The SAEORA Flap for Prosthetic Breast Reconstruction: A Novel Flap Design without the Use of Acellular Dermal Matrices.

Background: The gold standard for implant-based breast reconstruction uses acellular dermal matrices (ADMs). They provide improved inferolateral pole coverage, reduced capsular contracture rates, and increased primary expander fill volumes. However, ADMs are costly and have been associated with increased rates of postoperative infection, seroma, hematoma, implant malposition, and mastectomy flap necrosis (MFN). This study describes a novel autologous flap without the need of ADM, the serratus anterior external oblique rectus abdominis (SAEORA) flap, as an alternative in prosthetic-based breast reconstruction. Methods: A retrospective study was conducted on all patients who underwent SAEORA flap breast reconstruction by a single surgeon between January 1, 2013 and May 31, 2020 at a single institution. Patient demographics, diagnosis, treatment, tissue expander (TE) volume, implant size, complications, and results were assessed. Results: Forty-seven patients underwent 78 SAEORA flaps. Sixty-two had TEs placed, and 14 were direct-to-implant. Mean body mass index was 23.1 kg per m². Median primary TE fill volume was 150 mL, and final implant volume average was 450 mL. Mean follow-up was 14.5 months. Complications included infection/cellulitis (7.9%), seroma (6.6%), hematoma (5.2%), and MFN (7.9%). Conclusions: The SAEORA flap is a novel autologous flap and is a viable option for prosthetic-based breast reconstruction, with an acceptable complication profile relative to ADM-based reconstructions. Additionally, SAEORA is MFN-resistant and has been used effectively in salvage of exposed implants or ADM, and in double-bubble deformity correction.

Pedicled hand fillet flap to preserve stump length in below-elbow amputation.

Spare-parts surgery in traumatic amputation sources tissue from the amputated part to cover the residual amputation defect. This case describes a trauma patient requiring below-elbow amputation. Stump closure was accomplished with a pedicled fillet flap derived from the still-attached hand, avoiding donor site morbidity and maximizing stump length.

Destination Design msTRAM: For Greater Reconstructive Certainty.

Performing delayed reconstruction to a unilateral breast while simultaneously performing a balancing procedure on the contralateral side can be the most difficult situation to achieve symmetry. We present here a novel approach to free TRAM-based breast reconstruction using reverse planning and subunit principles with simultaneous balancing reduction mastopexy and immediate nipple reconstruction. METHODS: A retrospective chart review and a BREAST-Q questionnaire of a single surgeon's practice was performed to compare revision rates and patient satisfaction following Destination Design msTRAM reconstruction compared with a historical cohort of patients who received traditional free TRAM reconstruction. RESULTS: The chart review identified 39 patients treated with the traditional unilateral technique from 1997 to 2004 and 88 patients treated with the novel unilateral technique from 2004 to 2017. Traditional technique patients had a breast revision rate of 64.1% and a nipple revision rate of 42.3% after secondary nipple reconstruction. Destination Design patients had a breast revision rate of 44.3% (P = 0.0394) and a nipple revision rate of 37.9% (P = 0.689) after primary nipple reconstruction. The BREAST-Q questionnaire was sent to nine traditional technique patients with 8 responses (89%), and 35 Destination Design patients with 25 responses (71%). Survey results showed that traditional technique and Destination Design patients had an overall breast satisfaction rate of 67.5% and 63.9%, respectively. CONCLUSIONS: The Destination Design msTRAM breast reconstruction technique leads to a statistically significant reduction in breast flap revisions, and allows for equally accurate immediate nipple reconstruction compared with traditional methods with no additional complications. Overall patient satisfaction is comparable with both techniques.

Locally administered ketorolac and bupivacaine for control of postoperative pain in breast augmentation patients: part II. 10-day follow-up.

BACKGROUND: Previously, it was shown that locally applied intraoperative ketorolac and bupivacaine significantly reduced pain in the recovery room. The objective of this study was to test the effectiveness of the same solution over the first 10 days. METHODS: This study was a prospective, randomized, double-blind clinical trial with ethical approval. Fifty submuscular breast augmentation patients were enrolled, and informed consent was obtained. Standard anesthetic and surgical protocols were followed. Either normal saline or ketorolac and bupivacaine (30 mg and 150 mg, respectively) were placed into the pocket. The power of this study to detect a 20 percent difference was 0.90, and values of p < 0.05 were considered significant. The primary outcome was pain measured with the visual analogue pain scale recorded in a take-home diary. The secondary outcome was codeine usage. RESULTS: Forty-five patients completed the study. Of the patients who did not, three were in the normal saline group (n = 22) and two were in the ketorolac-bupivacaine group (n = 23). The ketorolac-bupivacaine combination significantly reduced pain over the first 5 days. By the tenth day postoperatively, the effect had dissipated. These patients also used less codeine. There were no significant complications. CONCLUSION: Locally applied, intraoperative ketorolac and bupivacaine significantly reduced pain for 5 days after surgery in women who had undergone primary breast augmentation.

Locally administered ketorolac and bupivacaine for control of postoperative pain in breast augmentation patients.

With recent developments in the field of analgesia, the question arises whether there is a role for placing local anesthetics, nonsteroidal anti-inflammatory drugs, or both into the breast implant pocket. The objective of this study was to test the effectiveness of locally administered intraoperative ketorolac and bupivacaine with epinephrine at reducing pain in the postoperative period. The study was a prospective, randomized, double-blind clinical trial. One hundred consecutive retropectoral breast augmentation patients were enrolled, and informed consent was obtained. A standard anesthetic protocol and surgical procedure were followed. Normal saline, ketorolac alone (30 mg), bupivacaine alone (150 mg), or ketorolac and bupivacaine (30 mg and 150 mg respectively) were placed into the implant pocket before implant insertion. All patients completed the study. The power of this study to detect a 20 percent difference with respect to the primary outcome was 0.90 and confidence intervals of 95 percent were used to determine significance. The primary outcome was pain as measured by the visual analogue pain scale. The secondary outcome was time spent in the recovery room. Intraoperative placement of ketorolac combined with bupivacaine reduced pain in the postoperative period. It did not appear that anesthesiologist, anesthesia time, surgeon, operating room time, difficulty of dissection, breast incision, or implant size had a significant effect on postoperative pain. There was a trend that the ketorolac and bupivacaine patients spent less time in the recovery room and used fewer analgesics postoperatively than the other patients. There were no hematomas requiring reoperation and no complications. Locally administered intraoperative ketorolac and bupivacaine with epinephrine significantly reduced pain in the postoperative period.