Nipple delay prior to nipple-sparing mastectomy: the protective effect on nipple-areola complex ischaemia.

BACKGROUND: Nipple-sparing mastectomy (NSM) has become increasingly popular over the past decade, offering perceived superior cosmetic outcomes and psychological benefits. The main concern in NSM is that of nipple-areola complex (NAC) ischaemia, occurring in up to 15% of cases. We investigate the utility of nipple delay (ND) in protecting the NAC from ischaemic complications. METHODS: A retrospective study of all NSM for a single surgeon from 2010 to 2020 was performed, with those not receiving a prior ND procedure included as a control arm. Variables were recorded, including time to mastectomy from delay, degree of breast ptosis, cup size, mastectomy weight, previous radiotherapy, and presence of ischaemic risk factors. Outcomes recorded were the development of NAC ischaemia, graded from epidermolysis to partial or full-thickness necrosis (FTN). RESULTS: A total of 62 women for a total of 84 breasts were part of the delay cohort. Ten (12%) breasts in the delay group developed ischaemic complications, with only five breasts developing FTN requiring debridement. Moreover, 33 women for a total of 43 breasts were part of the non-delay cohort. A total of 14 (33%) breasts in the non-delay cohort developed ischaemic complications, with six breasts developing FTN requiring debridement. Delay was protective against ischaemic complications with an OR 0.28 (p=0.007). Mastectomy weight of >600 g and >400 g predicted the development of ischaemic complications in the delay and non-delay cohorts, respectively. CONCLUSION: ND was shown to protect against the development of ischaemic complications prior to NSM, with the greatest protective effects shown in those with morphologically large breasts.

Case Report: Revisiting the Internal Mammary Artery Perforator Flap: Salvage Option for Circumferential Pharyngo-Esophageal Defects.

Patients that present with pharyngeal strictures and pharyngocutaneous fistulas in the context of previous reconstruction and post-operative radiotherapy often report significant morbidity and reduction in quality of life. Reconstruction of such defects present a substantial clinical challenge requiring the importation of unirradiated vascularized tissue to facilitate healing in a friable, fibrotic, and vessel depleted tissue bed. The authors present a case report demonstrating an adaptation of the internal mammary artery perforator (IMAP) flap for reliable reconstruction of circumferential pharyngeal defects with primary tension free closure of the donor site. This technique avoids the use of free tissue transfer in a hostile, irradiated neck. The tubed IMAP flap is an excellent option, serving the purposes of reconstruction as well as addressing the patient's presenting issues of a chronic sinus and pharyngeal stricture inhibiting oral intake.

Refining our knowledge of macrovascular arteriovenous shunts (MAS): Anatomical and pathological studies.

BACKGROUND: The macrovascular arteriovenous shunt (MAS) connecting the deep inferior epigastric artery (DIEA) and superficial inferior epigastric vein (SIEV) in the abdominal wall has already been identified as an important structure, and further study has been deemed necessary to establish its role and function. METHODS: Review of CT angiograms (CTA) of 38 female patients was undertaken, by means of analysis of fine-cut axial images and three-dimensional image reconstructions of the cutaneous vasculature of the deep and superficial vasculature. In vivo dissection of the structure was also performed to establish its communications. Lastly, a histopathological analysis was carried out to investigate its intrinsic structure and function. RESULTS: The MAS was identified in both sides of the abdomen in all subjects and the diameter ranges from 0.72 to 2.81 mm with a median diameter of 1.28 mm. In vivo dissection revealed it as a distinct structure connecting the DIEA and SIEV. Pathological analysis showed that it has characteristics of both elastic and muscular arteries, which constitutes a new vessel. CONCLUSION: These further investigations have yielded a better understanding of the MAS shunt, its position, structure and function. This can be of crucial importance to reconstructive surgeons when raising the DIEP flap.

Intramuscular pathway and fascicular characteristics of the segmental intercostal innervation to rectus abdominis.

