Anita Hazari

Preoperative planning for DIEP breast reconstruction: early experience of the use of computerised tomography angiography with VoNavix 3D software for perforator navigation

The deep inferior epigastric perforator (DIEP) flap is normally the first choice in breast reconstruction; however, due to the considerable vascular anatomical variation and the learning curve for the procedure, muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flaps are still frequently performed to reduce the rate of complications. Accurate preoperative investigation of the perforators would allow better operative preparation and possibly shorten the learning curve. In an effort to increase accuracy of preoperative planning and to aid preoperative decision-making in free abdominal flap breast reconstruction, we have acquired the use of VoNavix, software that creates three dimensional images from computerised tomography angiography (CTA) data. The use of the VoNavix software for analysis of CTA provides superior imaging that can be viewed in theatre. It, together with CTA, enables decisions to be made preoperatively, including: which side to raise the flap; whether to aim for a medial or lateral row perforator; whether to take a segment of muscle and whether to expect an easy or difficult dissection. We have now performed over 60 free abdominal flap breast reconstructions aided with CTA, and 10 of these cases also used VoNavix technology. This paper presents our initial experience with the use of this software, illustrated with three patient examples. The advantages and disadvantages are discussed.

Superior sternal cleft : Construction with a titanium plate

Sternal cleft is a rare congenital deformity, with a superior cleft being the most common. Although sternal clefting is known to be associated with vascular dysplasia, to our knowledge, we report the first case of superior sternal cleft with cervicofacial hemangiomata and cardiac defects in the absence of true ectopia cordis in a neonate. Early surgery in all cases of sternal clefting is advocated, preferably within the first 4 weeks of life. However, if the child is unfit for operation at this stage, repair should be carried out as soon as the child is stable and fit. The method of choice is primary approximation with the intraoperative precaution of confirming cardiorespiratory stability. We suggest reinforcing the primary approximation with a titanium plate to achieve rigid internal fixation and to reduce the tension at the approximation site. Because titanium osseointegrates well, this procedure results in a solid bony sternum.

The inframammary approach for the correction of iatrogenic synmastia.

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Avoiding compression of the DIEP pedicle at inset.

-seefrontmattera2009BritishAssociationofPlastic,Reconstruc doi:10.1016/j.bjps.2009.01.013 Congenital synmastia is rare. Nevertheless, the exact incidence of both iatrogenic and congenital synmastia is not known. We present an unusual case of iatrogenic synmastia along with the surgical technique to correct the deformity. A 25-year-old female presented with ‘loss of cleavage’ following two previous operations to her sternum. She had cysts excised from the sternal area at age 19 and developed webbing across her sternum post-operatively. She subsequently underwent a scar revision at age 21 with no improvement to the appearance of her cleavage. She was otherwise happy with the size of her breasts, had no other significant medical history, did not take any regular medications and was a non-smoker.

The use of blood products in free flap based breast reconstruction: A cost and safety analysis

Compression of the deep inferior epigastic perforator (DIEP) flap pedicle by the contractile apposition of the previously divided pectoralis muscle or it kinking over the inferior edge of the pectoralis can compromise the pedicle blood flow necessitating a return to theatre for flap re-exploration, which if unsuccessful can result in flap loss. We describe a technical modification, performed after breast flap anastomosis as the flap is inset. Our approach is fairly standard, the pectoralis major muscle is split along its fibers over the appropriate rib costal cartilage which is then removed and the internal mammary artery and vein (IMA/V) vessels are exposed and prepared. Microsurgical anastomosis of the pedicle is performed with the IMA/V using an end-to-end anastomosis. The pedicle exits the rib space region and usually lays over the cut inferior edge of the pectoralis major. This can often be the case when a flap is inset after an immediate mastectomy where the tight skin flaps and increased post-operative swelling can add further compression on the flap pedicle. To avoid these problems we cut with monopolar cautery a vertical 2 cm groove in the inferior edge of the divided pectoralis major muscle at the point where the pedicle wants to lie. This groove reduces the acute angle of the pedicle from rib space to chest wall and is not compressible by the muscle contracting (Figs. 1a and 1b).

Post-operative splinting to maintain full extension of the PIPJ after fasciectomy.

As surgeons we are under increasing pressure to improve efficiency and cost saving without negatively impacting on the quality and safety of our patient’s care. The demand for breast reconstruction both immediate and delayed is increasing. Deep inferior epigastric perforator (DIEP) free flap based reconstruction is now considered the gold standard in breast reconstruction. Free flap based breast reconstruction has been associated with high rates of blood transfusion and the Maximum Surgical Blood Ordering Schedule (MSBOS) recommends cross matching 2e6 units. Published rates of red cell transfusion in free flap based breast reconstruction range widely, reaching as high as 80%. Although some surgeons use adrenaline infiltrate to reduce donor site bleeding, our unit uses nothing other than diathermy for meticulous intraoperative haemostasis. Anecdotally, we felt that our transfusion rates were low enough that routinely cross matching blood was likely to be an inefficient use of resources. We retrospectively reviewed a year of free flap based breast reconstruction activity at a regional centre for breast reconstruction. This involved interrogating our free flap database, reviewing theatre logbooks, carrying out case note reviews and confirming the findings with a list of all the blood products supplied to the hospital over that year. We included deep inferior epigastric perforator (DIEP), muscle-sparing transverse rectus abdominis (MSTRAM) and transverse upper gracilis (TUG) free flaps for breast reconstruction and included both delayed and immediate procedures. Data on patient demographics, type and timing of reconstruction, preand post-operative haemoglobin/haematocrit, complications, the use of blood products and the timing of their administration were all collected. Statistical analysis using the two-tailed Student t-test and the chi-squared significance test was carried out.