Versatility of Pedicled Perforator-Based V-Y Advancement Flaps for Reconstruction of the Upper Limb: A Case Series and Review of the Literature.

INTRODUCTION: The aim of any reconstruction is to provide a robust and cosmetically pleasing result that does not significantly alter function. We describe our experience of using the V-Y principle in advancement flaps designed around a distinct perforator to reconstruct soft tissue defects of the upper limb. The shortcomings of fasciocutaneous and fascial flaps requiring skin grafting can be eliminated. METHODS: This was a 10-year retrospective review of patients who had V-Y flaps based on a distinct perforator for defects of the shoulder, axilla, arm, elbow, forearm, wrist, and hand. Defects of the digits and thumb were excluded. RESULTS: There were 59 flaps in 52 patients with an average age of 44 years (18-72 years). Skin malignancy was the most common primary etiology. The average defect size was 35 cm (9-80 cm). There were no total flap failures; however, there were 4 partial losses, which healed by secondary intention. Seven flaps had to be explored for the hematoma evacuation. CONCLUSIONS: The use of V-Y flaps based on distinct perforators in the upper limb retains limb aesthetics, allows early mobility and is a safe and reliable technique.

Tuberous breast deformity: A modified technique for single-stage correction.

INTRODUCTION: Tuberous breast deformity is one of the most challenging congenital breast anomalies. Severe forms present as hypoplasia of lower medial and lateral quadrants and breast base constriction. We present a modified technique based on redistribution of breast tissue for single-stage aesthetic correction of this deformity. MATERIAL METHODS AND SURGICAL TECHNIQUE: The technique is based on Lejour's method of single vertical scar breast reduction. The breast tissue is divided into three superiorly based pedicles. However, instead of joining the three pedicles, they are spread to redistribute tissue to quadrants which are deficient. This technique is combined with implant insertion if the breast volume is deficient or mastopexy if there is significant ptosis. The level of nipples is matched to achieve symmetry and areolar reduction done where indicated. We have used this for six patients with Type I/II/III (von Heimburg, 2000) tuberous breast deformity. RESULTS AND DISCUSSION: The aesthetic results have been very good in terms of shape, volume, symmetry and patient satisfaction. A historical summary of the development of techniques for correction of tuberous breast is presented along with description of our method and its results.

Segmental V-Y flaps for reconstruction of longitudinal defects in the digit.

Longitudinal defects of the finger that extend beyond 1 phalangeal segment such as wounds that expose the flexor tendon are challenging to reconstruct because of their elongated shape. We present the use of segmental V-Y flaps to reconstruct these defects. These are ≥2 V-Y flaps orientated transversely and advanced segmentally to close the defect avoiding a linear scar. Nineteen patients had soft-tissue defects of the digits successfully reconstructed with segmental V-Y flaps in this retrospective case series. There were no total or partial flap failures and all flaps retained sensation. Segmental V-Y flaps are a safe method for reconstructing digital defects and are particularly useful in the reconstruction of longitudinal defects. They have the advantages of being homodigital, sensate, technically easy; allow direct closure of the donor site and break up linear defects that might otherwise lead to contractures.

A systematic review of the applications of free tissue transfer for paediatric lower limb salvage following trauma.

BACKGROUND: Since the advent of microsurgical free tissue transfer in the 1960s, it has now become an indispensable part of limb salvage surgery. However, its application in children was initially met with concerns regarding vessel diameter, increased potential for vasospasm and its potential impact on normal growth and development. This resulted in its restriction to specialist paediatric facilities. With improvements and greater confidence in microsurgical techniques, more units are starting to rewrite the initially popularised narrative regarding free tissue transfer in paediatric limb salvage following trauma. A systematic review was undertaken, using the PRISMA criteria for systematic reviews, of all published literature relating to the use of free flaps in paediatric lower limb salvage following trauma. METHODS: Inclusion and exclusion criteria were defined and Medline, Embase, PubMed and Google Scholar databases were searched from inception to September 2014 with the following search terms: "free tissue transfer", "free flaps", "microvascular free tissue transfer", "paediatric/pediatric", "children", "lower limb", "trauma" and "reconstruction". RESULTS: A total of 375 studies were retrieved following the electronic database search, of which 23 studies met the inclusion criteria. Two further studies were found via a hand-search of the reference lists of the retrieved studies. A total of 25 studies were, thus, included in the review. CONCLUSIONS: This study presents a synthesis of the literature available on the indications, timing, selection, viability, complications and functional outcome of free tissue transfer following lower limb trauma in paediatric patients. Limitations of current studies with potential areas for further research are also discussed.

Perianal Paget's disease: a diagnostic dilemma.

