Robert H. Caulfield

Innovative Techniques: A Novel Technique for Intraoperative Estimation of Breast Implant Size in Aesthetic and Reconstructive Breast Surgery

The estimation of breast implant size in both aesthetic and reconstructive surgery often is a matter of clinical and intraoperative trial and error, with subsequent differences in the resulting postoperative outcomes. Numerous techniques for preoperative estimation of implant size are in current use. However, although such techniques are inexpensive, they often are inaccurate and prone to error on the part of both the surgeon and the patient. Techniques for intraoperative estimation of breast implant size involve either the use of trial sizers or the surgeon’s own guesswork based on the preoperative consultation. A novel technique is presented that uses commonly available surgical gauze swabs. The senior author has applied this technique in both aesthetic and reconstructive breast surgery for many years. This easily reproducible method is inexpensive and produces reliable and highly satisfactory results.

Salvage of total loss of DIEP and skin envelope in breast reconstruction with tissue expansion

We present two cases of breast reconstruction using abdominal tissue expansion as a salvage procedure for those patients who have had multiple sequential complications using the traditional free flap techniques yet still request some form of reliable breast reconstruction.

The use of subcutaneous fat to facilitate drainage during wound closure

quired non-malignant tracheoesophageal fistula. Ann Thorac Surg 1991;52:759e65. 18. Mizobuchi S, Kuge K, Maeda H, et al. Endoscopic clip application for closure of an oesophagomediastinal-tracheal fistula after surgery for oesophageal cancer. Gastrointest Endosc 2003; 57:962e5. 19. Gerwat J, Bryce DP. Management of traumatic tracheoesophageal fistula. Laryngoscope 1975;101:67e70. 20. Bahn CH, Vitkainen KJ. Repair of tracheal intubation injuries. Am J Surg 1981;141:528e30. 21. Shesol BF, Clarke JS. Intra thoracic application of the latissimus dorsi musculocutaneous flap. Plast Reconstr Surg 1980;66: 842e5. 22. Siu KF, Wei WI, Lam KH, et al. Use of the pectoralis major muscle for the repair of a tracheoesophageal fistula. Am J Surg 1985;150:617e9. 23. Delare P, Delsuphe KG. Closure of persistent tracheostomal fistula after removal of the voice prosthesis. Laryngoscope 1994; 104:494e6. 24. Baisi A, Bonavina L, Narne S, et al. Benign tracheoesophageal fistula: results of surgical therapy. Dis Esophagus 1999;12: 209e11. 25. Marty-Ane CH, Prudhorne M, Fabre JM, et al. Tracheoesophageal anastomosis fistula: a rare complication of oesophagectomy. Ann Thorac Surg 1995;60:690e3. 26. Toohil RJ. Autogenous graft reconstruction of the larynx and upper trachea. Otolaryngol-Clinic North Am 1979;12:909e17. 412 C.J. Baldwin, M.I. Liddington

A simple technique for introducing small diameter vessels into a coupler device

Dear Sir, The venous coupler device is a safe method of venous anastomosis (Jandali, Wu, Vega, Kovach, & Serletti, 2010). The coupling device is at least equivalent to hand-sewn anastomosis in preventing venous thrombosis (Kulkarni et al., 2016). Small diameter vessels, 1–1.5 mm, can present a difficult challenge when introducing them through the coupler. We present a simple technique for introducing a small diameter vein into the coupler. A single suture can be placed in the edge of the lumen and tied loosely with the suture ends left long (Figure 1A). While holding the suture end with minimum tension the coupler can be guided over the suture. The vein can then be atraumatically pulled through the coupling device. Alternatively a triangulation technique can be used as described by Alexis Carrel in 1902 to maximize lumen area (Figure 1B). We feel that this is a simple and safe technique, which decreases the time, vessel handling and stress involved with dealing with small caliber vessels. Matthew Philip Murphy, MB BCh BAO MRCSI, Niall Michael Mc Inerney, FRCS (Plast), Katherine Mary Browne, MB BCh BAO MRCSI, Robert Henry Caulfield, FRCS (Plast), Richard Patrick Hanson, FRCS (Plast) Department of Plastic Surgery, Mater Misercordiae University Hospital, Eccles Street, Dublin, Ireland

A simple innovation to improve recipient vessel exposure in the axilla during microvascular breast reconstruction with DIEAP flap