BACKGROUND: Rectus abdominis is a muscle that is commonly used clinically as a muscle flap, especially in reconstructive surgery. Its intramuscular innervation, however, has rarely been examined in detail or accurately mapped. The purpose of this study was to use biopsied, histological specimens complemented with a staining technique to investigate intramuscular nerve connections and distribution of the rectus abdominis. METHODS: Four fresh human cadavers were included in the study and rectus abdominis was dissected bilaterally. Nerve sections innervating the rectus abdominis were biopsied and histologically processed. Sections were viewed under the microscope, and axons within each fascicle were counted using imaging software. All specimens were stained with a modified Sihler's staining technique. Intramuscular innervation was observed and the number as well as distribution was recorded. RESULTS: Macroscopically stained specimens showed that the eighth, ninth, 10th and 12th intercostal nerves innervated the eight muscle bellies of rectus abdominis. The greatest number of minor nerve branching as well as intramuscular nerve communications originated from nerve roots T9 and T10. Minor nerve branches crossed tendinous intersections to communicate with adjacent nerves and innervate adjacent muscle bellies. Nerves originating from T9 had the greatest number of nerve fascicles and the highest axon count in each cadaver. CONCLUSION: The rectus abdominis is divided into four compartments with each receiving its own independent nerve supply. Minor nerve branches crossed tendinous intersections to communicate with adjacent muscle bellies and nerves suggesting that rectus abdominis can be used as a whole in innervated free flap transfer procedures.

Lymphoedema rates in pedicled anterolateral thigh flaps for coverage of irradiated groin defects.

BACKGROUND: Limb salvage surgery in conjunction with adjuvant radiotherapy is the preferred treatment for soft tissue sarcoma. This study aims to determine if ipsilateral pedicled anterolateral thigh (ALT) flap reconstruction of groin defects post soft tissue sarcoma resection results in acceptable rates of lymphoedema, while also providing good soft tissue cover and minimal donor site morbidity. METHODS: A retrospective chart audit was conducted with ethics approval, obtaining a case series of 16 patients operated on at a single institution by the senior surgeon. Patients who underwent ipsilateral pedicled ALT flap coverage of irradiated groin defects following soft tissue sarcoma resection were included. Comparative six-point limb circumference measurements were utilized to diagnose lymphoedema, with a difference of 10% when compared to the non-operative side being deemed significant. RESULTS: Lymphoedema was noted in three patients (18.8%) with an average follow-up period of 40.9 (range 8-59) months. CONCLUSION: Previously published lymphoedema rates in sarcoma limb salvage surgery of 15.5-30% are comparable to the rates obtained in this cohort. Lymphoedema rates do not appear to be higher in patients undergoing ipsilateral pedicled ALT flap reconstruction, thus making it a useful soft tissue coverage technique in this cohort.

Outcomes of dental and craniofacial osseointegrated implantation in head and neck cancer patients.

BACKGROUND: Treatment of head and neck cancer may result in disfiguring and debilitating anatomical changes. Osseointegrated implants may be used in these patients to facilitate attachment of implant-retained dentures or cosmetic prostheses. METHODS: A retrospective audit was performed, reviewing the treatment of patients who received dental or craniofacial osseointegrated implants during treatment of head and neck cancer. RESULTS: One hundred sixty implants were inserted in 54 patients with oral, nasal, orbital, or auricular defects. Overall, 85% of implants were successful after mean follow-up of 25.7 months. The brand of implant used was shown to impart a statistically significant implant survival difference, and orbital implants had poorer survival compared to nonorbital implants. There was a statistical insignificant implant survival advantage in both nonsmokers and patients who did not undergo radiotherapy. CONCLUSIONS: Dental and craniofacial osseointegrated implants may be reliably used in patients with head and neck cancer. However, further research is required to clarify the role of smoking in osseointegrated implant failure.

Comparative osteoradionecrosis rates in bony reconstructions for head and neck malignancy.