Perianal Paget's disease (PPD) is part of the spectrum of pagetoid skin lesions occurring outside the region of the nipple/areolar complex that are collectively referred to as extramammary Paget's disease (EMPD). However, unlike Paget's disease of the breast, which in the vast majority of cases is invariably associated with an underlying ductal carcinoma, most cases of EMPD occur as either insitu or invasive adenocarcinomas with visceral malignancy being a rare entity. We present a case of a 50-year-old man who was referred to us with PPD. This case highlights the difficulties associated with making a clinical diagnosis of this condition. Furthermore, investigative workup to exclude possible malignancy with associated metastatic spread as well as the treatment options available are also discussed. In addition, this case highlights the need for a multidisciplinary team approach when dealing with this difficult problem.

A case of toxic shock syndrome following a DIEP breast reconstruction.

Mastectomy with immediate breast reconstruction has become the standard treatment for Carcinoma breast in UK and many parts of the world. Autologus reconstruction with muscle sparing TRAM/ DIEP is the 'Gold Standard' for assessing the newer options for breast reconstruction. Toxic Shock Syndrome (TSS) is a rare but fatal condition particularly seen in the female population. Few cases of TSS have been reported in the Plastic Surgery literature following Silicone implant based reconstruction. We report a case of TSS following Deep Inferior Epigastric Perforator flap (DIEP)reconstruction. Due to the aggressive nature of TSS, the European Society of Intensive Care Medicine (ESICM) has initiated the 'Surviving Sepsis' campaign to propagate, information and management guidelines for the general public and health professionals. We present a case report with the pathophysiology of TSS.

Structured assessment of microsurgery skills in the clinical setting.

Microsurgery is an essential component in plastic surgery training. Competence has become an important issue in current surgical practice and training. The complexity of microsurgery requires detailed assessment and feedback on skills components. This article proposes a method of Structured Assessment of Microsurgery Skills (SAMS) in a clinical setting. Three types of assessment (i.e., modified Global Rating Score, errors list and summative rating) were incorporated to develop the SAMS method. Clinical anastomoses were recorded on videos using a digital microscope system and were rated by three consultants independently and in a blinded fashion. Fifteen clinical cases of microvascular anastomoses performed by trainees and a consultant microsurgeon were assessed using SAMS. The consultant had consistently the highest scores. Construct validity was also demonstrated by improvement of SAMS scores of microsurgery trainees. The overall inter-rater reliability was strong (alpha=0.78). The SAMS method provides both formative and summative assessment of microsurgery skills. It is demonstrated to be a valid, reliable and feasible assessment tool of operating room performance to provide systematic and comprehensive feedback as part of the learning cycle.

Recipient vessel exposure in the axilla during microvascular breast reconstruction.

Over the years, the favored recipient vessels for microvascular breast reconstruction have changed from the thoracodorsal to the internal mammary vessels, mainly due to the deep position and poor exposure of the vessels in the axilla and all the technical difficulties this reflects. We used the simple maneuver of arm adduction during microvascular anastomoses in the axilla and compared it with the conventional method of abducted arm regarding the exposure of the vessels, the position of the operator and the assistant, and the operative time. We found that this innovation considerably improved the exposure of the vessels and the operator's position, facilitating easier and faster anastomoses.

A method for protecting the anastomosis in deep inferior epigastric artery perforator flap breast reconstruction.

In cases of microvascular breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps, many authors often express concern about possible trauma to the microanastomosis from the suction drain routinely placed in the wound at the end of the case. The senior author has devised and practiced for many years a novel technique to protect the anastomosis from this potential trauma in breast reconstructions. This technique involves harvesting a "sleeve" of scarpa's fascia in the direction of the planned orientation and inset of the flap pedicle. In our experience, this technique is effective and robust, and we would like to recommend this to others for use in their DIEP flap reconstructions.

Retrograde dissection of the vascular pedicle of deep inferior epigastric artery perforator (DIEAP) flap.

The deep inferior epigastric artery perforator (DIEAP) flap became the gold standard in breast reconstruction, but the dissection has a steep learning curve and the most demanding stage is the intramuscular dissection of the vascular pedicle. We present a retrograde technique to dissect the deep inferior epigastric pedicle that permits completion of the dissection and check the viability of the flap on one side before progressing to the other, which can be used as a lifeboat. We consider this technique reliable, safer than the conventional technique, and a brilliant training model in DIEAP flap harvesting.

Innovative techniques: a novel technique for intraoperative estimation of breast implant size in aesthetic and reconstructive breast surgery.

The estimation of breast implant size in both aesthetic and reconstructive surgery often is a matter of clinical and intraoperative trial and error, with subsequent differences in the resulting postoperative outcomes. Numerous techniques for preoperative estimation of implant size are in current use. However, although such techniques are inexpensive, they often are inaccurate and prone to error on the part of both the surgeon and the patient. Techniques for intraoperative estimation of breast implant size involve either the use of trial sizers or the surgeon's own guesswork based on the preoperative consultation. A novel technique is presented that uses commonly available surgical gauze swabs. The senior author has applied this technique in both aesthetic and reconstructive breast surgery for many years. This easily reproducible method is inexpensive and produces reliable and highly satisfactory results.