Clinical Outcomes and Risk Stratification of Early-Stage Melanoma Micrometastases From an International Multicenter Study: Implications for the Management of American Joint Committee on Cancer IIIA Disease.

Purpose: Indications for offering adjuvant systemic therapy for patients with early-stage melanomas with low disease burden sentinel node (SN) micrometastases, namely, American Joint Committee on Cancer (AJCC; eighth edition) stage IIIA disease, are presently controversial. The current study sought to identify high-risk SN-positive AJCC stage IIIA patients who are more likely to derive benefit from adjuvant systemic therapy.

Methods: Patients were recruited from an intercontinental (Australia/Europe/North America) consortium of nine high-volume cancer centers.

Unilateral breast reconstruction using double transverse upper gracilis (TUG) flaps.

Introduction: When the deep inferior epigastric perforator (DIEP) flap is unavailable, autologous reconstruction of a moderate-to-large breast presents a surgical challenge. We retrospectively review our experience of unilateral breast reconstruction using double transverse upper gracilis (TUG) flaps and highlight specific technical considerations.

Methods: Thirty-four patients underwent double TUG flaps for unilateral breast reconstruction between 2012 and 2020.

Relaxing fish-mouth incision for a tight coupler anastomosis.

The microvascular coupler device has reduced operative times and increased patency rates. Attempting to place a smaller tightly fitting vessel around a larger coupler ring can tear vessels and may require substitution with a smaller coupler device, which can not only add additional cost but also compromise the flap. We describe the theoretic and clinical aspects of the 'fish-mouthing' technique that we employ to help with the discrepancy in size of a smaller vessel compared to the coupler ring.

Performance of infrared thermography and thermal stress test in perforator mapping and flap monitoring: A meta-analysis of diagnostic accuracy.

Background: Accurate mapping of perforators prior to flap reconstruction and early detection of poor flap perfusion reduces the risk of flap failure. Infrared thermography (IRT) has recently regained popularity within reconstructive surgery to aid flap design, reduce operative time and assess flap viability based on surface temperature changes. The aim of this review is to quantify the diagnostic ability of IRT in perforator mapping preoperatively and monitor flap perfusion perioperatively.

Microsurgical Tissue Transfer in Breast Reconstruction.

Autologous breast reconstructions have grown in popularity because of their durability, aesthetic outcomes, symmetry, increase in external beam radiotherapy use, and potential aesthetic enhancement at the donor site. Increasing patient expectations for predictable high aesthetic outcomes with minimal complications or need for further procedures has been met by refinement in the use of flaps. The authors' microsurgical breast reconstruction center aims to provide this while delivering efficient service.

Enhancing breast projection in autologous reconstruction using the St Andrew's coning technique and 3D volumetric analysis.

Background: An increasing number of women undergo mastectomy for breast cancer and post-mastectomy autologous breast reconstruction has been shown to significantly improve the psychosexual wellbeing of the patients. A goal of treatment is to achieve symmetry and projection to match the native breast, and/or the contralateral breast in the case of a unilateral reconstruction. Autologous reconstruction, particularly with the deep inferior epigastric artery perforator (DIEP) flap, is particularly advantageous as it can be manipulated to mimic the shape and turgor of the native breast.

The Best of Abdominal Wall Reconstruction.

Learning Objectives: After reviewing this article, the participant should be able to: 1. List major risk factors for hernia formation and for failure of primary repair. 2.

Microsurgical Tissue Transfer in Breast Reconstruction.

Autologous breast reconstructions have grown in popularity because of their durability, aesthetic outcomes, symmetry, increase in external beam radiotherapy use, and potential aesthetic enhancement at the donor site. Increasing patient expectations for predictable high aesthetic outcomes with minimal complications or need for further procedures has been met by refinement in the use of flaps. The authors' microsurgical breast reconstruction center aims to provide this while delivering efficient service.

Increasing options in autologous microsurgical breast reconstruction: four free flaps for 'stacked' bilateral breast reconstruction.

For autologous breast reconstruction, there are cases where one free flap cannot provide the volume of tissue required, and the concept of 'stacked' bilateral deep inferior epigastric artery (DIEP) flaps was developed, in which hemi-abdominal flaps are raised on each deep inferior epigastric artery (DIEA), and both flaps transferred to the chest. In cases of bilateral breast reconstruction, stacked flaps may be required to achieve volume replacement, however options are not described. We demonstrate the use of stacked free flaps for bilateral breast reconstruction, using one DIEP flap stacked with one transverse upper gracilis (TUG) flap for each side.

Modern use of smartphone applications in the perioperative management in microsurgical breast reconstruction.

Background: Advances in mobile telecommunication, improved mobile internet and affordability have led to a significant increase in smartphone use within medicine. The capability of instant messaging, photography, videography, word processing, drawing and internet access allow significant potential in this small portable device. Smartphone use within medicine has grown tremendously worldwide given its affordability, improved internet and capabilities.

Stacked and bipedicled abdominal free flaps for breast reconstruction: considerations for shaping.

Background: Stacked and bipedicled abdominal flaps are useful in women who require a large breast reconstruction but have relative paucity of abdominal tissue. A new classification system is described to assist the surgeon in achieving the best possible aesthetic outcome.

Methods: A retrospective review of 25 consecutive stacked and/or bipedicled deep inferior epigastric perforator (DIEP) flap reconstructions was assessed from 2009 to 2014.

Three routine free flaps per day in a single operating theatre: principles of a process mapping approach to improving surgical efficiency.

Background: Breast reconstruction is a multi-stage process, involving many individual procedures and many healthcare professionals which take the patient through from diagnosis of breast cancer to the completion of cancer treatment and ultimate breast reconstruction. With an experience of over 3,000 autologous breast reconstructions, we have refined both our surgical technique and overall approach to breast reconstruction to improve the efficiency in free flap based breast reconstruction surgery.

Methods: Through a process mapping approach similar to that employed by large-scale industry, we have broken down free flap based breast reconstruction into multiple smaller processes.

The microvascular anastomotic coupler for venous anastomoses in free flap breast reconstruction improves outcomes.

Background: Venous couplers are ubiquitous around the world and are a useful tool for the reconstructive microsurgeon. A systematic review of coupler performance studies demonstrated a thrombosis rate range of 0% to 3%, whilst the average time of using the device is 5 minutes. There is sparse published data on cost analysis and the impact of operator experience on the anastomotic coupler device success.

Five recipient vessels for metachronous chest wall reconstruction: Case report and literature review.

Selecting potential recipient vessel options for free flap anastomosis is an important consideration in microsurgical breast and chest wall reconstruction. In these settings, the most common comprise the internal mammary and thoracodorsal vessels, although alternative anastomotic sites have also been described. On occasion, consideration of these alternatives becomes a necessity.

Microsurgical Reconstruction of Large Oncologic Chest Wall Defects for Locally Advanced Breast Cancer or Osteoradionecrosis: A Retrospective Review of 26 Cases over a 5-Year Period.

Background: Locally advanced breast cancer (LABC) and chest wall osteoradionecrosis (ORN) often require extensive and composite tissue resection, including muscles, ribs, pleura, and lung parenchyma. As such, these cases necessitate complex reconstructive procedures for skeletal chest wall reconstruction and soft tissue resurfacing of extensive defects. Traditional local and regional flaps are often inadequate, and many such cases are prospectively labeled "unresectable.