BACKGROUND: Bony free flaps are used to reconstruct head and neck cancer defects. The most commonly used flaps are the free fibula flap and the deep circumflex iliac artery (DCIA) flap. Radiotherapy may be given post-operatively to prevent cancer recurrence. This radiotherapy can, however, destroy the bone; a complication termed osteoradionecrosis (ORN). Although there have been studies comparing free fibula and DCIA flaps in terms of success rates and complications, few have assessed the incidence of ORN in both groups. METHODS: A retrospective cohort study was conducted involving patients from Royal Melbourne Hospital and St Vincent's Hospital Melbourne who had either a free fibula or DCIA flap for head and neck cancer reconstruction in the past 10 years. Data collected included demographic, operative, and postoperative data. Analysis was performed using Statistical Package for Social Sciences and Microsoft Excel, utilising t-tests, chi-square tests and logistic regression analyses. RESULTS: A total of 154 patients were identified. Of these patients, 127 had free fibula flaps and 27 had free DCIA flaps. Twelve patients had ORN post-op, 10 had free fibula flaps, and 2 had free DCIA flaps. No statistically significant difference was found between the ORN rates in free fibula flaps and free DCIA flaps. CONCLUSION: Rates of ORN incidence should not be a major consideration in preoperative planning of free flaps for mandibular reconstruction as both fibula and DCIA free flaps are comparable.

The innervated rectus abdominis flap for quadriceps reconstruction.

BACKGROUND: The vertical rectus abdominis myocutaneous (VRAM) and transverse rectus abdominis myocutaneous (TRAM) flaps have traditionally been excluded from consideration of reconstructions with functional potential, because of their segmental innervation. We present a case series that aimed to demonstrate that segmental innervation does not preclude successful neural anastomoses and can deliver a functional reconstruction of a total compartment in the anterior thigh. METHODS: This review included all patients who required total anterior thigh compartmentectomy and reconstruction between December 2009 and February 2016 were included from the first author's prospective database. RESULTS: Eleven cases were identified, with innervated rectus abdominis flaps used for anterior thigh reconstruction. During the median follow up period of 12 months, all patients had reinnervation of the rectus with six reaching M5, one M4+, one M4, two M3 and one M2, according to Medical Research Council power grades. CONCLUSION: All patients had successful functional reconstruction in the thigh using the rectus abdominis myocutaneous flap.

Composite pronator quadratus: radial forearm free flap in functional lip reconstruction.

BACKGROUND: Reconstruction of lip defects following neoplasia and trauma is a common procedure in plastic surgery. Reconstruction of large lip defects is a difficult undertaking and some degree of residual functional impairment and disability are likely to occur. Microsurgical reconstruction is the recommended technique for large lip defects; however, limitations exist regarding optimal aesthetic and functional outcomes with current free flap options. METHOD: We propose a new composite flap design based on the innervated pronator quadratus with the radial forearm free flap for a more dynamic reconstruction of total or near total lip defects. Results of our series of four patients have been reviewed. RESULTS: The radial forearm flap - innervated pronator quadratus flap has been used in four patients thus far for lip reconstruction. This flap, in our limited series has shown excellent results in achieving oral competence, good motor function and acceptable cosmetic appearance. CONCLUSION: The composite radial forearm-pronator quadratus flap is a promising new lip reconstruction technique that has potential to provide a higher level of oral competence, sphincteric function and symmetrical lip movement, than current microsurgical options in dynamic lip reconstruction. This method warrants further investigation in plastic surgery literature.

Propeller flap reconstruction of irradiated sarcoma defects: A comparison✰.

