Bhagwat Mathur

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. The transverse myocutaneous gracilis (TMG) flap is one of the most recent additions to the armamentarium of breast-reconstructive surgeons. This flap can provide adequate autologous tissue with a hidden scar. Since its description for breast reconstruction in 2004, no series have been published and its recognition is still lacking. The main criticism of this flap is the lack of volume that can be achieved and the potential for donor morbidity. We report upon a 2-year experience with the use of TMG flaps for breast reconstruction, assessing the potential indications and introducing some technical refinements in order to expand the role of this flap in breast reconstruction. MATERIALS AND METHODS Information regarding all TMG flaps performed in the period between January 2006 and December 2007 was prospectively collected. Indications and outcomes were reviewed. The surgical technique was revised and standardised to achieve a routine set-up. RESULTS During the study period, 19 TMG flaps were performed in 12 patients (seven double procedures: five bilateral cases and two stacked flaps for unilateral breast reconstruction). One flap was lost 9 days postoperatively. Follow-up ranged from 6 months to 2 years. We detail our surgical technique and describe refinements to speed up flap harvest, increase flap volume, optimise flap inset and minimise donor-site complications. CONCLUSION Although the DIEP flap is still our preferred choice for breast reconstruction, the TMG flap is suitable as a first-line option in small-to-moderate breasted women or as a second-line choice for larger-breasted women for whom the DIEP flap may not be the preferred choice. It is also a reliable salvage flap in cases of previous flap failure.

Developmental Breast Asymmetry

Abstract:  Developmental breast asymmetry (DBA) can affect psychosocial well‐being in the young female. Correction of breast asymmetry may present a reconstructive challenge, especially in tuberous breasts. Fifty‐two cases of DBA treated between January 2002 and January 2006 were reviewed. Preoperative clinical assessment of the specific anatomical deformity, subsequent surgical treatment modalities, esthetic outcome, and patient’s satisfaction were evaluated. Surgical modalities used in our series include augmentation mammaplasty with or without tissue expansion, parenchymal scoring, nipple areola complex reduction, glanduloplasty techniques, mastopexy and reduction mammaplasty. The mean age of DBA presentation was 21 years; 69% (36/52) patients had tuberous breasts, of which 67% (24/36) were unilateral and 33% (12/36) were bilateral deformities. Patients with tuberous breast deformity presented consistently under the age of 25 years. Esthetic outcome was rated “good” in 75% (39/52), and symmetry rated as “good” in 58% (30/52) by professional evaluation. Surgical treatment is tailored to the affected esthetic units of the individual breast. In our experience, symmetry is the hardest parameter to achieve, particularly in tuberous breasts. Operative treatment is of great value to the psychosocial well‐being of the patient. A conceptual approach in the assessment and treatment of DBA is emphasized by this series.

Management of inguinal lymphadenopathy: immediate sartorius transposition and reconstruction of recurrence with pedicled ALT flap.

Inguinal lymphadenectomy is associated with considerable morbidity, and several attempts have been made to minimize the morbidity by well-vascularized flaps of adequate bulk to obliterate the dead space and promote wound healing. In the case of recurrence, the overlying skin is usually involved and the reconstructive surgeon is confronted with exposed femoral vessels and complex groin defects.We report a series of 40 patients that underwent inguinal lymphadenectomy and immediate sartorius transposition for skin malignancies, and 4 patients with recurrence that was treated with radical surgical excision and pedicled anterolateral thigh flap (ATL). We examined complications such as infection, skin necrosis, lymphorea, lymphoedema, and wound healing time.The immediate sartorius transposition was associated with 7.5% infection rate, 5% superficial skin edge necrosis, 0% of persistent lymph, and 27.5% of mild lymphoedema. All ALT flaps survived completely and wounds healed uneventfully within 2 weeks without any signs of infection, seroma, or wound dehiscence.Sartorius and ALT flap are reliable methods to reconstruct the groin following inguinal lymphadenectomy. They ensure low complication rate with no donor site morbidity, and should be the first line treatment of immediate and secondary groin reconstruction, respectively.