of persistent localized pain and tenderness. After a mean follow-up of 24 months (range, 4-34), only 1 patient developed a recurrent lower abdominal bulge. CONCLUSION: Our single operator series demonstrated that Mitek bone anchor fixation of prosthetic mesh reinforcement of abdominal wall hernia repair is an effective treatment technique associated with a low morbidity. This method of recalcitrant hernia repair may be a useful addition to the armamentarium of the plastic surgeon.

"Uro-abdominoplasty": an adaptation of abdominal contouring for revision of complicated urostomies.

BACKGROUND: The aim of this study was to describe the indications, surgical technique and outcomes of abdominoplasty as a novel tool for revising complicated urostomies. PATIENTS AND METHODS: Four patients (3 female, 1 male; mean body mass index = 32 kg/m; mean age = 56 years) who underwent abdominoplasty for urostomy revision 2007-2009 were identified. Ileal conduits had been performed following ablative or diversion surgery for cervical carcinoma, bladder carcinoma, interstitial cystitis, and neuropathic bladder. A postal questionnaire was used to establish pre- and postabdominoplasty stoma function. RESULTS: Patients were referred to the reconstructive team with problems fitting their urostomy-appliance leading to urinary leakage, skin irritation, and social embarrassment. Uro-abdominoplasty indications included multiple abdominal scars (n = 2), large abdominal apron (n = 4), and deep skin creases (n = 2). Three patients had undergone previous failed urostomy repositioning or peristomal liposuction. The joint plastic surgical-urological operations lasted a mean of 3 hours, with no major postoperative complications. Patients were discharged 8 days later. Of 4 patients, 3 reported improved appliance fitting and reduced urinary leakage (>50%) and the remaining patient had intermittent leakage due to a persistent abdominal fold superiorly, and has since undergone reverse abdominoplasty. Two patients complained of long-term lower abdominal numbness, but all 4 were satisfied with the aesthetic improvement. CONCLUSIONS: Abdominoplasty has been successfully used in our center for the purpose of improving urostomy dysfunction of intractable mechanical leakage by creating a flatter surface for appliance fitting. Uro-abdominoplasty widens the reconstructive repertoire of plastic surgeons and can be considered in those who have exhausted conservative or simpler surgical solutions.

Importance of long-term monitoring of patients with breast reconstructions: a case of 10-year cancer recurrence.

We report a case of breast cancer recurrence in a 41 -year old female ten years post mastectomy, and two years post tertiary DIEP flap reconstruction. Reconstructed patients, especially those with aggressive cancers, must be informed of long term risk of recurrence and monitored long term following mastectomy and reconstruction.

Diagnosis and management of breast implant capsule recurrence following mastectomy and subpectoral implant - innovative use of ADM for reconstruction.

It is well reported that patients who have undergone breast augmentation and subsequently develop breast cancer can successfully undergo breast-conserving therapy with preservation of their implants. However, there is a paucity of literature on the radiological investigations and surgical techniques in postmastectomy implant-reconstructed patients who develop recurrences to enable preservation of their implant-based reconstruction whilst effectively treating the local recurrence. The wide adoption of acellular dermal matrix use in prosthetic breast reconstruction in recent years has made radiological evaluation of such patients challenging. Herein presented is a case of a 37-year-old woman where wide local excision of a local recurrence abutting a peri-implant capsule following previous mastectomy and implant-acellular dermal matrix (ADM) reconstruction was performed with successful preservation of reconstruction volume (and shape) using an ADM patch to repair the capsular defect whilst retaining the implant in situ. Radiological investigation facilitated and guided the surgical planning and oncological clearance.

A multicentre study of the relationship between abdominal flap and mastectomy weights in immediate unilateral free flap breast reconstruction and the effect of adjuvant radiotherapy.

Abdominal free flaps are considered the gold standard for post-mastectomy autologous breast reconstruction. A key element of outcome assessment is breast symmetry often achieved by approximating the reconstructed breast dimensions such as weight (wt) to those of the mastectomy. However, the ideal relationship between these two entities remains unclear. 525 immediate unilateral abdominal free flap breast reconstruction (FFBR) patients were enrolled in a multicentre study (UK 141; Italy 384) and subdivided into Group A (flap wt < mastectomy wt, n = 163), Group B (flap wt > mastectomy wt, n = 260) and Group C (flap wt = mastectomy wt, n = 102). Their rates of contralateral balancing and ipsilateral revision surgeries were compared using Chi-Square tests. Radiotherapy influence on these adjustment procedures was also assessed. More contralateral balancing procedures (17%) were performed than ipsilateral revisions (10%). Group A rates of contralateral balancing procedures were three times higher than Group B's with a ratio of 37 to 1 versus Group C (37% vs 11% vs 1% respectively, p < 0.001). Similarly, the ipsilateral breast revision surgery rate in Group A was double that of Group B and almost three times that of Group C (17% vs 8% vs 6% respectively, p = 0.01). Adjuvant radiotherapy disproportionately increased ipsilateral revisions versus contralateral balancing surgeries (p = 0.028). A flap-to-mastectomy weight ratio of less than 1 (Group A) significantly increases subsequent adjustments on both contralateral and reconstructed breasts whilst irradiation predisposes to ipsilateral revisions. This is important in patient counselling and intraoperative flap contouring. Flap weight should ideally approximate or exceed mastectomy weight in unilateral FFBR.