INTRODUCTION: The treatment for soft tissue sarcomas has evolved to include radiotherapy, wide local excision and plastic surgical reconstruction. Goals for the reconstruction of these irradiated defects are the introduction of non-irradiated healthy tissue, tension-free closure and obliteration of potential dead space. Although many defects once required free tissue transfer for reconstruction, greater knowledge of anatomical vascular pattern has led to the increasing use of propeller perforator flaps, islanded and transposed into the defect. Propeller flap outcomes for the reconstruction of irradiated skin defects have only been reported in case reports. We evaluated the use of propeller perforator flaps at St Vincent's Hospital Melbourne in a series of patients for the reconstruction of irradiated sarcoma defects. METHODS: All patients who underwent sarcoma resection with plastic surgical reconstruction at St Vincent's Hospital from January 2009 to February 2017 were identified from unit audits and medical record data and compared depending on the type of reconstruction. Propeller perforator flaps were evaluated compared to other methods of reconstruction. RESULTS: Thirty-nine cases involved single perforator propeller flaps for reconstruction. The frequency of propeller flap reconstruction has greatly increased from 3 in their first year of use in 2013 to 12 in 2015. Most propeller flaps were used to reconstruct thigh defects (43.6%) followed by shoulder defects (17.9%). Generally the defects were smaller (138.7 cm2) than free flaps (214.2 cm2), and the usual composition of the defect was skin and subcutaneous tissue only. Patients who underwent propeller flap reconstruction had a significantly short length of inpatient stay (p < 0.01), and there were no total failures. CONCLUSION: Propeller perforator flaps are useful for the reconstruction of irradiated defects in sarcoma reconstruction surgery, particularly small- to moderate-sized fasciocutaneous defects. They offer less morbidity, faster recovery and better aesthetic results than free or standard pedicle flaps. The success of propeller flaps has changed the algorithm for how we approach towards the reconstruction of irradiated sarcoma defects to consider their use as the first reconstructive option for superficial sarcoma defects.

Y-Peg-in-a-Round-Hole Closure for Immediate Periareolar Mastectomy Expander Reconstruction.

INTRODUCTION: Mastectomies closed with a linear scar can distort the resulting shape of the breast. We present our novel Y-peg-in-a-round-hole closure method of the mastectomy scar, which improves the shape of the reconstructed breast while maintaining reliable healing, implant coverage, and minimum scar size for covering by tattoo. MATERIALS AND METHODS: A retrospective review of all breast reconstruction cases performed by the senior surgeon during the period from January 2010 to January 2017 was undertaken. Data were analyzed for wound healing problems, infection rates and mastectomy skin flap necrosis. RESULTS: Data were extracted for 126 consecutive patients with 154 breast reconstructions. Twelve breasts (7.7%) experienced wound healing problems, for which 7 (4.5%) required revisionary surgery. Eighteen breasts (11.7%) developed an infection requiring antibiotics, of which 8 (5.2%) needed a further operation. Four breasts (2.6%) needed removal of the implant. No patients were lost to follow-up. CONCLUSION: After nipple resecting mastectomy, the Y-peg-in-a-round-hole scar minimizes radial size and contour deformity but allows for reliable wound healing.

Reconstructive options for large back free flap donor sites.

BACKGROUND: Reconstruction of posterior thoracic and trunk defects can prove challenging even to the most seasoned surgeons. Many commonly used techniques for closing back defects include primary closure and split skin grafts. Often times, however, other techniques are needed in order to give the patient the best aesthetic and functional outcome. In this study, we focus on and evaluate donor site closure techniques for defects in the back created by harvesting scapular and parascapular flaps. METHODS: Twenty patients were operated on to remove pathologically diagnosed sarcomas using a wide local excision. The defects, ranging from 5 to 22 cm in width, were closed using donor flaps from the scapular/parascapular region. Nine donor sites were then closed primarily with wide undermining, while 11 donor sites were closed using multiple techniques, such as large transposition flaps, large rotation advancement flaps, keystone neurovascular island flaps, latissimus dorsi advancement flap and large Y-V advancement flaps. RESULTS: All recipient and donor flaps survived with good aesthetic and functional outcome. Patient satisfaction was high and only two of 20 donor site flaps required further surgery due to wound dehiscence. No other complications were seen during the follow-up period. CONCLUSION: The proposed advanced techniques for donor site closure in back defects have shown that primary wound healing can be achieved with the use of a variety of different techniques and the avoidance of the complications of a skin graft.

Immediate autologous breast reconstruction after neoadjuvant chemoradiotherapy for breast cancer: initial results of the first 29 patients.

