Microvascular breast reconstruction and thromboembolic events in patients on hormone therapy: Audit of practice from a tertiary referral centre.

INTRODUCTION: Hormonal therapy with tamoxifen and aromatase inhibitors reduces breast cancer recurrence and mortality but represents a risk factor for thromboembolic events. Therefore, most surgeons discontinue hormonal agents before microvascular surgery and for a variable period thereafter. There are no guidelines regarding when therapy should be stopped (preoperatively) or when it should be resumed (post-operatively). We, therefore, audited our hospital practice with the objective of making recommendations for microvascular breast reconstruction patients. PATIENTS AND METHODS: A review was performed of all free flap breast reconstructions between 2014 and 2019. Patients were classified according to hormone medication status at operation. Timings of drug cessation and recommencement were recorded. Thrombotic events, namely flap microvascular thrombosis, deep vein thrombosis, superficial vein thrombosis and pulmonary embolism, were compared. RESULTS: A total of 240 patients had 275 free flaps over five years with 36 receiving hormone therapy within one month prior to surgery, which was discontinued 8.5 days (range: 0-28 days) before surgery. Intraoperative microvascular thromboses (HT 2.0%, NHT 0%, and p = 0.869) and post-operative microvascular complications/flap re-explorations (HT 6.6%, NHT 0%, and p = 0.234) were comparable between the two groups. Systemic venous thromboembolic events were also similar (HT 8.3%, NHT 6.1%, and p = 0.893). Age, BMI, smoking status and preoperative chemotherapy did not influence the incidence of thrombotic complications. CONCLUSION: Hormone therapy did not significantly increase the risk of thromboembolic events. Despite the widespread practice of withholding it for 2 weeks prior to reconstructive surgery, this study does not support such practice being beneficial in terms of thromboembolic events and flap viability. Large-scale trials are needed to establish definitive protocols.

An unusual "venous circle" of the internal mammary vein encountered during microvascular anastomosis and implications for practice.

The internal mammary vessels are commonly used for anastomosis in breast reconstruction. The anatomy when using the 2nd ICS has been shown to be predictable and hence preferentially used by the senior author. We present an unusual case of internal mammary vein bifurcation and immediate confluence forming a 'venous circle'.

The ideal intercostal space for internal mammary vessel exposure during total rib-sparing microvascular breast reconstruction: A critical evaluation.

BACKGROUND: Total rib-preserving free flap breast reconstruction (RP-FFBR) using internal mammary vessel (IMV) recipients usually involves vessel exposure in the second or third intercostal spaces (ICS). Although the third one is more commonly used, no direct comparisons between the two have hitherto been performed. OBJECTIVES: To compare the in-vivo topography and vascular anatomy of second and third ICSs in patients undergoing FFBR using the rib-preservation technique of IMV exposure. METHODS: An analysis of prospectively collected data on intercostal space distance (ISD), number and arrangement of IMVs, location of venous confluence, and vessel exposure time was conducted on a single surgeon's consecutive RP-FFBRs. RESULTS: A total of 296 RP-FFBRs were performed in 246 consecutive patients. The second, third, or both second and third spaces were utilized in 282, 28, and 22 cases, respectively. The ISDs were 20.6 mm ±â€¯3.52 for the second ICS and 14.0 mm ± 4.35 for the third ICS (p<0.0001, CI = 5.17-7.97, t-test). The second versus third ICS vein content was as follows: single 81.4% vs. 74%, dual 18.6% vs. 26%, and confluence 3.7% vs. 13%. The second ICS single vein was medial to the artery in 92.6%. The third ICS single vein was medial to the artery in 88.2% Vessel exposure times for second (47.2 mins ±â€¯26.7) and third (46.5 mins ±â€¯31.4) spaces were similar (p = 0.93). The overall intraoperative anastomotic revision rate was 9.1%, and the postoperative flap re-exploration rate was 4.0%, with 99.7% overall flap success. DISCUSSION AND CONCLUSION: Preferential use of the second ICS is supported by its more predictable vascular anatomy, a broader space for performing the microanastomoses and a higher frequency of a single postconfluence (and thus larger) vein facilitating the microsurgery.

Combination of acellular dermal matrix with a de-epithelialised dermal flap during skin-reducing mastectomy and immediate breast reconstruction.