Microvascular transfer of autogenous tissue has become the gold standard for breast reconstruction, and the use of DIEAP flap has been widely accepted because of reliability, adequate volume, and minimal donor site morbidity. The selection of recipient vessels is as well of critical importance, and the use of internal mammary has been popularized the last decade because of their reliable flow and adequate exposure. The sharp decline in the use of the thoracodorsal vessels was due to the poor exposure of the vessels during microsurgery, especially in overweight patients, and consequently the technical difficulties that this reflects. Moreover, the recent innovations in breast cancer surgery, such as sentinel lymph node biopsy or the more conservative axillary lymph node treatment, contributed to the transition in the choice of recipient vessels toward the internal mammary. On the other hand, recent innovations in breast cancer surgery such as envelope mastectomy that results in superior cosmetic results might lead to new changing trend in recipient vessel selection towards thoracodorsal vessels. To the best of our knowledge, all references in the literature are consistent with the arm abducted during microanastomosis to obtain adequate exposure of the axillary vessels. The anastomoses are usually performed with the arm abducted 758–908 and the microscope operator is sited between the abducted arm and the torso of the patient. The variety of instruments and retractors that have been described (Gelpi retractor, dura hooks, sutures, self-retainers) are usually inadequate, and the assistant is always necessary to retract the lateral border of pectoralis major muscle to keep the vessels exposed. Moreover, it is almost impossible to achieve parallel position of microscope lens to the operative field, and both operator and assistant have comfortless position. We use the simple maneuver of the arm adduction that considerably improves the exposure of the vessels (see Fig. 1). The anastomoses are performed with the arm adducted 158–208, and the microscope operator is sited on the top of the patient’s shoulder. In a prospective study of 40 patients that had breast reconstruction with free DIEAP flap plugged to the thoracodorsal vessels, we used the simple maneuver of arm adduction during microvascular anastomoses in the axilla (n 5 20), and we compared it with the conventional method of abducted arm (n 5 20), regarding the exposure of the vessels, the position of the operator and the assistant, and the operative time. We found that this innovation considerably improved the exposure of the vessels and operator’s position, facilitating easier and faster anastomoses. This is mainly explained by the shape and the position of pectoralis major muscle. The muscle is relaxed and four-sided when the arm hangs down, and when the arm is raised its borders form a tight triangle. When the arm is adducted, the operative field is kept easily exposed only with the use of two self-retaining retractors (see Fig. 1), because it is significantly easier to pull back the relaxed lateral border of pectoralis major muscle. To the contrary with the arm abducted the lateral border of the *Correspondence to: Andreas Gravvanis, M.D., Ph.D., FEBOPRAS, Queen Victoria Hospital NHS Foundation Trust, Holtye Road, East Grinstead, West Sussex, RH19 3DZ, UK. E-mail: gravvani@yahoo.com Received 27 December 2007; Accepted 20 February 2008 Published online 31 March 2008 in Wiley InterScience (www.interscience.wiley. com). DOI 10.1002/micr.20505

Nipple reconstruction using the free transfer of a previously reconstructed nipple.

Nipple reconstruction is regarded by both patient and surgeon alike as the final end point of breast reconstruction, and many techniques exist for reconstructing a nipple using various local flaps [1–4]. Many of these reconstructed nipples show loss of projection and volume after a number of months [5–7], leaving the surgeon with the difficult problem of a secondary reconstruction in the presence of local scarring and a lack of adjacent normal skin for local flap techniques. We report a case in which a previously reconstructed nipple ‘‘bottomed out,’’ resulting in an asymmetric position. In this case, the nipple was subsequently transferred as a free graft to an appropriate position in a secondary procedure. A 48-year-old patient had a nipple reconstruction using a standard Trefoil technique 18 months after immediate deep inferior epigastric artery perforator flap (DIEP) flap reconstruction. Subsequently, the reconstructed breast ‘‘bottomed out,’’ resulting in malposition of the nipple. This necessitated a secondary procedure to correct the malposition. Local scarring restricted repositioning of the nipple using additional local flaps, so we elected to remove the previously reconstructed nipple and transfer it as a free graft to its new corrected position. The 1-year postoperative outpatient review demonstrated a nipple of satisfactory height and volume in a symmetric position relative to the normal breast (Fig.1). We recommend this technique as an additional method for nipple reconstruction in cases requiring refashioning or recorrection of the primary technique after loss of nipple position due to postreconstruction ptosis.