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.

The use of plasmakinetic cautery compared to conventional electrocautery for dissection of abdominal free flap for breast reconstruction: single-centre, randomized controlled study.

Background: The plasmakinetic cautery is a surgical dissection instrument that combines scalpel-like cutting precision with electrocautery-like haemostasis properties, and operates at lower temperatures (40-170 °C) than conventional electrocautery (200-350 °C). The aim of this study is to evaluate the clinical benefits of using plasmakinetic cautery in abdominal free flap dissection for breast reconstruction.

Methods: Forty women undergoing abdominal-based microsurgical breast reconstruction (DIEP/MS-TRAM) were randomized to plasmakinetic cautery (n=20) or conventional electrocautery (n=20) for dissection of the abdominal free flap.

Risk factors and timing of postoperative hematomas following microvascular breast reconstruction: A prospective cohort study.

Background: Microvascular free tissue transfer has become the gold standard for breast reconstruction. While safe and reliable, there are operative complications, with hematomas developing under the free flap among the more common. These can compromise flap viability, lead to hemodynamic instability and infection.

A systematic review of intraoperative process mapping in surgery.

Process mapping has been identified as a strategy to improve surgical efficiency but has been inconsistently applied in the literature and underutilised in surgical practice. In this journal, we recently described our utilisation of these approaches when applied to breast reconstruction. We showed that in surgery as complex as autologous breast reconstruction, process mapping can improve efficiency, and may improve surgical teaching, education and audit.

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.

Preoperative computed tomography angiography for planning DIEP flap breast reconstruction reduces operative time and overall complications.

Background: The approach and operative techniques associated with breast reconstruction have steadily been refined since its inception, with abdominal perforator-based flaps becoming the gold standard reconstructive option for women undergoing breast cancer surgery. The current study comprises a cohort of 632 patients, in whom specific operative times are recorded by a blinded observer, and aims to address the potential benefits seen with the use of computer tomography (CT) scanning preoperatively on operative outcomes, complications and surgical times.

Methods: A prospectively recorded, retrospective review was undertaken of patients undergoing autologous breast reconstruction with a DIEP flap at the St Andrews Centre over a 4-year period from 2010 to 2014.

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.

Venous perforators in DIEAP flaps: an observational anatomical study using duplex ultrasonography.

Background: The DIEAP flap has gained popularity for breast reconstruction worldwide. Despite DIEAP flap arterial anatomy being well known, venous congestion is still an important complication and the literature on DIEAP flap venous anatomy is lacking. Venous drainage is less predictable and research on venous perforators is of increasing interest.

Intraoperative esophageal Doppler hemodynamic monitoring in free perforator flap surgery.

Goal-directed fluid therapy optimizes cardiac output and flap perfusion during anesthesia. Intraoperative esophageal Doppler (ED) monitoring has been reported as more accurate and reliable, demonstrating improved surgical outcomes compared with central venous pressure and arterial catheter monitoring. A prospective study of patients undergoing free perforator (deep inferior epigastric artery perforator/anterolateral thigh) flap surgery with intraoperative ED monitoring (51 patients) or central venous pressure monitoring (53 patients) was undertaken.

The 'round-the-clock' training model for assessment and warm up of microsurgical skills: a validation study.

Microsurgery is an essential technique in free flap reconstructions today. The technical skills involved require a learning curve, which may be affected by the current issues of limited training resources and patient safety. We describe a study on the value of a microsurgery training device as an assessment and warm up tool in basic microsurgery skills.

The transverse myocutaneous gracilis flap: technical refinements.

Unlabelled: Autologous free tissue transfer is an ideal method for breast reconstruction. The deep inferior epigastric perforator (DIEP) flap is considered the gold-standard procedure worldwide. However, in selected patients this flap cannot be performed to achieve satisfactory outcomes.