Introduction Patients with large ptotic breasts undergoing immediate implant-based reconstruction often require skin-reducing mastectomy to optimise the aesthetic outcome. However, healing complications, especially at the resulting inverted T-junction, leading to wound dehiscence, infection, skin necrosis, implant exposure and failed reconstruction have been widely reported. We present an innovative approach for immediate implant-based reconstruction combining porcine- or bovine-derived acellular dermal matrices with a de-epithelialised dermal sling to protect and support the implant, while improving clinical outcomes in this challenging group of patients. Materials and methods Demographic, tumour and surgical data were reviewed for patients undergoing Wise pattern (T-scar) skin-reducing mastectomies with immediate implant-based reconstruction combining porcine- or bovine-derived acellular dermal matrices with a de-epithelialised dermal sling. Results This technique was successfully employed to reconstruct five large pendulous breasts in four breast cancer patients with a median age of 50.5 years (range 34-61 years) who were not suitable for, or had declined, flap-based reconstruction. The acellular dermal matrices used were SurgiMend®, StratticeTM and Braxon® and the expandable implants were placed in the sub-pectoral (n = 3) and pre-pectoral (n = 1) planes. The technical steps and clinical outcomes are presented. One patient experienced T-junction breakdown overlying the de-epithelialised dermis without implant loss. Conclusion The combination of an acellular dermal matrix and a dermal sling provides a double-layer 'water-proofing' and support for the implants inferiorly, avoiding T-junction breakdown complications, since any dehiscence is on to well-vascularised dermis. Furthermore, the acellular dermal matrix stabilises the implant in the large mastectomy cavity (pocket control). This approach provides a viable option which facilitates mastectomy and immediate implant reconstruction in large-breasted patients.

A comparison of patient satisfaction (using the BREAST-Q questionnaire) with bilateral breast reconstruction following risk-reducing or therapeutic mastectomy.

INTRODUCTION: Patients undergoing mastectomy and immediate breast reconstruction for cancer may be expected to have different perceptions of long-term outcomes compared with those who have this operation prophylactically. METHODS: Patients who underwent bilateral mastectomy and breast reconstruction from 2008 to 2014 at the Cambridge Breast Unit were identified from a prospective register and their notes were audited. They were classified according to their indication for surgery as follows: bilaterally therapeutic, bilaterally risk-reducing or combination. The BREAST-Q™ questionnaire was posted to participants using the 'total Dillman method'. Q-SCORE software was utilised to analyse patient satisfaction scores. RESULTS: Sixty-five (58%) responses were received, of which 8 were excluded, leaving 57 usable for the study. The therapeutic group had higher patient satisfaction than the risk-reducing group across most domains including breast, outcome, psychosocial, sexual, physical and information. The combination group scored lower and BRCA gene mutation-positive patients scored the lowest. Physical well-being was maintained across all groups but psychosocial/sexual well-being varied. Good psychosocial well-being was linked to a higher satisfaction with the outcome in the combination and risk-reducing groups. CONCLUSION: This study highlights the need for clinicians to take into account the indication for surgery as a major psychological factor in patients' perception of self and experience of surgery. It demonstrates that bilateral immediate reconstruction patients report similar physical symptoms irrespective of indication for mastectomy, but the decision-making process in terms of risk-balancing and diagnosis influences satisfaction with self and surgery. It underlines the importance of preoperative management of expectations for patients undergoing risk-reducing procedures.

Infection of PTFE mesh 15 years following pedicled TRAM flap breast reconstruction: mechanism and aetiology.

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedure is still widely used for breast reconstruction. The repair of the flap harvest site in the transverse rectus abdominis muscle and sheath is often assisted by the use of prosthetic meshes. This decreases the risk of abdominal wall weakness and herniation but, being a foreign body, it also carries the risk of infection. In this report, we describe the case of a 63-year-old patient who, whilst receiving chemotherapy for metastatic breast cancer, presented with an infected polytetrafluoroethylene mesh 15 years after pedicled TRAM flap immediate breast reconstruction. This necessitated mesh removal to treat the infection. Following a thorough review of the English literature, this is the longest recorded presentation of an abdominal prosthetic mesh infection. The mechanism and aetiology of such a late complication are discussed.

Innovative combination of therapeutic mammoplasty and expandable-implant breast augmentation for immediate partial breast reconstruction.

