Bilateral Transverse Upper Gracilis Flaps for Unilateral Breast Reconstruction: A 4-Year Retrospective Study of the "2-in-1" Technique and a Systematic Review With Meta-analysis.

INTRODUCTION: The transverse upper gracilis (TUG) flap is a reliable alternative to abdominally based breast reconstruction because of its advantageous anatomy. However, the limited tissue volume prevents reconstruction of large breasts. The bilateral TUG flaps for unilateral breast reconstruction can overcome this problem. METHODS: A retrospective analysis was performed regarding unilateral breast reconstruction with bilateral TUGs at the Queen Victoria Hospital from 2015 to 2019. Associations between categorical variables were examined with Fisher exact test, and any differences in continuous variables by complication status were evaluated with Mann-Whitney-Wilcoxon test for independent samples. A relevant systematic review was conducted with a meta-analysis of proportions using the Freeman-Tukey arcsine transformation for the estimation of the overall survival rates. RESULTS: Ten cases were identified with 6 having a delayed reconstruction. Median age and body mass index were 50.8 years and 23.9 kg/m 2 , respectively, and average flap weight was 268.3 g. One flap was placed superiorly with its pedicle anastomosed to the retrograde internal mammary vessels, except of half of the cases where a second anterograde vein was used. The mean follow-up was 21.4 months, and all flaps survived. Two patients returned to theater, and 4 experienced donor-site problems. The presence of complications was not associated with age, ever smoking, body mass index, TUG weight, or anastomosis to retrograde internal mammary vein. The systematic review resulted in 8 eligible articles with a total sample of 156 flaps. The overall survival rate was 96.8%. In 6 cases, the indication was Poland syndrome (7.7%), and in 48.7%, axillary vessels were also used as recipient vessels. The estimated overall flap survival rate was 100% (95% confidence interval, 99%-100%), and no significant heterogeneity was noted ( I2 = 0%, P = 0.71). CONCLUSIONS: The "2-in-1" technique can lead to symmetrical aesthetically pleasant results for both recipient and donor sites. Our case series and the conducted systematic review reiterate the reliability of this approach.

Optimal postoperative management of perineal flaps in oncologic patients undergoing extralevator abdominoperineal excision: An introduction of a postoperative monitoring and flap management protocol.

There is extensive discussion regarding method of perineal defect closure extralevator abdominoperineal excision, but little consideration of optimal postoperative management of the flaps, or use of Enhanced Recovery After Surgery in flap reconstruction. Literature review revealed little discussion of optimum postoperative care of perineal flaps following extralevator abdominoperineal excision. We have developed a protocol for postoperative care of perineal flaps for use in conjunction with colorectal Enhanced Recovery After Surgery pathways, easily followed in units not specialising in plastic surgery. The protocol was developed using translatable evidence from guidelines for flap care from other subspecialties, as well as the experience of management of post-extralevator abdominoperineal excision perineal flaps in our trust, with the aim of enabling early detection of deterioration in this complex cohort, with a multidisciplinary enhanced recovery approach.

The Use of the Bipedicled Deep Inferior Epigastric Perforator Flap for Unilateral Breast Reconstruction: A Systematic Review and Meta-analysis.

INTRODUCTION: The use of abdominal flaps is recognized as a very advantageous approach for breast reconstruction with gradual refinements leading from the pedicled transverse rectus abdominis musculocutaneous flap to the criterion standard deep inferior epigastric perforator (DIEP) flap and its several variations. A systematic review with meta-analysis attempts to investigate the safety of the bipedicled DIEP flap for unilateral breast reconstruction. METHODS: The literature search used "PubMed" database, and a relevant study conducted at the Queen Victoria Hospital was also included. The extraction of data included study type, follow-up, patients' age, body mass index, preexisting abdominal scars, timing of reconstruction, operating time, flap inset, pedicles' configuration, flap failure, revision, and complication rates. Proportions were pooled with Freeman-Tukey arcsine transformation, and meta-regression was performed to evaluate whether complication rates were modified by different variables. RESULTS: Fourteen eligible articles provided an overall sample of 486 flaps, with a median follow-up of 18.5 months. In most cases, immediate reconstruction with undivided flap was performed, with equal use of extraflap and intraflap pedicles' configuration. Only 4 cases of flap failure (0.82%) were documented, with 18% overall complications and 3% fat necrosis rate. The forest plot showed significant between-study heterogeneity, and meta-regression revealed marginal positive association between older patient and complication rate. CONCLUSIONS: Bipedicled DIEP flap for unilateral breast reconstruction is a technique that maintains the complications rate relatively low in challenging postmastectomy cases. Further comparative studies are needed to substantiate the findings of this study.

Microvascular modifications to optimize the transverse upper gracilis flap for breast reconstruction.

