Martin E. Jones

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.

The influence of breast mound reconstruction type on nipple reconstruction projection

viscoelastic properties of human skin and even though expensive could help surgeons in predicting an N-IMF stretch. However our study has several confounding factors as variation of the skin tension due to variability of implant size, pregnancy or displacement of IMF. The stretching of the nipple to IMF distance is not entirely due to skin expansion, but at least partially due to lowering of this level during surgical intervention. This is a pilot study and cannot be used as a “guide to preoperative planning” due to the other variables that affect the N-IMF distance. Further studies are needed, especially studies with a control group, two-dimensional or three-dimensional measurements that provide more information, a multivariate analysis for considering confounding factors so as to obtain sound evidence concerning skin elasticity and N-IMF stretch. The continued monitoring of our patients over a longer period should confirm these results and encourage the use of the Cutometer in other centers that will promote multicentric data.

Venous thromboembolism prophylaxis for abdominal free tissue breast reconstruction: A multicenter survey

and does not account for the cost of inefficient use of haematology/transfusionservices. If thispracticewas takenupwidely (in centres with similar transfusion rates) significant savings couldbemade.Wehave sincechangedourpractice in-linewith our findings and we would encourage other departments to review their practice as a potential area for improving cost efficiency without any additional increase in risk.

Presentation of Mycobacterium abscessus infection following rhytidectomy to a UK plastic surgery unit.

We report the presentation of a patient to a UK plastic surgery unit with Mycobacterium abscessus infection following a facelift surgery in Southern India. Treatment was protracted requiring surgical debridement and 6 months of antibiotics including a 3-week hospital admission for intravenous antibiotic therapy. We describe the clinical presentation, diagnosis and treatment of this unusual microorganism with reference to more familiar pyogenic infections.

The bilobed flap as a lifeboat flap for a forearm soft tissue defect

The bilobed flap is most commonly suited to reconstruct defects on the nasal tip. However its use has been extended to other anatomical locations including the upper limb. Onishi et al. described the use of the bilobed fasciocutaneous flap for large upper arm soft tissue defects. They reported its reliability, ease of dissection and also the selection of perforators to maintain a robust blood supply to the flap. Other authors have described its use for correction of radial club hand and closure of radial forearm donor site. We describe its use in a challenging case where reconstructive options were limited. A 62-year-old lady presented with local recurrence of epitheloid sarcoma in her right arm. Previously she had excision of this tumour from the dorsum of her forearm and soft tissue and bony resection required a free osseocutaneous fibula flap, which had been anastomosed end-to-side onto her radial artery. A staging CT also revealed metastatic spread of the sarcoma to distant sites (Pulmonary, Hepatic). Further palliative excision of the upper limb sarcoma was advised after MDT discussion. However several challenges were present, firstly the patient would not tolerate a prolonged general anaesthetic or procedure due to diminished pulmonary function and metastatic disease. One option proposed was a radial forearm flap, however no radial pulse was felt on palpation. An ulnar artery based flap was also deemed too risky and would possibly jeopardize the vascularlty of the hand. Furthermore free tissue transfer into an irradiated site was felt inappropriate in light of the patient’s comorbidities. Local fasciocutaneous options such as a large hatchet flap or Keystone type flap were considered however these flaps could not close the large defect or would require skin grafting of the donor site. The original recurrent sarcoma had been excised 1 month ago at another surgical institution and the patient had been referred to us for a reconstructive procedure. The

Developing a Three-Layered Synthetic Microsurgical Simulation Vessel

Background Microsurgery is increasingly relevant, and is difficult to learn. Simulation is relied upon ever more in microvascular training. While living models provide the ultimate physiological feedback, we are ethically obliged to optimize non‐living models to replace, refine, and reduce the use of animals in training. There is currently no three‐layered synthetic vessel available for microsurgical training. Methods A three‐layered synthetic vessel was designed with a simulation company. One anastomosis was performed by 14 microsurgical experts at one center. The realism of the vessel was assessed via user questionnaires and the construct validity using objective, validated task scores to assess the anastomosis performance and the final product. Videos were obtained, which were anonymized and marked remotely by a consultant plastic surgeon. Results The synthetic vessel intima and media displayed reasonable realism, while the adventitia was less realistic. Areas for improvement were identified. Both the task specific assessment score and the final product assessment appropriately identified experts. Conclusion A three‐layered synthetic model for microvascular training is a hygienic and useful intermediate‐level alternative to commonly used synthetic and ex vivo alternatives.