INTRODUCTION: Therapeutic mammoplasty is used in the treatment of suitably-sized and appropriately-located breast cancers to achieve adequate cancer excision, resulting in well-shaped but smaller breasts. In patients wishing to maintain or increase their breast size, simultaneous augmentation will be required. PRESENTATION OF CASE: A 48-year-old female underwent an "augmentation-therapeutic mastopexy". She required mastectomy for a multifocal cancer of the right breast and breast conservation for a unifocal localised cancer in the upper part of the left breast. She requested right immediate breast reconstruction and hoped for larger breasts than she had. Due to complications during neoadjuvant chemotherapy, the right reconstruction plan was changed from a deep inferior epigastric perforator (DIEP) flap to an implant-based technique. On the left, an extended superomedial pedicle therapeutic mammoplasty was combined with a subpectoral augmentation using an expandable-implant. DISCUSSION: The use of expandable-implants for reconstruction of partial mastectomy defects in combination with therapeutic mammoplasty has not been reported. This case report shows that such "augmentation-therapeutic mastopexy" is feasible. CONCLUSION: A "novel" oncoplastic technique herein termed "augmentation-therapeutic mastopexy" is described for partial breast reconstruction during the treatment of a patient with bilateral breast cancer. It enabled adequate treatment of her cancer while reshaping the breast and achieving the desired larger breast size. It should be considered in selected breast-conservation patients who wish to maintain or increase their breast size.

Infrared evaluation of the heat-sink bipolar diathermy dissection technique.

BACKGROUND: The use of the bipolar diathermy dissection technique is widespread amongst surgeons performing flap perforator dissection and microvascular surgery. The 'heat-sink' modification uses a DeBakey forcep as a heat sinking interposition between the bipolar tip and the main (vascular or flap) pedicle aiming to protect it from the thermal effects of the bipolar diathermy. This study examines the thermal effects of bipolar cautery upon the microvasculature and investigates the efficacy of heat sinking as a thermally protective technique in microsurgical dissection. METHODS: A chicken thigh microsurgical training model was used to examine the effects of bipolar cautery. The effects of bipolar were examined using high definition, real-time infrared thermographic imaging (FLIR Systems) and temperature quantitatively assessed at various distances away from the point of bipolar cautery. Comparison was made using the heat sink technique to determine if it conferred a thermoprotective effect compared to the standard technique without heat sink. RESULTS: Using paired t-test analysis (SPSS) the heat sink modification of the bipolar dissection technique was found to have a highly statistically significant effect (P < 0.000000001) in reducing the conductive temperature along the vascular pedicle. This protective effect kept temperatures comparable to controls. CONCLUSION: Bipolar cautery is an extremely safe method of electrosurgery, however when its use is required within 3 mm of important vascular architecture, the heat-sink method is a viable and easy technique to prevent thermal spread and limit potential coagulopathic changes.

Pre-operative thrombotic complications of neoadjuvant chemotherapy for breast cancer: Implications for immediate breast reconstruction.

UNLABELLED: Thrombotic complications arising during the treatment of breast cancer can impact the breast reconstruction pathway. We set out to review the details of cases of thromboembolism occurring during neoadjuvant chemotherapy and peri-operatively to study the impact of the event and its management on subsequent breast reconstruction. METHODS: We retrospectively reviewed the medical records of seven patients who had experienced a thrombotic event during their treatment of breast cancer between 2008 and 2012, who then proceeded to breast reconstruction. We recorded size and grade of tumour, neoadjuvant chemotherapeutic regimen, details of port insertion, planned reconstruction, thrombotic event and its management and the surgery performed and outcome. RESULTS: All patients received chemotherapy via central venous access and went on to present with local symptomatic thrombosis. They were managed with anticoagulant regimens at the time of mastectomy and reconstruction, which were unique for each patient. The results revealed delays to surgery and modifications to planned reconstruction. DISCUSSION: The majority of patients developing thrombotic complications go on to achieve successful reconstruction. There is significant variation in the anticoagulation management in this patient group. Identification of optimal anticoagulant regimes and the possibilities for prophylaxis may prove key in informing surgeons when planning the reconstructive process. CONCLUSION: An awareness of the effects of thrombotic events in this patient group is important in terms of developing an understanding of its impact on the performance of reconstruction, on the management of anticoagulation peri-operatively and on monitoring for post-operative complications.