BACKGROUND: The free transverse upper gracilis flap is well described for breast reconstruction and is the authors' second choice. Medial thigh soft tissue creates a durable, pliable, aesthetic breast; however, it has been criticized for modest volume and short pedicle. This demands frequent use of bilateral flaps for unilateral reconstructions, sacrifice of thoracodorsal vessels, and/or use of vein grafts. The authors have overcome these issues by modifying their microvascular techniques. METHODS: The authors describe several maneuvers that they have introduced, including excision and replacement of costal cartilage, using nontraditional internal mammary arterial anastomoses, and using adductor branches for flap-to-flap anastomoses to allow double flap reconstructions. The authors describe their case series of 30 transverse upper gracilis flaps to reconstruct 20 breasts in 18 patients. RESULTS: All flaps have survived. Seventy-five percent of the reconstructions were unilateral, although of these, 67 percent used two flaps to reconstruct one breast. The mean reconstructed breast was 360.9 g. Of 10 breasts reconstructed with double flaps, six used available adductor branches, whereas the others used internal mammary perforators, end-to-side anastomoses, or retrograde arterial flow. To complement this clinical approach, an anatomical study of the branching patterns from the gracilis pedicle has been carried out on 33 cadaveric specimens. CONCLUSIONS: The authors' study has allowed a new classification system to be defined and demonstrates suitable branching patterns to allow flap-to-flap anastomoses in 75 percent of patients; in those 25 percent where this is not possible, alternative strategies for double flaps can be sought and have been used successfully in our clinical series. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Exploring the myth of the valveless internal mammary vein--a cadaveric study.

Over the last thirty years the internal mammary system has become the recipient of choice when performing free tissue transfer breast reconstruction. The cranial ends of the internal mammary artery and vein are safely and reliably used for anastomosis following division. Using these cranial vessels maintains their normal antegrade direction of flow. As the complexity of reconstruction has increased, use of the caudal end of the internal mammary vein (IMV) has been cited as a convenient option for additional venous drainage. This requires blood flow in a retrograde fashion. The literature to date suggests that this is possible based on the principle that there are no valves in the internal mammary vein. This will be shown to be incorrect. In this study, the internal mammary veins of 32 formalin-preserved cadavers were dissected to specifically look for and to map valves. 21 valves were discovered in the internal mammary veins of 14 of the 32 cadavers (99 internal mammary veins and major branches). 20 of these were bicuspid in nature, one being tricuspid. Valves were found before or after the branching point of the IMVs, and at multiple sites within some individuals. The significance of valve position relative to rib-space and arborisation of parent IMVs is discussed. Whereas existing data support the use of retrograde IMVs to provide a source of additional venous drainage, we would urge caution in using them exclusively. A proportion of IMVs appear to have valves between the commonly used 2nd or 3rd rib-spaces, and the next draining side-branch.

Metachronous melanoma in breast reconstruction patients.

The incidence and mortality due to malignant melanoma has increased three- to four-fold across males and females in England and Wales over the past thirty years. Ninety percent of patients with primary melanoma have no clinical evidence of lymphadenopathy at presentation. In this paper we describe our management of impalpable axillary melanoma deposits in a patient with a pedicled latissimus dorsi (LD) flap reconstruction to the ipsilateral breast. No such case has been previously described in the literature.

Orthoplastic classification systems: the good, the bad, and the ungainly.

Over the last few decades, there have been many important advances in the treatment of severe lower limb injuries. This article looks at a few of the more widely used classification systems and Injury Severity Scores to examine their utility in a practical setting. Gustilo and Anderson formulated their landmark classification system in 1976 (J Bone Joint Surg Am. 1976;58:453-458). For the Gustilo classification system to serve any useful purpose, it is necessary to include supplemental information, whenever discussing these injuries, that includes the mechanism and energy of the injury and the presence of any other concomitant injuries or comorbidities. Byrd et al (Plast Reconstr Surg. 1985;76:719-728) recognized some of the shortcomings of the Gustilo-Anderson system and proposed a classification system of their own in 1985. The Byrd-Spicer classification is less commonly used, mainly because of a large degree of interobserver variability, but it includes energy and presence of devitalized tissue. The Predictive Salvage Index, devised in 1987, recognized the importance of vascular injury as a prognostic indicator and was formulated in an attempt to avoid not only unnecessary amputations, but also to avoid protracted attempts at salvage that might eventually be converted into a delayed amputation. The Mangled Extremity Severity Score looked at 4 variables: patient age; the presence and duration of shock; ischemia time; and the energy of the injury. Critics question the relevance of its parameters. The 7 components of the Limb Salvage Index include injury to an artery, deep vein, nerve, bone, skin, and muscle as well as warm ischemia time. However, predictive results have not been reproduced. The Hanover Fracture Scale was initially developed on the basis of 13 weighted variables to quantify risk factors for amputation and complications in high-energy trauma to a limb. This included index bacteriology, and was weighted heavily toward the presence of vascular injury. Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score attempted to address criticized weaknesses of the Mangled Extremity Severity Score. These scores can be useful tools in the decision-making process when used cautiously, but should not be used as the principal means for reaching difficult decisions.

Breast carcinoma in diabetic mastopathy.

Diabetic mastopathy, or diabetic fibrous breast disease is a well-characterised benign, fibro-inflammatory condition affecting women with insulin dependent diabetes. To date the relationship between this condition and breast carcinoma has been poorly reported. We describe a case of breast carcinoma arising within a diabetic fibrous breast lesion, in a renal transplant recipient.