Double Free Transverse Upper Gracilis Flap Breast Reconstruction: Advantages of Using LD Flap as a Salvage Solution.

The lower abdominal tissue is still the most common donor site used for free autologous breast reconstruction. If this site is not available, multiple secondary choices exist. The transverse upper gracilis flap is a valuable choice and it can be used alone or in combination with other flaps. We present a case of a 49-year-old patient who underwent delayed unilateral breast reconstruction by using a double transverse upper gracilis flap. Due to venous thrombosis, the flap inserted in the lower pole was lost. We managed the complication tailoring a latissimus dorsi flap to close the defect. We reported the advantages of the latissimus dorsi flap as a rescue solution and its superior aesthetic result in this particular case. Breast reconstruction with transverse upper gracilis flap in addition to the latissimus dorsi flap allowed us to obtain an adequate breast volume avoiding the use of breast implants as desired by the patient. We thought that the double free transverse upper gracilis flap for delayed, or immediate unilateral reconstruction of small to moderate breast could be a valuable option to avoid the use of implants and when abdominal tissue is not available. However, it should be taken into consideration the shortness of the transverse upper gracilis pedicle, the necessity to perform a retrograde flow anastomosis at the level of the internal mammary, and the discrepancy of skin color tones with the receiving site. The latissimus dorsi flap was an excellent rescue solution and put in evidence the aesthetic superiority of this flap compared to the transverse upper gracilis flap.

Modifield musculocutaneous gracilis flap A case report.

A heterogeneous range of malignant pathologies affects vulvar and perineal regions. Today standard radical mutilating surgery for the treatment of invasive vulvar carcinoma is being replaced by a conservative and individualized approach. Defects of the external pelvis and perineal lining are usually reconstructed with local or regional fasciocutaneous flaps. However, in particular situations, the asymmetrical distribution of the defect and its location, close to sources of infec-tion such as the perineal area, may suggest a different approach. This report presents a patient who underwent conservative vulvectomy bilaterally and reconstruction with a unilateral modified gracilis flap. A V shaped incision was designed in the skin paddle of the flap, allowing it to fit the loss of substance around the remaining vulvar skin. Patient was highly satisfied with the result, she had no pain, no problem in defecation or urination nor during deambulation. In case with asymmetrical defect in the vulvo-perineal area the modified gracilis flap can be considered as a valid reconstructive option. KEY WORDS: Modified gracilis flap, Vulvo-perineal reconstruction.

Posterior tibial perforators relationship with superficial nerves and veins: A cadaver study.

BACKGROUND: Most authors have evaluated the location of lower leg arterial perforators, but little is still known about the relationship between the arterial network and great saphenous vein (GSV) and saphenous nerve (SN). The aim of this study is to evaluate the relationship between the arterial network of the posterior tibial artery perforators, the cutaneous nerves, and the superficial venous system in the lower one third of the leg. METHODS: Eighteen lower limbs from cadavers were used for this study. The arterial and venous compartment were selectively injected with a mixture of barium sulfate and epoxy. The specimen were CT scanned and the superficial veins, nerves, and the arterial perforators were dissected. RESULTS: A large perforator of the posterior tibial artery was found at a mean distance of 6.23 cm ± 0.88, with a 95% CI: 5.79-6.67, from the medial malleolus. The average diameter was 0.9 mm ± 0.17, with a 95% CI: 0.81-0.99. In 67% the connection of the venae comitantes to the superficial venous system was established with the GSV, in the other cases, with Leonardo's vein. Both dissection and imaging studies showed perineural interperforator connections along the branches of SN in all the specimens examined. CONCLUSIONS: The distribution pattern of posterior tibial artery perforators followed the superficial nerves in this region. There is an interperforator anastomotic network along the SN. The various patterns of the venous drainage system, in relationship to the distribution of the branches of posterior tibial artery perforators, have been clarified.

Sub-muscular Breast Augmentation Using Tumescent Local Anesthesia.

BACKGROUND: Tumescent local anesthesia (TLA) consists of infiltration of saline solution with lidocaine and epinephrine into the tissues to obtain regional anesthesia and vasoconstriction. The use of TLA in augmentation mammoplasty has been described for sub-glandular positioning. We describe a modified TLA technique for primary sub-muscular breast augmentation reporting our experience during the past 7 years. METHODS: From 2010 to 2017, 300 patients underwent bilateral primary sub-muscular breast augmentation under TLA and conscious sedation. The tumescent solution was prepared with 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. Firstly, the solution was infiltrated between the pectoral fascia and the mammary gland, secondarily, during surgery, under the pectoralis major muscle. RESULTS: The average amount of tumescent solution infiltrated while performing TLA was 740 mL per breast. No signs of adrenaline or lidocaine toxicity were reported and conversion to general anesthesia was never required. In all patients, no pain nor discomfort was reported during the pre-operating infiltration and surgical procedure. We reported a major complication rate of 3.3% (4 hematomas and 6 seromas) and a minor complication rate of 6.0% (8 implant dislocation and 10 dystrophic scars formation). CONCLUSIONS: TLA represents a safe and efficacious technique for performing breast augmentation surgery with sub-muscular implant positioning. This technique guarantees good pain control during and after surgery and has low incidence of postoperative side effects. Patients subjected to sub-muscular breast augmentation with TLA were satisfied. 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 .

Flap monitoring with continuous oxygen partial tension measurement in breast reconstructive surgery: A preliminary report.

BACKGROUND: The best method for the postoperative monitoring of flaps in reconstructive surgery is still a matter of debate. The aim of this study is to evaluate the usefulness of an oxygen partial tension monitoring system for the postoperative follow-up of a series of breast flaps, in addition to the traditional periodical clinical evaluations. PATIENTS AND METHODS: Twenty-one consecutive female patients (mean age: 61 years) who underwent free- or pedicled-flap reconstruction of the breast were included in the study. Fifteen patients had a deep inferior epigastric perforator flap breast reconstruction, while the remaining six patients underwent a transverse rectus abdominus myocutaneous flap reconstruction. The Licox® Recon (Integra LifeSciences Corp, Plainsboro, New Jersey) system was used for the monitoring of the flaps. The oxygen partial tension (PtO2 ) values were displayed on the system monitor and registered with appropriate software for statistical analysis. RESULTS: A decreasing trend in the mean PtO2 values was observed over the first five postoperative days. The mean values registered in the first postoperative day were higher than those observed in the subsequent four days. Three patients were lost due to misplacement of the probe. Among the remaining 18 flaps, 3 (17%) reported a remarkable decrease in PtO2 values, with the mean PtO2 registered in the second postoperative day being significantly lower than in the other flaps (7.3 ± 0.7 vs. 17.0 ± 0.9; P-value <.05). These three flaps have been promptly re-explored, with a final flap failure rate of 5.5% (1 flap). CONCLUSIONS: The continuous oxygen tension evaluation represents a promising method for the postoperative monitoring of breast reconstructive surgery flaps when used in combination with the traditional periodic clinical evaluations.