Dermal fat graft from simultaneous abdominoplasty as an adjunct to revision aesthetic and reconstructive breast surgery: A poor man's acellular dermal matrix?

INTRODUCTION: The global use of acellular dermal matrices as an adjunct to tissue expander or implant-based breast reconstruction, by surgeons wishing to cover and support the inferior breast pole, has increased in frequency in the last two decades. However despite the reported enhanced cosmetic outcomes, issues regarding their cost effectiveness have led to their infrequent use within the UK National Health Service and the need for an equally efficacious but cheaper alternative. PRESENTATION OF CASE: We report two patients requiring bilateral revision breast surgery for severely asymmetrical, tender, ptotic breasts and cosmetically poor abdomens. Both were denied assisted acellular dermal matrix reconstructive surgery on the state NHS system and unable to afford the private costs. We therefore utilised free dermal fat grafts, harvested from concomitant abdominoplasties to extend the pectoralis major muscle and smoothen surface irregularities. DISCUSSION: Both patients achieved excellent cosmetic outcomes and aside from a small, spontaneously resolving abdominal site seroma in one patient, have remained free of any complications for over two years. This cost effective procedure is only feasible in patients with an adequate pannus who are amenable to the extra surgery and resultant scarring. CONCLUSION: We herein report the use of free dermal fat graft in revision aesthetic and reconstructive surgery in a manner akin to recent acellular dermal matrix use. The comparable enhanced aesthetic outcomes, minimal complication rate and substantial cost savings merit dissemination to a global audience and encourage surgeons to consider this economic alternative.

Successful use of a gastrocnemius flap for an exposed PTFE femorodistal graft: a case report.

Peripheral vascular disease (PVD) is a condition requiring aggressive management to minimise the associated increased morbidity and mortality. Femoro-distal bypass grafting is used in patients with extensive occlusion affecting the crural arteries and poor limb function, but is associated with infection, wound dehiscence and graft exposure. We report a case of a 73-year-old male with history of PVD and occluded ipsilateral femoro-distal bypass graft who underwent limb salvage surgery with a left 6 mm heparin-bonded polytetrafluoroethylene femoro-distal bypass graft in September 2011. He later presented with exposure of the graft over the lateral aspect of the knee following wound dehiscence. During surgery, the exposed portion of the graft was covered by a lateral gastrocnemius muscle flap with an overlying split thickness skin graft. Minor donor site healing problems were noted, but he otherwise made an excellent recovery. While gastrocnemius muscle flaps have been used to cover soft tissue tibial defects secondary to sarcoma and exposed knee joint prostheses, our case adds to the limited literature demonstrating successful salvage of an exposed synthetic graft as a viable alternative to amputation. We therefore recommend prompt referral to plastic services for the management of these complex wounds.

Gluteal fold flap in perineal reconstruction for Crohn's disease-associated fistulae.

INTRODUCTION: Crohn's disease is increasing in incidence worldwide. It is associated with many complications including fistulae, which may require surgical intervention. Occasionally, formal perineal reconstruction is needed for extensive or definitive fistula surgery. Reconstruction for inflammatory disease presents unique challenges and often calls for innovative solutions. Gluteal fold flaps (GFFs), which have been widely used in vulvo-vaginal malignancy and anorectal cancer surgery, have not hitherto been reported for Crohn's disease-associated fistulae. CASE PRESENTATION: A 30-year-old female presented with a 5-year history of Crohn's-associated perianal and rectovaginal fistulae. She had a previous small bowel resection and ileostomy. A laparascopic pan-proctocolectomy was carried out followed by perineal reconstruction in a single stage procedure using a pedicled fasciocutaneous GFF. Seven months postoperatively, revisional surgery was carried out using the contralateral GFF due to two areas of persistent wound dehiscence. The outcome was complete resolution of the fistulae, stable wound closure and good cosmesis. DISCUSSION & CONCLUSION: This case demonstrates that it is practical to use the GFF for perineal reconstruction following excision of complex Crohn's-associated fistulae. The flap avoids the sequelae associated with sacrifice of regional muscle flaps and specifically circumvents the unavailability of the rectus abdominis flap in slim patients or those with in-situ ileostomies. It is easy and quick to raise and does not require an intra-operative change in the patient's position. The GFF ensured well vascularised skin cover, adequate flap volume with no loss of function and low donor site morbidity.