Clinical application and outcomes of reconstructive microsurgery in Africa: A systematic review and meta-analysis.

BACKGROUND: Reconstructive microsurgical free flap techniques are often the treatment of choice for a variety of complex tissue defects across multiple surgical specialties. However, the practice is underdeveloped in low- and middle-income countries. The aim of this systematic review was to evaluate the clinical application and outcomes of reconstructive microsurgery performed in Africa. METHODS: Seven databases (PubMed, Web of Science, MEDLINE, CINAHL, Academic Search Complete, Embase, and Google Scholar) were searched for studies reporting microsurgical procedures performed in Africa. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools and quality of evidence using the GRADE approach. Meta-analysis was performed using a random effects model to estimate the pooled proportion of events with 95% confidence intervals. The primary outcome was free flap success rate, and the secondary outcomes were the complication and flap salvage rates. RESULTS: Ninety-two studies were included in the narrative synthesis and nine in the pooled meta-analysis. In total, 1376 free flaps in 1327 patients from 1976 to 2020 were analyzed. Head and neck oncologic reconstruction made up 30% of cases, while breast reconstruction comprised 2%. The pooled flap survival rate was 89% (95% CI: 0.84, 0.93), complication rate 51% (95% CI: 0.36, 0.65), and free flap salvage rate was 45% (95% CI: 0.08, 0.84). CONCLUSION: This meta-analysis showed that the free flap success rates in Africa are high and comparable to those reported in high-income countries. However, the comparatively higher complication rate and lower salvage rate suggest a need for improved perioperative care. REVIEW REGISTRATION: Registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 25th September 2020, ID: CRD42020192344.

Tips for successful microvascular abdominal flap breast reconstruction utilizing the "total rib preservation" technique for internal mammary vessel exposure.

INTRODUCTION: The internal mammary vessels (IMVs) are increasingly the recipients for free flap breast reconstruction (FFBR). Access traditionally entails removing a segment of the third costal cartilage. Despite excellent exposure, some authors have reported localized tenderness as well as a thoracic contour deformity. We introduced the "total rib preservation" technique for IMV exposure after specific request by a patient, and have used it for all subsequent reconstructions. METHODS: All patients who underwent FFBR with rib preservation by a single surgeon in the year beginning June 2008 were studied prospectively. Intraoperative measurements of the inter-rib space available for microvascular anastomosis were taken. Operative details and flap outcomes were compared with a cohort of earlier patients who underwent rib sacrifice. RESULTS: Over a 12-month period, 42 FFBRs in 37 patients (36 deep inferior epigastric perforator, five muscle-sparing transverse rectus abdominis myocutaneous, and one superficial inferior epigastric artery flap) were performed by a single operator. All flap transfers were successful. In the first 4 patients, the interspace between the third and fourth ribs was used; but for all subsequent patients the second and third rib interspace was used. The average distance between adjacent ribs was 21.3 mm (range, 9-28 mm) and the vessel preparation time decreased from an average of 93 to 49 minutes (first and last 5 cases). There was no significant difference in mean ischemia time between the rib preservation and the rib sacrifice groups (104.4 vs. 103.6 minutes). CONCLUSIONS: The total rib preservation method of IMV exposure is a viable, reproducible, and reliable option for microvascular breast reconstruction. It does not increase warm ischemia, which suggests time taken for anastomosis is not affected by rib preservation. There is a learning curve and care has to be taken to avoid possible pitfalls. We recommend the use of a higher rib interspace than originally described because of the greater vessel calibre, superior vessel exposure, and therefore, easier anastomosis.

Aesthetic and functional abdominal wall reconstruction after multiple bowel perforations secondary to liposuction.

This report describes a case of aesthetic and functional abdominal wall reconstruction performed to salvage a deformed, scarred, and herniated anterior abdomen after severe peritonitis and partial rectus muscle necrosis secondary to multiple bowel perforations sustained during liposuction performed in a cosmetic clinic. The diagnosis of intestinal perforation was missed intraoperatively and in the immediate postoperative period. The patient was admitted 4 days after the surgery to the intensive therapy unit in septicemic shock. After resuscitation and stabilization, she was treated by debridement of the abdominal wall, bowel resection, and temporary jejunostomy and colostomy (reversed 10 months later). She was referred 18 months after liposuction to the Plastic Surgery Service with a large central midline abdominal incisional hernia presenting with thinned out skin (14 × 11 cm) overlying adherent bowel. A components separation technique was successfully used to reconstruct the abdominal wall, with no recurrent herniation 2 years later. Survivors of bowel perforations sustained during abdominal liposuction may later present with challenging aesthetic and functional problems, as described in this report. These long-term sequelae have not been addressed hitherto in the literature.