Primary lipofilling as an adjunct in transverse upper gracilis flap breast reconstruction.

In many centres, the myocutaneous transverse upper gracilis (TUG) flap represents an alternative choice in autologous breast reconstruction when abdominal tissue is unavailable. However, a single TUG flap may be volume deficient, particularly in the upper pole. We describe the application of simultaneous lipofilling to the pectoralis major muscle at the index procedure and present our decision-making algorithm, technique and outcomes. A retrospective review of all TUG flaps between January 2011 and May 2021 was conducted. Patient demographics, volume of primary and any subsequent fat grafting and complications were recorded. A total of 183 patients (242 TUG flaps) were included in this study. Of these; 130 patients were reconstructed with single TUG flaps, 16 patients received a single TUG flap with immediate lipofilling, and 37 patients underwent stacked, double TUG flap reconstructions. Of the 242 flaps, there were 2 flap losses (<1%), neither of which occurred in the immediate lipofilling cohort. Among the 130 single TUG patients, 28 (21.5%) required a cumulative total of 40, and a mean of 1.4, secondary lipofilling procedures. The immediate lipofilling patients were injected with a mean of 42 ml fat (range: 20-80 ml). In this group, only 2 of 16 patients required secondary lipofilling. The mean follow-up was 67 months (17-141). Primary lipofilling may reduce the need for secondary revisional procedures and appears safe at the index operation, adds little operative time and has negligible donor site morbidity. In patients where a second (stacked) flap would add unnecessary volume and complexity, it can be considered a useful adjunct.

Seasonal variation in high-risk phenotypes of cutaneous malignant melanoma diagnosed in Eastern England: An observational study.

BACKGROUND: Despite seasonal variation in malignant melanoma diagnosis being well described, data on the annual variation in high-risk melanomas are scarce. OBJECTIVES: We set out to investigate the relationship between seasonality, the incidence of melanoma, and the distribution of melanoma characteristics, including Breslow thickness, ulceration, mitotic rate, lymphovascular and perineural invasion, and the presence of microsatellites. METHODS: Primary cutaneous malignant melanomas diagnosed between 2011 and 2019 in Eastern England were identified from our prospectively maintained melanoma database (n = 2199). These were analysed by year and season of diagnosis, patient demographics, and melanoma characteristics. RESULTS: There was a variation in rates of melanoma diagnosis across the year, with Summer having the highest incidence (p < 0.0001). There was a significant trend towards more male than female diagnosis in Winter (p = 0.0354). There were no significant seasonal trends in Breslow thickness, ulceration, tumour infiltrating lymphocytes, or mitotic rate. Multivariate analysis showed that microsatellites were more likely to be diagnosed in the Winter (OR=2.00 (1.19-3.43), p = 0.010), lymphovascular invasion significantly more likely to be diagnosed in Autumn (OR=1.78 (1.16-2.76), p = 0.009), and perineural invasion was more likely to be diagnosed in the Summer (OR=0.44 (0.23-0.79), p = 0.007). CONCLUSIONS: These data confirm that high-risk phenotypes are associated with increasing Breslow thickness and mitotic rate. However, season variability as an independent risk factor for the phenotypes is a novel finding.

Breast reconstruction with immediate autologous free tissue transfer in a peri-operative COVID-19 positive patient: A case report illustrating feasibility of aftercare.

Globally, there has been a measured response to rationalise elective operating during the Coronavirus disease 2019 (COVID-19) pandemic. In terms of breast cancer care, this has led to a restricted provision of reconstruction with autologous free tissue transfer. A primary concern is the risk of mortality in elective surgery patients who develop COVID-19. The aim of this report is to describe the observed physiological impact of the virus on our patient, and to address how outpatient care after autologous free tissue transfer can be delivered to COVID-19 positive patients. In March 2020, we performed a bilateral breast reconstruction with a deep inferior epigastric perforator flap and a superficial inferior epigastric perforator flap. The patient became symptomatic on day three post-operatively, tested positive for COVID-19 and was discharged home. Drain and dressing management was continued through the use of telemedicine. Two weeks following the operation, a breast seroma formed that was drained semi-electively in the COVID-19 positive area of the Emergency Department. The patient visited the dressing clinic twice in total and healed after three weeks. Despite undergoing complex surgery and having pre-operative chemotherapy, our patient suffered a mild form of the virus limited to upper respiratory symptoms. Physiologically we did not see any significant difference to that of the normal post-operative course. This case demonstrates the possibility of managing autologous breast reconstruction patients using telemedicine. Although COVID-19 can complicate, or even be fatal, in the perioperative course, our patient thankfully suffered no discernable negative outcome from her infection.