Avoiding pitfalls in open augmentation rhinoplasty with autologous L-shaped costal cartilage strut grafts for saddle nose collapse due to autoimmune disease: the Cambridge experience.

INTRODUCTION: Saddle nose deformity due to autoimmune diseases such as Wegener's Granulomatosis and Relapsing Polychondritis is aesthetically, functionally and psychologically distressing for patients. However, "reliable" options for surgical correction remain limited in the literature. We present our experience of augmentation rhinoplasty in this patient population focussing on the techniques and pitfalls of L-shaped costal cartilage grafting. METHODS: Five patients undergoing rhinoplasty for saddle nose deformity due to an autoimmune condition were identified over an 11-year period at a major tertiary centre. All patients were in remission from their condition at surgery and underwent L-shaped costal cartilage grafting at augmentation rhinoplasty. Case notes were reviewed retrospectively. RESULTS: All patients achieved a marked improvement in nasal position, shape and contour and were very pleased with their overall appearance. The average length of follow up was 2.8 years. There were no infections, graft exposure or warping. No resorption of cartilage was observed and there have been no recurrent deformities. CONCLUSION: This case series describes a possible approach to corrective rhinoplasty in patients with saddle nose deformity caused by autoimmune disease, highlighting the key technical steps and potential pitfalls of intraoperative and perioperative care in this population. The approach is straightforward, reproducible, and achieved pleasing aesthetic outcomes and high patient satisfaction. Given careful planning and meticulous execution, L-strut cartilage grafts for augmentation rhinoplasty to correct saddle nose deformity in these patients is of great benefit. LEVEL OF EVIDENCE: Therapeutic Study Level IV, case series with pre/post test.

Salvage of failed prosthetic breast reconstructions by autologous conversion with free tissue transfers.

OBJECTIVE: Implant-based breast reconstructions are conceptually simple but prone to surgical revisions. Additional procedures often fail to address the problems associated with the reconstructive outcome, especially in patients who have received radiotherapy. However, conversion to free flaps may improve symptoms and aesthetic results. We reviewed our experience in the United Kingdom with autologous replacement of failed prosthetic reconstructions with the aims of documenting the indications for "tertiary" reconstructions and comparing our outcomes with those of other centers. METHODS: Patients undergoing salvage surgery for suboptimal prosthetic breast reconstructions between 2000 and 2012 were retrospectively reviewed for their original reconstructive operation, previous radiotherapy, indications for revision, corrective procedures undertaken, and final outcomes. RESULTS: Of 14 patients identified, 7 had delayed and 7 had immediate reconstructions. Twelve had received radiotherapy; 6 before the initial delayed prosthetic reconstructions and 6 after immediate reconstructions. Ten patients presented after undergoing previous revisions of their original reconstructions (average 1.6). Indications for autologous conversion were capsular contracture, persistent pain, and poor cosmetic outcomes (often in combination). Salvage comprised explantation, total capsulectomy, and abdominal free flap reconstruction using deep inferior epigastric artery flaps (9) and transverse rectus abdominis myocutaneous flaps (5). The average interval between initial reconstruction and salvage was 8 years (r = 1-14). All flap transfers were successful with satisfactory aesthetic outcomes (average 21 months follow-up). CONCLUSIONS: We recommend early salvage autologous conversion of implant-based reconstructions once initial prosthetic reconstructions become unsatisfactory, particularly in recipients of radiotherapy. Many of these patients may have been better served by initial autologous reconstruction; the challenge is to identify them prospectively.

Plastic surgical management of the contralateral breast in post-mastectomy breast reconstruction.

Breast reconstruction following mastectomy can be reliably undertaken using many different techniques. Although excellent cosmetic results can be achieved without contralateral balancing surgery, many unilateral breast reconstructions require a balancing procedure on the contralateral breast in order to achieve symmetry; the ultimate goal in breast reconstruction. This article attempts to summarise the existing literature on the plastic surgical management of the contralateral breast. It also outlines the multifactorial and complex issues involved in the planning and undertaking of such surgery with illustrative examples. The implications for future oncological management and radiological surveillance following the procedure are also discussed in brief.