Enhanced Recovery After Surgery in Immediate DIEP Flap Breast Reconstruction: Reducing Length of Stay and Opioid Use.

To improve patient outcomes amid reduced healthcare resources during the COVID-19 pandemic, a single Canadian cancer center implemented an Enhanced Recovery After Surgery (ERAS) protocol for autologous DIEP flap breast reconstruction. This retrospective cohort study included 100 consecutive patients undergoing microsurgical breast reconstruction with DIEP flaps using the ERAS protocol and 100 patients using a standard protocol. Primary outcomes were the hospital length of stay and opioid use.

Updates on Enhanced Recovery after Surgery protocols for plastic surgery of the breast and future directions.

Introduction: Perioperative pain control is an important component of any plastic surgery practice. Due to the incorporation of Enhanced Recovery after Surgery (ERAS) protocols, reported pain level, opioid consumption, and hospital length of stay numbers have decreased significantly. This article provides an up-to-date review of current ERAS protocols in use, reviews individual aspects of ERAS protocols, and discusses future directions for the continual improvement of ERAS protocols and control of postoperative pain.

Augmented Reality Microsurgery: Proof of Concept for a Novel Approach to Microsurgical Field Visualization in Plastic Surgery.

Background: Microsurgery is conducted on tiny anatomical structures such as blood vessels and nerves. Over the past few decades, little has changed in the way plastic surgeons visualize and interact with the microsurgical field. New advances in augmented reality (AR) technology present a novel method for microsurgical field visualization.

Modern Approaches to Alternative Flap-Based Breast Reconstruction: Transverse Upper Gracilis Flap.

The transverse upper/myocutaneous gracilis is a medial thigh-based flap primarily reserved as a secondary choice for autologous reconstruction of small to moderate-sized breasts in women without a suitable abdominal donor site. Its consistent and reliable anatomy based on the medial circumflex femoral artery permits expedient flap harvest with relatively low donor site morbidity. The primary disadvantage is the limited achievable volume, often necessitating augmentation such as extended flap modifications, autologous fat grafting, flap stacking, or even implant placement.

Decreasing Opioids in Outpatient Breast Surgery with an Enhanced Recovery after Surgery Program and Preoperative Education.

Background: Enhanced recovery after surgery (ERAS) programs have been detailed in the literature predominantly in the inpatient setting. The purpose of this study was to determine the effect of an ERAS protocol with a preoperative educational class on opioid prescribing and patient outcomes for outpatient breast surgery.

Methods: An ERAS protocol was formulated focusing on preoperative education, multimodal pain control, and an intraoperative block.

Comparison of Liposomal Bupivacaine to a Local Analgesic Cocktail for Transversus Abdominis Plane Blocks in Abdominally Based Microvascular Breast Reconstruction.

Background: Transversus abdominis plane blocks can improve pain control and decrease opioid use within an enhanced recovery after surgery (ERAS) protocol in patients undergoing abdominally based autologous breast reconstruction. The authors have transitioned to using a local analgesic cocktail for transversus abdominis plane blocks. The purpose of this study was to compare postoperative opioid use in patients who received the blocks.

Microsurgery in the era of COVID-19.

The COVID-19 pandemic has presented new challenges to microsurgeons. The virus is highly transmissible, with increased risk during operations that involve the aerodigestive tract. It is important to be able to identify high-risk operations and scenarios to guide management decisions and selection of personal protective equipment.

Propeller Flaps in Lower Extremity Reconstruction.

Propeller flaps represent an outstanding alternative to conventional pedicled and free flap options in lower extremity reconstruction, offering significant advantages over the latter. An understanding of the perforasome concept, hot and cold perforator locations, and basic flap design enable the surgeon to readily harvest flaps based on any clinically relevant perforator in freestyle fashion. The purpose of this article is to review fundamentals of propeller flap design and harvest in the lower extremity and discuss reconstructive strategies by level of injury.

A Protocol for Safe Head and Neck Reconstructive Surgery in the COVID-19 Pandemic.

The COVID-19 pandemic has had significant implications for citizens globally and for the healthcare system, including plastic surgeons. Operations of the upper aerodigestive tract, including head and neck reconstruction and craniomaxillofacial procedures, are of particularly high risk because they may aerosolize the virus and lead to severe surgeon and surgical team illness. Until the virus is eradicated or widespread vaccination occurs, we recommend certain precautions to safely perform these operations.

Preconditioning with Foam-mediated External Suction on Flap Microvasculature and Perfusion in a Rodent Model.

Unlabelled: Foam-mediated external suction (FMES) has previously shown to improve tissue microcirculation. We hypothesized that preconditioning fasciocutaneous perforator flaps with FMES would augment perfusion and demonstrate greater capillary recruitment.

Methods: Gluteal perforator flaps were designed on sixteen 400 g rats.

"Does ERAS benefit higher BMI patients? A single institutional review".

Background: Enhanced recovery after surgery (ERAS) is increasingly used in plastic surgery to optimize patient care. Mitigating the risk of postoperative complications is particularly important in patients with risk factors, such as obesity. The objective of this study is to evaluate the impact of the ERAS pathway in patients, stratified by BMI, undergoing free flap breast reconstruction on length of stay and complications.

Recent Advances in Microsurgery: An Update in the Past 4 Years.

