Risk factors for complications and implant loss after prepectoral implant-based immediate breast reconstruction: medium-term outcomes in a prospective cohort.

BACKGROUND: Prepectoral implant-based breast reconstruction with acellular dermal matrix has become an increasingly popular option for selected patients. There are no randomized data to demonstrate short- or long-term outcomes. Cohort studies to date have demonstrated safety, but risk factors for complications are unknown. METHODS: A prospective cohort study of all patients undergoing prepectoral implant-based breast reconstruction between 2013 and 2019. Clinical factors and those related to reconstruction were analysed in relation to complications and implant loss using univariable and multivariable logistic regression. RESULTS: A total of 469 reconstructions were undertaken in 289 women; the majority of reconstructions were performed using a one-stage direct-to-implant technique with acellular dermal matrix. Median follow-up was 21 (range 2-71) months. Minor complications were seen after 11·2 per cent of reconstructions, major complications after 5·9 per cent, and the rate of implant loss by 3 months was 3·1 per cent. In the final multivariable model, sentinel node biopsy (odds ratio (OR) 5·06, 95 per cent c.i. 2·00 to 12·80), axillary clearance (OR 6·67, 1·17 to 37·94) and adjuvant radiotherapy (OR 7·11, 1·60 to 31·61) were independent risk factors for development of a major complication, and sentinel node biopsy (OR 4·32, 1·23 to 15·22) for implant loss. CONCLUSION: Prepectoral implant-based breast reconstruction has acceptable medium-term results but careful patient selection is advised.

The use of venous anastomotic flow couplers to monitor buried free DIEP flap reconstructions following nipple-sparing mastectomy.

Nipple sparing mastectomy with free tissue transfer for breast reconstruction offers excellent aesthetic outcomes but poses a challenge in monitoring the buried flap. Venous anastomotic flow couplers directly monitor buried flaps without the need for monitoring skin paddles. In a two year period we used the Synovis GEM™ flow coupler on 24 DIEP flaps. In our practice, flow couplers are effective in monitoring buried free flaps for breast reconstruction. The avoidance of a second procedure to remove a skin paddle improves patient experience and nullifies the additional flow coupler cost. One patient needed return to theatre when a Doppler wire became dislodged early in the series. There were no other issues with flap monitoring and no flap failures. We offer our tips to optimise flow coupler use.

An analysis of the cosmetic surgery experience acquired through UK plastic surgery training.

AIMS: Cosmetic surgery is an essential component of Plastic Surgery training. Our study demonstrates the average cosmetic surgery experience of UK Plastic Surgery registrars over their 6-year training scheme. Comparison is made with the operative requirements for the Certificate of Completion of Training (CCT) and the Royal College of Surgeons (RCS) Cosmetic Certification scheme. METHODS: By using the web-based eLogbook, we analysed all the cosmetic surgery operations recorded by Plastic Surgery registrars during their specialist training. The weighted mean average number of procedures was calculated for different areas of cosmetic surgery practice, according to the level of supervision. The number of RCS cosmetic credits acquired for eight domains of cosmetic surgery was calculated, thus enabling comparison with the operative requirements for certification. RESULTS: eLogbook data were collated for 454 registrars from 2010 to 2016 inclusive. Trainees participated in a mean of 122 cosmetic operations during their training (50% as an assistant), which satisfies the requirement of 100 procedures for CCT. The majority of trainee involvement (66%) was with cosmetic breast and body contouring cases. Comparison with the criteria for cosmetic certification reveals that on average, trainees could certify in cosmetic breast and body contouring surgery but would be unable to accredit in other areas of practice. CONCLUSIONS: Current UK training affords sufficient cosmetic surgery exposure for CCT but offers a limited breadth of exposure. Trainees who wish to certify in cosmetic surgery of the head and neck region will likely be required to seek additional experience outside their deanery training programme.

Prophylactic venous cannulation of the pedicled TRAM flap in breast reconstruction.

Since its inception nearly 30 years ago, the pedicled TRAM flap has remained a reliable technique of breast reconstruction. However, venous congestion of the flap in the early postoperative period is well recognised and may lead to partial or total flap loss. This study describes a simple technique routinely employed by the senior author over 15 years involving intraoperative cannulation of the deep inferior epigastric vein and externalisation into an ileostomy bag, in order to facilitate drainage and reduce the likelihood of venous congestion. In addition to its role in breast reconstruction, this technique may be a useful adjunct to any form of free or pedicled tissue transfer.

Necrotising fasciitis of the thigh secondary to a perforated rectal cancer.

SUMMARY: We report a rare case of rectal cancer presenting with necrotising fasciitis of the posterior thigh. Perforation of a rectal cancer adjacent to the piriformis muscle provided a route for bowel contents to travel into, and contaminate, the posterior compartment of the thigh. This case highlights the need for prompt diagnosis, urgent aggressive surgical debridement and consideration of a rare underlying cause in the management of necrotising fasciitis.