Current status prepectoral and subpectoral breast reconstruction in the USA.

Breast cancer remains the most commonly diagnosed cancer in women in the United States. In the setting of a mastectomy, implant-based reconstruction (IBR) remains the most common type of breast reconstruction performed. IBR is typically performed in two-stages (tissue expander - implant) or one stage [direct-to-implant (DTI)]. As a consequence of the limitations associated with submuscular placement of implants, prepectoral implant placement has been gaining more acceptance worldwide. The prepectoral plane eliminates the need for chest wall muscle dissection, disinsertion and manipulation avoiding the muscle related complications of the subpectoral approach such as increased pain, spasm and animation deformity. In addition, prepectoral placement shortens the recovery time and provides greater control of breast shape and contour. With the latest generation form-stable silicone implants coupled with the wide use and acceptance of acellular dermal matrices (ADMs) and other meshes to support the implant, this technique is becoming the mainstay of implant-based reconstruction, under these circumstances the subpectoral technique will continue to be the benchmark to which the prepectoral technique will be compared to. The authors sought to review the literature emanating from North America that pertains to this topic and provide an up-to-date assessment of the current practices of the prepectoral and submuscular technique.

Immediate Breast Reconstruction with Deep Inferior Epigastric Perforator Flap in a Patient with Previous Surgical Correction of Pectus Excavatum.

Pectus excavatum is a deformity of the chest wall characterized by a sternal depression and possibly cardiac and pulmonary compression. Procedures performed during infancy for its correction may disrupt local anatomy and pose challenges to breast and reconstructive surgeons during mastectomy and reconstruction. We present a case report of a 45-year-old woman who had a Ravitch procedure for pectus excavatum correction in infancy who was diagnosed with right breast cancer undergoing bilateral nipple-sparing mastectomy with immediate deep inferior epigastric perforator flap reconstruction. A computed tomography angiography was used to study chest and abdominal anatomy before surgery. Patient safely underwent immediate breast reconstruction with deep inferior epigastric perforator flaps using the internal mammary vessels as recipient vessels. This case highlights the importance of preoperative vascular imaging and proper communication between the breast and plastic surgery teams during reconstructive surgery. It also displays the safety of performing immediate breast reconstruction using free tissue transfer and the internal mammary vessels as recipients for microvascular anastomosis.

Ankle Arthrodesis with Free Vascularized Fibula Autograft Using Saphenous Vein Grafts: A Case Series.

BACKGROUND: In select high-risk cases of ankle arthrodesis, conventional techniques may lead to a high incidence of failure because of a combination of multiple operations; high risk of infection; avascular, often bulky allografts; and poor soft-tissue quality. In high-risk distal limb salvage, the authors have performed ankle arthrodesis using a free vascularized fibula graft from the ipsilateral limb with saphenous vein grafts. METHODS: The authors present data from six patients. The cause of the defect was avascular necrosis of the talus (n = 4), osteomyelitis (n = 1), and failed total ankle replacement (n = 1). The ipsilateral fibula was used in all cases as a free vascularized graft. Nonviable bone and soft tissue were débrided, and the fibula was shortened to size and impacted into the cavitary space spanning the distance between the tibia, talus, and calcaneus. The pedicle distally was anastomosed to saphenous vein grafts and proximally anastomosed to the divided peroneal vessels. RESULTS: The flap success rate was 83 percent (n = 5). The complication rate was 83 percent; complications included flap loss (intraoperative arterial thrombosis), loss of skin island, hematoma, and arterial thrombosis. Despite one flap failure and a high complication rate, successful union was obtained in all patients. All patients achieved full weight-bearing status by a mean of 4 months after surgery (range, 3 to 7 months). There were no amputations. CONCLUSIONS: Vascularized free fibula graft is a reliable option for ankle arthrodesis in complex salvage situations. Using a saphenous vein graft to perform the anastomosis with the divided peroneal vessels proximally should be considered.