Venkat Ramakrishnan

Aesthetic outcome of different techniques of reconstruction following nipple-areola-preserving envelope mastectomy with immediate reconstruction.

Background: Nipple-preserving mastectomy and immediate reconstruction has further improved the aesthetic outcome of skin-sparing mastectomy. To investigate the effect of the type of reconstruction technique on aesthetic outcome, three different methods of reconstruction were compared using four evaluation modalities. Methods: Sixty-one cases of nipple-sparing envelope mastectomy with immediate reconstruction were studied, with a mean follow-up of 48 months. The methods of reconstruction used were implant-only reconstruction, pedicled latissimus dorsi muscle with implant, and deep inferior epigastric perforator flap. Evaluation methods were objective applanation tonometry, clinical evaluation, photography-based assessment, and patient satisfaction survey. Results: All three reconstruction methods achieved good evaluation scores in the four modalities. However, in patients who had postoperative radiotherapy, objective tonometry showed that the breast remained softer in deep inferior epigastric perforator flap reconstruction. Conclusion: In patients who are undergoing nipple-preserving envelope mastectomy with immediate reconstruction and who are likely to have postoperative radiotherapy, deep inferior epigastric perforator flap reconstruction achieved a better aesthetic outcome.

Evaluation of the factors related to postmastectomy breast reconstruction.

A retrospective study was conducted in 75 consecutive patients requiring postmastectomy breast reconstruction over a period of 30 months. Each woman was offered one of the following four reconstructive options: free transverse rectus abdominis musculocutaneous flap (total number of reconstructions, n = 34); latissimus dorsi musculocutaneous flap (with or without expander and implant, n = 14); endoscopically assisted harvest of the latissimus dorsi muscle (with expander and implant, n = 13); and application of expander and implant only (n = 12). Of those patients originally selected for retrospective study, six did not meet the short‐term prognostic criteria, and concerted attempts to contact two others proved unsuccessful. The remaining 67 patients were examined for the clinically assessed aesthetic appearance of the reconstructed breast(s), the subjective self‐assessment of patient satisfaction, and the possible development of postoperative complications. Of these patients, six required bilateral surgery, which accounts for a final sample size of 73 individual breast reconstructions. The 67 individual patients were assessed after a minimum time of 6 months postreconstruction and became the sampling units for analysis. The free transverse rectus abdominis musculocutaneous flap procedure was the preferred method of breast reconstruction in 34 of 73 patients (47 percent), provided that it was generally agreed that the patient could endure a prolonged operation and that there was sufficient unscarred abdominal tissue available. Thereafter, postmastectomy radiotherapy at the chest wall became the primary criterion for assignment of a patient to a particular surgical procedure. Whenever radiotherapy resulted in poor‐quality skin at the chest wall, endoscopically assisted transfer of latissimus dorsi muscle flap was considered to be the optimal treatment (13 of 73 patients, or 18 percent). Body mass index and smoking were secondary factors that were taken into account when this alternative technique was being considered. In the absence of radiotherapy, and provided that the chest wall was minimally scarred, patients who were reluctant to have reconstruction with autologous tissue were treated with expander and implant only (12 of 73, or 16 percent). This third procedure is a physically less arduous ordeal for the patient and was therefore the choice for all patients for whom a prolonged operation was not a realistic option. The fourth (and final) surgical procedure, latissimus dorsi musculocutaneous flap (with or without expander and implant), was selected for all patients with a better quality of skin over the chest wall, those whose abdomen was extensively scarred, and those who were on a general surgeons operating list to undergo immediate breast reconstruction after mastectomy (14 of 73, or 19 percent). Equally good aesthetic results could be demonstrated with each of the four treatment options, provided that the reconstructive procedure selected was optimal for the individual patient and in accordance with the criteria described above. A variety of potential risk factors were considered for association with postoperative complications, including prescribed medication, obesity, smoking behavior, use of radiotherapy, and the recorded aggregated operative time. Of these, only body mass index (p < 0.001) and use of steroids (p = 0.016) were identified as having statistically significant effects on the incidence of adverse events. Finally, the general level of satisfaction expressed by the patient was highly correlated with a good appearance of the reconstructed breast, the physical comfort experienced while wearing a brassiere, and the general mobility of the unsupported reconstruction. (Plast. Reconstr. Surg. 107: 1694, 2001.)

