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.

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.

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.

Application of adipose-derived stromal cells in fat grafting: Basic science and literature review.

Autologous fat is considered the ideal material for soft-tissue augmentation in plastic and reconstructive surgery. The primary drawback of autologous fat grafting is the high resorption rate. The isolation of mesenchymal stem cells from adipose tissue inevitably led to research focusing on the study of combined transplantation of autologous fat and adipose derived stem cells (ADSCs) and introduced the theory of 'cell-assisted lipotransfer'. Transplantation of ADSCs is a promising strategy, due to the high proliferative capacity of stem cells, their potential to induce paracrine signalling and ability to differentiate into adipocytes and vascular cells. The current study examined the literature for clinical and experimental studies on cell-assisted lipotransfer to assess the efficacy of this novel technique when compared with traditional fat grafting. A total of 30 studies were included in the present review. The current study demonstrates that cell-assisted lipotransfer has improved efficacy compared with conventional fat grafting. Despite relatively positive outcomes, further investigation is required to establish a consensus in cell-assisted lipotransfer.

Microsurgery simulation training system and set up: An essential system to complement every training programme.

INTRODUCTION: Microsurgical techniques are essential in plastic surgery; however, inconsistent training practices, acquiring these skills can be difficult. To address this, we designed a standardised laboratory-based microsurgical training programme, which allows trainees to develop their dexterity, visuospatial ability, operative flow and judgement as separate components. METHOD: Thirty trainees completed an initial microsurgical anastomosis on a chicken femoral artery, assessed using the structured assessment of microsurgical skills (SAMS) method. The study group (n = 18) then completed a 3-month training programme, while the control group (n = 19) did not. A final anastomosis was completed by all trainees (n = 30). RESULTS: The study group had a significant improvement in the microsurgical technique, assessed using the SAMS score, when the initial and final scores were compared (Mean: 24 SAMS initial versus 49 SAMS final) (p < 0.05, Wilcoxon's rank test). The control group had a significantly lower rate of improvement (Mean: 23 SAMS initial versus 25 SAMS final). There was a significant difference between the final SAMS score of the study group and that of senior surgeons (Mean: 49 study final SAMS versus 58 senior SAMS). CONCLUSION: This validated programme is a safe, cost-effective and flexible method of allowing trainees to develop microsurgical skills in a non-pressurized environment. In addition, the objectified skills allow trainers to assess the trainees' level of proficiency before operating on patients.

Acquisition of basic microsurgery skills using home-based simulation training: A randomised control study.

INTRODUCTION: Acquisition of fine motor skills required in microsurgery can be challenging in the current training system. Therefore, there is an increased demand for novel training and assessment methods to optimise learning outside the clinical setting. Here, we present a randomised control trial of three microsurgical training models, namely laboratory tabletop training microscope (Laboratory Microscope, LM), low-cost jewellers microscope (Home Microscope, HM) and iPad trainer (Home Tablet, HT). METHODS: Thirty-nine participants were allocated to four groups, control n = 9, LM n = 10, HM n = 10 and HT n = 10. The participants performed a chicken femoral artery anastomosis at baseline and at the completion of training. The performance was assessed as follows: structured assessment of microsurgery skills (SAMS) score, time taken to complete anastomosis and time for suture placement. RESULT: No statistically significant difference was noted between the groups at baseline. There was a statistically significant improvement in all training arms between the baseline and post-training for SAMS score, time taken to complete the anastomosis and time per suture placement. In addition, a reduction was observed in the leak rate. No statistical difference was observed among the training arms. CONCLUSION: Our study demonstrated that at the early stages of microsurgical skill acquisition, home training using either the jewellers microscope or iPad produces comparable results to laboratory-based training using a tabletop microscope. Therefore, home microsurgical training is a viable, easily accessible cost-effective modality that allows trainees to practice and take ownership of their technical skill development in this area.

Using manual dexterity to predict the quality of the final product in the small bowel anastomosis after a period of training.

OBJECTIVE: The use of aptitude tests in the selection of surgeons has gained recent attention. Few have described its relevance in predicting the acquisition of surgical techniques. We aim to show whether assessing manual dexterity can predict the quality of the final product after a period of training. METHODS: Thirty-six medical students had their manual dexterity assessed completed bench model small bowel anastomosis in 8 consecutive sessions. The fine details (accuracy (number of sutures that traversed full thickness) and number of sutures placed) and gross details (bowel apposition) of quality of final product was objectively assessed. RESULTS: Manual dexterity correlated with grade only in the initial sessions (Pearson correlation coefficient, r = -.578, P < .01). There was no significant correlation with the fine details with any session. CONCLUSIONS: There was a correlation with manual dexterity and outcome measures in the initial sessions of training with grade only. This relationship was eliminated by the end of training sessions. This suggests that the outcome of procedures after a period of training cannot be predicted by measuring manual dexterity skills.

Differences in final product of a bowel anastomosis of male and female novice surgeons.

INTRODUCTION: There is a disproportionate ratio of male to female surgeons when compared with the ratio at medical school. Although gender differences in surgical technical ability is not known, studies have shown gender differences in visuospatial ability and manual dexterity. We devised a study to assess objectively the quality of final product of small bowel anastomosis in male and female novice surgeons to explore differences in surgical technical ability. METHODS: Thirty-six novice surgeons in the final year of medical school with minimal surgical experience were taught surgical knot tying and small bowel suturing. The students were asked to complete 7 small bowel anastomosis in 7 separate sessions. The quality of the final product was assessed looking at the "fine details" (number of sutures and accuracy, ie, ratio of sutures piercing the full thickness of the bowel) and the "gross apposition" of the bowel ends at the anastomotic site. A grading system for apposition was devised to assess apposition. RESULTS: The results with fine details and accuracy of suturing revealed that female surgeons were significantly better in the fourth to the sixth sessions with no gender difference in the number of sutures placed. With gross apposition at the anastomotic ends, male surgeons were consistently better between the third to the sixth session. However, these differences were eliminated with training. CONCLUSIONS: Known gender differences in visuospatial ability and manual dexterity may explain the initial gender differences in the quality of the final product. However, these differences were not present by the end of the training sessions. Therefore, with training, no difference in surgical technical ability was found between male and female novice surgeons.

Current practice on preoperative correct site surgical marking.

Performing surgery at an incorrect site has devastating outcomes. The National Patient Safety agency and Royal College of Surgeons England have provided recommendations to promote correct site surgery with emphasis on surgical markings. There is little published data on surgical site marking practices amongst surgeons. A prospective audit on surgical site marking was performed on 500 surgical procedures: 204 inguinal hernias, 35 umbilical hernias, 48 varicose veins, 40 toenail removals, 123 excisions of skin lesions, 10 femoral artery procedures and 40 breast procedures. The results showed that 59% of markings were visible in theatre post sterile draping, 40.4% markings were not visible, and 0.6% (3/500) were not marked. Recommendations suggest the use of an arrow with an indelible marker pen. Our results show the use of an arrow in 64% of patients and this was the most common form of mark used. An appropriate marker pen was used on 88% of patients. There is no evident published data to compare our practice to that of other surgical units, however, to improve correct site surgery markings should be visible, recognisable and understood by all specialties and grades. A universal marking system to improve correct site surgery may be beneficial.