Azhar Iqbal

Modified muscle sparing latissimus dorsi with implant for total breast reconstruction – extending the boundaries

UNLABELLED Refinements in breast reconstruction have led to a better understanding of aesthetics and a reduction of donor morbidity. The muscle sparing latissimus dorsi (MS-LD) is a step towards this. It has previously been described for reconstruction in partial mastectomy defects. We describe a modification of the MS-LD that permits total breast reconstruction. MATERIAL AND METHODS Between June 2006 and October 2008, 22 MS-LD flaps were used in 18 patients. A tiny lateral muscle segment containing the descending branch of the thoracodorsal artery along with its thoracodorsal artery perforators (TDAPs) was used as a pedicle to carry a large skin and fascial flap in all cases. The fascial component permitted complete coverage of the implant in a pre-pectoral pocket. Innervation and vascularity to the remaining muscle was preserved. Postoperatively, DASH questionnaires were sent out to the patients to objectively assess shoulder morbidity. RESULTS Skin dimensions ranged from 16x8 centimetres (cm) to 25x10cm. Follow up ranged from 3 to 30 months. Four minor and three major complications occurred. There was no total flap loss and no seromas. We achieved high patient satisfaction regarding the aesthetic outcome and with preservation of functional latissimus dorsi (LD) muscle. CONCLUSION The muscle sparing technique is useful in a selected group of highly active post-mastectomy patients. It is quicker and more reliable(1) than a pure perforator flap approach and can be used to reconstruct the entire breast, preserving the remaining functional muscle for possible backup option in cases of salvage.

Customised chest wall implant to correct pectus excavatum and bilateral breast reconstruction with muscle-sparing latissimus dorsi (MS-LD) flap in a single stage

1748-6815/

Inferiorly Based Lotus Petal Flap & Laser Therapy in Difficult Pilonidal Sinus Management

-seefrontmattera2011BritishAssociationofPlastic,Reconstruc doi:10.1016/j.bjps.2010.12.023 manufacture and use of customised chest implants using alginate impression or CT scan with three-dimensional reconstruction to produce the final mould from which the silicone prosthesis was fabricated. We describe a case of bilateral delayed breast reconstruction with MS-LD flap and pectus excavatum correction with customised chest implant in a single stage. The surface of the silicone implant was textured to reduce capsular contracture and holes were incorporated to allow for tissue integration. A 54 year old lady underwent sequential bilateral mastectomy for breast cancer and implant based reconstruction which resulted in severe capsular contracture and

A comparative study of postoperative patient-controlled analgesia use in latissimus dorsi and muscle-sparing latissimus dorsi flaps in breast reconstruction.

AIM To assess the efficacy of the lotus petal flap in difficult pilonidal sinus management. BACKGROUND Pilonidal sinuses may be difficult to treat. Five year recurrence rates range from 18% to 50% Recurrence rates fall with primary closure rather than healing by secondary intention. Techniques such as z-plasty however, distort natal architecture. The lotus petal flap taken from the superior buttock fills dead space whilst conforming to the natural concave appearance of the natal cleft. The contralateral buttock is spared. It is straightforward and reproducible. Multiple perforators make it robust and promote wound healing in this difficult group. METHOD We present a series of 14 patients who had a lotus petal flap reconstruction following pilonidal sinus excision between 2007 and 2015. The majority of these patients had previous multiple failed attempts at eradication. Recurrence rates, re-operation rates, time for complete healing, wound breakdown, discharge, infection, cosmesis and patient comfort were assessed. RESULTS Many patients had coarse hair; felt to predispose to recurrence of symptoms, poor hygiene and prolonged wound healing. 50% of patients underwent Alexandrite laser (755 nm wavelength) for a minimum of 6 treatments. There was excellent compliance and good patient outcome. Overall in this complex patient group only 14% had prolonged wound healing and recurrence rates were lower than those in the literature. CONCLUSION The lotus petal flap is an excellent choice for problematic pilonidal sinus reconstruction. When combined with tumour like excision, meticulous surgical technique and complimentary laser hair removal results can be improved further.

Discard little, learn more: the real tissue training model.

175e A Comparative Study of Postoperative Patient-Controlled Analgesia Use in Latissimus Dorsi and Muscle-Sparing Latissimus Dorsi Flaps in Breast Reconstruction Sir: T latissimus dorsi has been the workhorse flap in breast reconstruction for several decades. The flap has a high reliability but is becoming less frequently used because of the recognized limitations of this flap. These disadvantages include functional impairment such as reduced shoulder mobility and strength. The rate of seroma formation has also been reported to be high with traditional latissimus dorsi flaps. We describe the use of the muscle-sparing latissimus dorsi flap within our unit for breast reconstruction. Our technique is a modification of a number of different techniques that have been described previously.1 The lateral segment (6 to 8 cm) of the latissimus dorsi is raised incorporating the descending branch of the thoracodorsal artery and thoracodorsal artery perforators. This is similar to the muscle-sparing latissimus dorsi type II flap as described by Hamdi.2 Our flap includes a fascial envelope, similar to the extended latissimus dorsi flap, that allows full implant coverage and placement of the implant in the prepectoral plane.1 We undertook a retrospective study comparing the muscle-sparing latissimus dorsi and latissimus dorsi flaps over a 2-year period. All muscle-sparing latissimus dorsi procedures were performed by one surgeon and the latissimus dorsi procedures were performed by three surgeons. During this period, 43 patients underwent surgery; 21 of the patients underwent muscle-sparing latissimus dorsi flap surgery and 22 of the patients underwent latissimus dorsi flap surgery. The muscle-sparing latissimus dorsi flap group comprised 15 unilateral and six bilateral reconstructions. The latissimus dorsi group consisted of 20 unilateral and two bilateral cases. The mean age for all patients was 51.9 years. The majority of cases (81.4 percent) were delayed reconstructions. We reviewed patient drug charts for total patient-controlled analgesia use postoperatively. This was then adjusted for patient weight to allow comparison. Total postoperative donor-site drainage was also noted. Statistical analysis was performed using independent samples t tests to allow comparison of the muscle-sparing latissimus dorsi and latissimus dorsi flap groups. There was no statistical difference in operative times for unilateral latissimus dorsi and muscle-sparing latissimus dorsi flap reconstructions (latissimus dorsi, 4.80 hours; muscle-sparing latissimus dorsi, 4.53 hours). There was a statistically significant difference in the mean total patient-controlled analgesia use between the unilateral latissimus dorsi and muscle-sparing latissimus dorsi flap reconstructions (0.935 mg/kg versus 0.498 mg/kg, respectively; p < 0.05) (Table 1). There was also a significant difference in terms of postoperative drainage using the two techniques (Table 2). This consequently translates to a shorter hospital stay in the Stefan J. Cano, Ph.D. Clinical Neurology Research Group Plymouth University Peninsula School of Medicine and Dentistry Plymouth, United Kingdom