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.

Structured assessment of microsurgery skills in the clinical setting

Microsurgery is an essential component in plastic surgery training. Competence has become an important issue in current surgical practice and training. The complexity of microsurgery requires detailed assessment and feedback on skills components. This article proposes a method of Structured Assessment of Microsurgery Skills (SAMS) in a clinical setting. Three types of assessment (i.e., modified Global Rating Score, errors list and summative rating) were incorporated to develop the SAMS method. Clinical anastomoses were recorded on videos using a digital microscope system and were rated by three consultants independently and in a blinded fashion. Fifteen clinical cases of microvascular anastomoses performed by trainees and a consultant microsurgeon were assessed using SAMS. The consultant had consistently the highest scores. Construct validity was also demonstrated by improvement of SAMS scores of microsurgery trainees. The overall inter-rater reliability was strong (alpha=0.78). The SAMS method provides both formative and summative assessment of microsurgery skills. It is demonstrated to be a valid, reliable and feasible assessment tool of operating room performance to provide systematic and comprehensive feedback as part of the learning cycle.

Flap size/flow rate relationship in perforator flaps and its importance in DIEAP flap drainage ☆

The vascular architecture within a perforator flap is different from a conventional muscle or myocutaneous flap. The purpose of this paper is to understand the correlation between flow rate and flap size in perforator flaps. With extrapolation of these data, we have provided an indirect analysis of the venous drainage and its correlation with flap size. A prospective study was planned. Twenty-five patients were enrolled in this study: six patients were operated on using an anterolateral thigh (ALT) flap and 19 using a deep inferior epigastric artery perforator (DIEAP) flap. One month postoperatively, echo-colour-Doppler measurements were performed on pedicle and perforator arteries to calculate blood flow rate in the flaps. A correlation between weight and flow rate was analysed. Spearman rho statistic was calculated. A linear regression model was made from patient data of flow rate/flap weight and predicted values of flow per flap weight were calculated. Then, flow rate values of veins of various diameters were estimated using Hagen-Poiseuilles formula. Our data show that flow rate measured postoperatively on flap arteries is significantly correlated with flap weight [rho(23 d.f.)=0.725, P<0.01 (two-tailed)]. Moreover, we have calculated the minimum size of veins able to drain flaps of increasing weights with different patterns, i.e. our data show that veins of 1.30, 1.50 and 1.75 mm diameter could safely drain flaps of, respectively, 300, 500 and 900 g in weight. This can be useful preoperatively to estimate the risk of flap congestion and in planning additional drainage.

Hemodynamic changes in the microcirculation of DIEP flaps.

Perforator flaps are widely used in reconstructive surgery, but little is known about the hemodynamic changes within these flaps. Recently, the blood velocity in the perforator artery was shown to be higher than that at the source vessel. This study was carried out to demonstrate the effect of this increased velocity within the perforators in the cutaneous microcirculation of the perforator flap. Twenty-six consecutive patients who underwent unilateral immediate breast reconstruction with deep inferior epigastric perforator (DIEP) flaps were selected. A 3-stage prospective study using 2 laser Doppler probes was carried out. Stage 1: preoperative measurements; Stage 2: immediate postoperative measurements; Stage 3: postoperative measurements after 3 months. Statistically significant increase of blood velocity in the microcirculation of DIEP flaps was demonstrated in stages 2 and 3 when compared with stage 1 (P < 0.01, Friedman and Wilcoxon tests). The higher blood velocity within the perforator flap microcirculation may be a favorable rheologic feature of perforator flaps.

A comparison of a new skin closure device and intradermal sutures in the closure of full-thickness surgical incisions.