The importance of bone shortening in digital replantation

We write in order to highlight an interesting finding in the early stages of a retrospective case note service evaluation of digital replantation at the Queen Victoria Hospital, East Grinstead, West Sussex, UK. The subject of digital replantation has been controversial in recent years owing to the lack of long term outcome data comparing replantation with termination. But as we see microsurgery becoming more commonplace within the specialty, we may expect to see a rise in the number of surgeons opting to replant, rather than terminate. With that in mind, we were keen to investigate methods to further improve replant success. Recent literature suggests survival rates for replantation fall between 80 and 90%, although allowing for publication and reporting bias, there is likely further room for improvement. The Queen Victoria Hospital, East Grinstead (QVH) serves as the receiving centre for acute upper limb injury for the south east of England, with a patient population of approximately 4.3 million. We assessed digital replants undertaken over a 4 year period and achieved a sample size of 36 patients, who collectively underwent 42 replantation attempts in total. The average age of the study population was 41 years, with the majority being male and employed in a manual trade. Replant success was judged on tissue survival and a decision not to terminate at the most recent clinic appointment. This gave an indication of patient and surgeon satisfaction with the motor, sensory and overall outcome. On observation, it became clear that shortening the bone surfaces prior to replanting was not standard practise, with many surgeons deciding to focus on the soft tissues. We hypothesised that bone shortening may improve the

Maximizing length and safety in gracilis free flap dissection

We present a photographic illustration of our approach to accessing and releasing the pedicle of the gracilis muscle with a view to maximizing safety and length in this key reconstructive option available to plastic surgeons. This approach requires creation of a window in the fascia on the lateral border of the adductor longus muscle, affording a direct visualization of the medial circumflex femoral artery coming off the profunda femoris. Small proximal branches can be dealt with under greater control and the pedicle released with maximal length and safety.

Metachronous melanoma in breast reconstruction patients

The incidence and mortality due to malignant melanoma has increased three- to four-fold across males and females in England and Wales over the past thirty years. Ninety percent of patients with primary melanoma have no clinical evidence of lymphadenopathy at presentation. In this paper we describe our management of impalpable axillary melanoma deposits in a patient with a pedicled latissimus dorsi (LD) flap reconstruction to the ipsilateral breast. No such case has been previously described in the literature.

Replant your own index finger? A survey of plastic surgeons and hand therapists in Southeast England

Sir, Replantation is traditionally indicated for the thumb, single digits distal to the flexor digitorum superficialis insertion, multiple digits and all amputations in children. Absolute contraindications include concomitant life-threatening injuries, widespread crush or degloving injuries and severe comorbidity. Single digit amputation, extreme contamination, lengthy warm ischemia or micro-arterial diseases are relative contraindications [1]. Avulsion is a controversial area, and some consider it not to be an absolute contraindication. Despite these guidelines, digital replantation remains a grey area. Digital survival does not necessarily equate with success; a stiff, painful finger may be a hindrance. Function is often better in distal replantations due to an intact proximal interphalangeal joint (PIPJ) and tendon apparatus. We e-mailed plastic surgeons and hand therapists in Southeast England enquiring whether they would undergo replantation following a clean amputation of their own dominant index finger at the PIPJ. There were 51 responses. 34 were male consisting of 25 trainee plastic surgeons and nine Consultants. Seventeen females replied, comprising nine hand therapists and eight trainee plastic surgeons. There were equivocal responses: 51% stated they would undergo replantation and 45% said not. Sex or profession did not appear to influence preference for replantation. However, six of nine consultant plastic surgeons responded that they would not consider replantation. Of these, half were hand specialists. The two Consultants who stated they would undergo replantation were both hand surgeons. Improved hand surgery training and microsurgical techniques have facilitated increasingly complicated replantations. However, it remains a highly equivocal area with the indications and contraindications altering little over the past two decades. Whilst we must not become entrenched by protocol, maybe it is time to reappraise the guidelines. Yours sincerely,