Abdominal-Based Microsurgical Breast Reconstruction: How to Inset the Flap to Maximize the Aesthetic Result-A Systematic Review.

Nowadays, the ultimate goal of microsurgical breast reconstruction is not merely the effective transfer of vascularized tissue but the achievement of a natural, symmetric appearance. The aim of this present study was to systematically summarize the published evidence on abdominal-based free flap inset for breast reconstruction in order to provide principles and classification that could guide the surgeon in choosing the most appropriate inset technique based on patient and flap characteristics. A comprehensive review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, looking for articles on the insetting technique for free flap breast reconstruction. After screening 306 publications, 24 papers (published from 1994 to 2020) were included in the study. We identified four main breast anatomical features on which the papers reviewed focused when describing their insetting technique: breast width, breast ptosis, breast projection, and upper pole fullness. Patient body type, type of mastectomy, and reported complications are also discussed. Flap shaping and inset during breast reconstruction are fundamental steps in any reconstructive procedure. Despite the low evidence in the current literature, this systematic review provides a framework to guide the surgeon's decision-making and optimize the aesthetic outcomes of abdominal-based free flap breast reconstruction.

A Two-Stage Diabetic Foot Salvage Using Synthetic Bone Void Filler and Lesser Toe Fillet Flap: A Case Report.

CASE: A 54-year-old type 2 diabetic man with a diabetic forefoot ulcer and osteomyelitis successfully underwent a staged reconstruction to salvage his foot. An antibiotic-carrying bone void filler was used to decrease the infection burden after initial debridement. The fifth toe fillet flap was performed to cover the large soft-tissue defect. The patient returned to baseline ambulation at the 1-year follow-up with a well-incorporated flap. CONCLUSION: This case highlights the utility of combining an antibiotic-carrying bone void filler and a toe fillet flap in a two-stage approach to salvage complex diabetic foot ulcers.

Chest resurfacing with a reverse abdominoplasty flap for invasive breast cancer recurrence.

We present a patient with recurrent breast cancer requiring massive resection of the upper chest. Management included a reverse abdominoplasty flap to resurface the anterior chest wall, with acceptable aesthetic outcomes, and adjuvant chemotherapy. RA is a simple and versatile coverage option in patients with high risk of disease recurrence.

Comparing outcomes of sheet grafting with 1:1 mesh grafting in patients with thermal burns: a randomized trial.

BACKGROUND: In many units, the standard mesh ratio is 1.5:1, but in our unit we have a 1:1 mesher, which does not expand the skin but provides regular fenestrations. There is some evidence that the unexpanded 1.5:1 meshed graft compares favourably with sheet grafts from a cosmetic perspective whilst reducing the risk of graft failure secondary to a subgraft haematoma, but none comparing the 1:1 meshed graft with the sheet graft. We conducted a randomized trial to compare surgical outcomes in unfenestrated sheet grafts with 1:1 meshed grafts. METHODS: All patients aged ≥16 years undergoing skin grafts with either a sheet or a 1:1 mesh for burn reconstruction were included. Patients on steroids, those with conditions that impair healing, and burns >20% were excluded. Patients were randomized into the sheet grafting or mesh graft using a computer-generated allocation system. The mean percentage of graft loss was assessed by a Visitrak overlay system. At 3-4 months, 7-8 months and at 1 year, photos were taken for scar assessment using the Vancouver Scar Score (VSS). RESULTS: Out of 72 patients, 48 patients (24 sheet vs. 24 mesh) completed the trial at 12 months. The mean age was 58 years (range 21-90). There was no total loss of graft in either group. The mean percentage of graft loss due to haematoma formation was higher in the sheet graft group (10%) compared to the 1:1 mesh group (6%) (P<0.062). The VSS score was 5 in both groups at 12 months. There was no significant difference in scar quality between the treatment groups. CONCLUSION: These results show that the 1:1 mesh graft is superior to the sheet graft with regard to graft loss, although this result is not statistically significant. There are comparable findings in terms of cosmetic perspective at 12 months post-operatively in both arms of the trial.

Interdigitation of the distal anastomosis between tubed fasciocutaneous flap and cervical esophagus for stricture prevention.

OBJECTIVES/HYPOTHESIS: Distal end circular stricture is a major complication following circumferential pharyngoesophageal reconstruction with tubed fasciocutaneous free flaps. To reduce the stricture rates, we have incorporated spatulation with interdigitation at the distal anastomosis site. This study investigated whether this procedure could decrease the stricture rate. STUDY DESIGN: Retrospective review. METHODS: There were 51 patients who underwent tubed fasciocutaneous free flap reconstruction following total laryngo-pharyngo-esophagectomy between July 2002 and August 2008. The interdigitation technique was applied in 10 patients; the 41 remaining patients underwent simple circumferential anastomosis. This modification technique consists of incising both distal skin tube and cervical esophagus into three triangular parts, respectively, and interdigitation by interposition of these flaps. Of the 10 patients with this procedure, five patients were reconstructed with an anterolateral thigh flap and five with a radial forearm flap. All 10 patients received postoperative radiotherapy. The mean follow-up period was 30.2 months. RESULTS: Of the 41 patients without any modification, 12 patients (29.3%) developed a stricture; however, in our series of 10 patients undergoing this modification, there was no stricture formation except one (10.0%) who had been reconstructed with a radial forearm flap. The nine remaining patients all achieved a modified or unrestricted full oral diet without complications. Esophagography revealed a wide and patent anastomosis without stricture. CONCLUSIONS: This interdigitation technique could prevent circular contracture at the neopharyngoesophageal segment in reconstruction with tubed fasciocutaneous free flaps.

Bilateral breast reduction surgery in England: a postcode lottery.

INTRODUCTION: There is good evidence for the benefits of bilateral breast reduction (BBR). However, such surgery is often considered cosmetic and is rationed. The NHS Modernisation Agency and the British Association of Plastic Surgeons (as was) have produced national guidelines, but Primary Care Trusts adapt these for local implementation. METHODS: We surveyed the funding criteria for BBR of all 303 Trusts in England. 245 (81%) responded. RESULTS: The NHS guidelines were followed accurately by only 11 Trusts. 198 trusts specified a maximum BMI (range 25 to 32; guideline 30). 187 accepted musculoskeletal symptoms as an indication and 117 accepted intertrigo. 31 required a professionally fitted bra. Many Trusts included other restricting criteria that are not in the NHS guidelines. Some Trusts mentioned the American Society of Plastic Surgeons' guidelines, but did not follow them wholly. CONCLUSIONS: Even with explicit guidelines, considerable variation in local funding criteria exists with resultant inequalities in provision. The so-called 'postcode lottery' of healthcare in the UK is rife within Plastic Surgery. The recent reconfiguration of English Primary Care Trusts provides an excellent opportunity for the rationalisation of BBR provision and to this end we will distribute our findings and the NHS guidelines to the new Trusts and to the National Institute for Health and Clinical Excellence.