BACKGROUND: Breast reconstruction after mastectomy in the treatment of locally advanced breast cancer is often done in stages and before radiotherapy. We have previously published an algorithm for immediate free autologous reconstruction after neoadjuvant chemotherapy and preoperative radiotherapy. This protocol was designed to provide a shorter and simpler reconstructive path whilst improving cosmesis and maintaining oncological efficiency. METHODS: A total of 29 patients were included and underwent surgery for 30 cancers by the first author between 2010 and September 2015. Data were prospectively entered into a database and analysed for tumour size, chemotherapeutic response, lymph node involvement, surgical complications and tumour recurrence. RESULTS: The mean age was 55 ± 7 years. Eighty percent of patients had either a partial or complete chemotherapeutic response defined as >25% decrease in tumour size. Twenty-eight patients had free abdominal tissue transfer. One patient was excluded due to advanced disease. There were no take-backs due to microsurgical issues. One patient was reoperated on for a haematoma. Four patients had recurrent cancer during follow-up, three of whom are deceased. CONCLUSION: Many, but not all, breast reconstructive surgeons consider autologous reconstruction as the 'gold' standard in the presence of radiotherapy. Rearranging the order of radiotherapy and surgery means operating in a recently irradiated field. We believe the surgical challenges are outweighed by a shorter and simpler reconstructive journey that additionally results in a better cosmesis. It is possible to perform immediate free autologous reconstruction after neoadjuvant chemotherapy and preoperative radiotherapy with excellent results and at least equivalent oncological efficacy.

Preoperative Radiotherapy and Wide Resection for Soft Tissue Sarcomas: Achieving a Low Rate of Major Wound Complications with the Use of Flaps. Results of a Single Surgical Team.

BACKGROUND: Surgery in combination with radiotherapy (RT) has become the standard of care for most soft tissue sarcomas. The choice between pre- and postoperative RT is controversial. Preoperative RT is associated with a 32-35% rate of major wound complications (MWC) and 16-25% rate of reoperation. The role of vascularized soft tissue "flaps" in reducing complications is unclear. We report the outcomes of patients treated with preoperative RT, resection, and flap reconstruction. PATIENTS AND METHODS: 122 treatment episodes involving 117 patients were retrospectively reviewed. All patients were treated with 50.4 Gy of external beam radiation. Surgery was performed at 4-8 weeks after completion of RT by the same combination of orthopedic oncology and plastic reconstructive surgeon. Defects were reconstructed with 64 free and 59 pedicled/local flaps. RESULTS: 30 (25%) patients experienced a MWC and 17 (14%) required further surgery. 20% of complications were exclusively related to the donor site. There was complete or partial loss of three flaps. There was no difference in the rate of MWC or reoperation for complications with respect to age, sex, tumor site, previous unplanned excision, tumor grade, depth, and type of flap. Tumor size ≥8 cm was associated with a higher rate of reoperation (11/44 vs 6/78; P = 0.008) but the rate of MWC was not significant (16/44 vs 14/78; P = 0.066). CONCLUSION: The use of soft tissue flaps is associated with a low rate of MWC and reoperation. Our results suggest that a high rate of flap usage may be required to observe a reduction in complication rates.

Creation of a Large Adipose Tissue Construct in Humans Using a Tissue-engineering Chamber: A Step Forward in the Clinical Application of Soft Tissue Engineering.

Tissue engineering is currently exploring new and exciting avenues for the repair of soft tissue and organ defects. Adipose tissue engineering using the tissue engineering chamber (TEC) model has yielded promising results in animals; however, to date, there have been no reports on the use of this device in humans. Five female post mastectomy patients ranging from 35 to 49years old were recruited and a pedicled thoracodorsal artery perforator fat flap ranging from 6 to 50ml was harvested, transposed onto the chest wall and covered by an acrylic perforated dome-shaped chamber ranging from 140 to 350cm(3). Magnetic resonance evaluation was performed at three and six months after chamber implantation. Chambers were removed at six months and samples were obtained for histological analysis. In one patient, newly formed tissue to a volume of 210ml was generated inside the chamber. One patient was unable to complete the trial and the other three failed to develop significant enlargement of the original fat flap, which, at the time of chamber explantation, was encased in a thick fibrous capsule. Our study provides evidence that generation of large well-vascularized tissue engineered constructs using the TEC is feasible in humans.