Microsurgery has broad applications in reconstructive surgery. As techniques, diagnostics, and advancing technology rapidly evolve, reconstructive microsurgeons can adapt to address new challenges and push the frontiers to achieve optimal functional and aesthetic reconstruction, and minimize donor site morbidity. This article briefly outlines some of the recent advances and innovations in microsurgery within the last 5 years in perforator flaps, breast, lymphedema surgery, extremity reconstruction, targeted muscle reinnervation, head and neck reconstruction, composite tissue allotransplantation, and robotic surgery.

Keystone and Perforator Flaps in Reconstruction: Modifications and Updated Applications.

Pedicle perforator flaps and keystone perforator island flaps provide additional tools for the reconstructive surgeon's armamentarium. Advances in understanding of vascular anatomy, dynamic nature of perforator perfusion, interperforator flow, and "hot spot" principle have led to reconstructive methods that allow for autologous tissue transfer, while limiting donor site morbidity. Further modifications in pedicle perforator flap enabled the propeller flap and freestyle perforator free flap for soft tissue reconstruction.

Maximizing the Utility of the Pedicled Anterolateral Thigh Flap for Locoregional Reconstruction: Technical Pearls and Pitfalls.

The pedicled anterolateral thigh (PALT) flap is an underutilized flap for locoregional reconstruction largely because methods to maximize its reach are neither universally implemented nor fully understood. In addition, most of the available literature has focused on the utility of the free anterolateral thigh flap with less emphasis on the PALT flap. Moreover, flap design concepts to maximize its utility and reach and optimize outcomes have not been comprehensively described.

Autologous Breast Reconstruction in Low Body Mass Index Patients: Strategies for Maximizing Skin Envelope and Breast Volume.

Pure autologous breast reconstruction in thin patients creates challenges. This review highlights techniques to optimize the scarce donor tissue available, approaches to reconstruction, and microsurgical techniques. A systematic approach to maximize breast volume and the skin envelope in patients who underwent pure autologous breast reconstruction by a single senior surgeon is presented with a clinical case series.

Risk Factors for Lymphedema after Thigh Sarcoma Resection and Reconstruction.

Unlabelled: Secondary lymphedema can be a lifelong and debilitating consequence of lower extremity oncologic resection and reconstruction. The goal of this study was to identify risk factors for the development of lymphedema in patients treated for thigh sarcoma.

Methods: A retrospective review analyzed all patients who underwent thigh sarcoma resection and reconstruction by a plastic surgeon at the Mayo Clinic between 1997 and 2014.

How Fat Grafting Works.

Unlabelled: Fat grafting has been shown to improve diseased soft issue. Although the mechanism behind fat grafting's regenerative properties is currently debated, published studies agree that there is an associated vasculogenic effect. A systematic literature review was conducted to elucidate the biochemical pathways responsible for establishing neo-vasculature to grafted fat.

Aesthetic Surgery in Plastic Surgery Academia.

Background: Aesthetic surgery is a critical component of academic plastic surgery. As institutions are placing increased focus on aesthetic surgery, there is an opportunity to identify factors that facilitate the creation and maintenance of successful aesthetic plastic surgery programs.

Objectives: The aim of this study was to conduct a national survey to evaluate the current state of academic aesthetic surgery and to identify factors that contribute to success.

Breast Reconstruction in Obese Patients: The Fat Grafted Latissimus versus Abdominal Free Tissue Transfer.

Unlabelled: Immediate fat grafting to the pedicled myocutaneous latissimus dorsi (LD) flap has recently gained in popularity as a means to supplement volume for breast reconstruction. The aim of this study is to compare complication rates of the immediately fat-grafted LD to free tissue transfer in the obese population.

Methods: In this retrospective cohort, 82 patients (149 breasts) from 2015 to 2019 were included.

Complications after thigh sarcoma resection.

Background And Objectives: Standard treatment for extremity sarcoma is limb-sparing surgery often with radiation, but complications occur frequently. We sought to determine factors predictive of wound complications after thigh sarcoma resection and reconstruction while analyzing trends over time.

Methods: We reviewed all thigh defects requiring plastic surgeon reconstruction following sarcoma resection at our institution from 1997 to 2014.

Percutaneous Fasciotomies versus Traditional Keystone Flap: Evaluating Tension in Complex Wound Closure.

Background: The keystone flap is a popular reconstructive option for closure of cutaneous defects. Traditionally, this is a perforator-based fasciocutaneous advancement flap that uses both skin incision and fascial release. We propose a limited skin incision technique that utilizes percutaneous fasciotomies to accomplish wound closure.

Flaps Based on the Dorsal Metacarpal Artery.

Dorsal metacarpal artery flaps have evolved with our knowledge of vascular anatomy of the hand. Since the description of the first transposition flap likely based on the first dorsal metacarpal artery in the 1950s until today, the indications and modifications of these flaps have greatly expanded. Reverse flow flaps have allowed coverage of the dorsum of each digit with vascularized tissue with minimal donor site morbidity and harvest of veins, bone, and tendon with them.

A reconstructive algorithm after thigh soft tissue sarcoma resection including predictors of free flap reconstruction.

Background: Reconstruction of defects of the thigh after oncologic resection plays a vital role in limb salvage. Our goal was to evaluate our institution's experience on thigh sarcomas to develop evidence-based recommendations to guide the reconstructive surgeon, including factors that would predict the need for free flap reconstruction.

Methods: We reviewed all thigh defects requiring plastic surgeon reconstruction following sarcoma resection at our institution from 1997 to 2014.