Background: A novel topical skin adhesive system was developed to close the outermost layer of skin in an expeditious manner. To determine its clinical utility, a clinical investigation was undertaken to demonstrate equivalence of a new adhesive skin closure system (Prineo Skin Closure System) to intradermal sutures in wound closure. Methods: The investigation included 83 patients who underwent elective abdominoplasty, circumferential body lift procedures, and breast reconstruction with deep inferior epigastric perforator flaps. Incisions were divided in half, and each half was randomized to wound closure with the new skin closure system, including a pressure-sensitive adhesive mesh tape for wound edge approximation and next-generation cyanoacrylate or intradermal sutures. Postoperative evaluations took place at 24 hours, 7 days, 12 to 25 days, 90 days, 6 months, and 12 months. Results: The new skin closure system was found to be equivalent to intradermal sutures for the continuous approximation of wounds. The upper limit of the two-sided 90 percent confidence interval for difference in proportions was 10.9 percent. The mean time to closure for the new skin closure system was 1.46 minutes, approximately 5 minutes faster than that for intradermal sutures (p < 0.0001). Both treatments had similar incision healing and cosmetic outcomes. No quantitative or qualitative differences of clinical significance were evident between the treatment groups. Conclusions: The Prineo Skin Closure System can be considered equivalent to intradermal sutures for full-thickness surgical incisions with regard to safety and effectiveness. The ease and speed of application contribute to shortened operative times (4.5 times faster than intradermal sutures). CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Twin flap technique for nipple reconstruction

A technique of nipple reconstruction using two local flaps is described. The central ‘core’ flap is surrounded by a peripheral ‘wrap’ flap, producing a natural nipple. Results of 24 nipple reconstructions in 22 cases are presented. This technique is useful when the neo-nipple location falls on the mastectomy scar.

Venous perforators in DIEAP flaps: An observational anatomical study using duplex ultrasonography *

BACKGROUND The DIEAP flap has gained popularity for breast reconstruction worldwide. Despite DIEAP flap arterial anatomy being well known, venous congestion is still an important complication and the literature on DIEAP flap venous anatomy is lacking. Venous drainage is less predictable and research on venous perforators is of increasing interest. The aim of this study was to investigate the anatomical distribution, diameters and relationships between arterial and venous perforators and their source vessels using Duplex ultrasonography, in order to evaluate the potential benefits of pre-operative evaluation of DIEAP flap venous perforators. METHODS Prospectively, 140 patients undergoing DIEAP flap breast reconstruction, were pre-operatively assessed using Duplex ultrasonography for location and diameter of arterial and venous perforators, DIEA, DIEV, and SIEV. Perforators were plotted laterally and inferiorly from the umbilicus. Means were compared using t-tests. Pearsons correlation coefficients were calculated. RESULTS We identified 702 arterial and 355 venous perforators in 280 lower hemi-abdomens. No venous perforators were identified in 9 (6.5%) patients; none on the right in 25 (17.9%) and none on the left in 36 (25.7%). Venous perforators were larger on the right (p=0.031) but DIEV and SIEV diameters were not statistically different on either sides. The diameters of DIEA, DIEV, perforating arteries and veins were correlated, but unrelated to the diameter of the SIEV. When a medium/large perforator vein is identified first, there is a 93.5% chance of finding an associated medium/large perforator artery; this reduces to 69.8% when a medium/large perforator artery is first identified. CONCLUSIONS There is no correlation between the sizes of perforator veins and DIEV, and the size of the SIEV. Our data suggests that first identifying a medium/large venous perforator increases the chances of finding a better suitable perforator complex. Pre-operative evaluation of venous perforators may be of great interest for its potential clinical benefits.

Transverse Upper Gracilis Flap with Implant In Postmastectomy Breast Reconstruction: a Case Report

Autologous flaps can be used in combination with prosthesis in postmastectomy breast reconstruction. The deep inferior epigastric perforator (DIEP) flap is considered the preferred choice among autologous tissue transfer techniques. However, in patients with a peculiar figure (moderately large breasts and large thighs with flat stomach), who cannot use their abdominal tissue, the transverse upper gracilis (TUG) flap with implant is investigated as a further option for breast reconstruction. This report presents a patient who underwent the TUG flap plus implant reconstruction. A bilateral skin‐sparing mastectomy was performed removing 340 g for each breast. The volume of the TUG flaps was 225 g (left) and 250 g (right). Preoperative volumes were restored by placing under the TUG muscle a round textured implant. No complications occurred during the postoperative period both in the recipient and donor site and the outcomes of the procedure were good. In cases where the use of the DIEP flap is not possible because of past laparotomies or inadequate abdominal volume, the TUG flap plus implant may be considered as a valid alternative.