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We compared the surgical skills and outcomes of microsurgical fellows who completed an independent versus integrated plastic surgery residency., Methods: We reviewed outcomes of abdominal wall reconstructions performed autonomously by microsurgical fellows at our institution from March 2005 to June 2019; outcome measures included hernia recurrence, surgical site occurrence, surgical site infection, length of hospital stay, unplanned return to the operating room, and 30-day readmission. The microsurgical skills were prospectively evaluated using the validated Structured Assessment of Microsurgical Skills at the start and end of the fellowship, in an animal laboratory model and clinical microsurgical cases. Multivariable hierarchical models were constructed to evaluate study outcomes., Results: We identified 44 fellows and 118 consecutive patients (52% women) who met our inclusion criteria. Independent fellows performed 55% (n = 65) of cases, and 45% were performed by integrated fellows. We found no significant difference in hernia recurrence, surgical site occurrences, surgical site infections, 30-day readmission, unplanned return to the operating room, or length of stay between the two groups in adjusted models. Although laboratory scores were similar between the groups, integrated fellows demonstrated higher initial clinical scores (42.0 ± 4.9 versus 37.7 ± 5.0, P = 0.04); however, the final clinical scores were similar (50.8 ± 6.0 versus 48.9 ± 5.2, P = 0.45)., Conclusions: Independent and integrated fellows demonstrated similar long-term patient outcomes. Although integrated fellows had better initial microsurgical skills, evaluation at the conclusion of fellowship revealed similar performance, indicating that fellowship training allows for further development of competent surgeons., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Although autologous free-flap breast reconstruction is the most durable means of reconstruction, it is unclear how many additional operations are needed to optimize the aesthetic outcome of the reconstructed breast. The present study aimed to determine the average number of elective breast revision procedures performed for aesthetic reasons in patients undergoing unilateral autologous breast reconstruction and to analyze variables associated with undergoing additional procedures., Methods: A retrospective review of all unilateral abdominal-based free-flap breast reconstructions performed from 2000 to 2014 was undertaken at a tertiary academic center., Results: Overall, 1251 patients were included in the analysis. The average number of breast revision procedures was 1.1 ± 0.9, and 903 patients (72.2%) underwent at least one revision procedure. Multiple logistic regression analysis demonstrated that younger age, higher body mass index, and prior oncologic surgery on the reconstructed breast were factors associated with increased likelihood of undergoing a revision procedure. The probability of undergoing at least one revision increased by 4% with every 1-unit (kg/m 2 ) increase in a patient's body mass index. Multiple Poisson regression modeling demonstrated that younger age, prior oncologic surgery on the reconstructed breast, and bipedicle flap reconstruction were significant factors associated with undergoing a greater number of revision procedures., Conclusions: Most patients who undergo unilateral autologous breast reconstruction require at least one additional operation to optimize their breast aesthetic results. Young age and obesity increase the likelihood of undergoing additional operations. These findings can aid reconstructive microsurgeons in counseling patients and establishing patient expectations prior to their undergoing microvascular breast reconstruction., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

The latissimus muscle continues to be a head to toe workhorse in free tissue transfer for coverage of large defects. Traditional full muscle harvest is performed in the lateral decubitus position which is frequently suboptimal or requires position change based on the recipient site and laterality. We present a multi-institutional case series of full muscle flap harvest from the supine position for a range of defects in 32 patients. The relevant operative setup and technique are described. In our experience, supine harvest has become the preferred open harvest technique compared to lateral positioning for both optimal exposure of the pedicle and reduction in operating time., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

The field of lymphedema surgery has grown tremendously in recent years. In particular, the diversity of available donor sites for vascularized lymph node transfer has increased, and new donor sites are emerging. Researchers have explored a number of different donor sites, and their reports have demonstrated promising results with each site. Unfortunately, there are limited studies providing a comprehensive analysis of the available donor sites focusing on both the technical aspects of the harvest, including complications and donor site morbidity, and the efficacy and outcomes following transfer. The present review aims to present a comprehensive analysis of the available donor sites for vascularized lymph node transfer and a summary of the experience from a single center of excellence., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Lymphedema is a lifelong, debilitating condition that plagues a large portion of patients who have undergone multimodality therapy for breast cancer. With the increasing experience in supermicrosurgical treatment of lymphedema, reconstructive surgeons have made a tremendous impact in improving the quality of life of patients suffering from breast cancer related lymphedema., Methods: Historical review of our evolution in treatment and management of breast cancer related lymphedema and implementation of our new algorithm. Retrospective review of patients who have undergone both the lymphovenous bypass and vascularized lymph node transfer with autologous breast reconstruction., Results: The combined Breast Reconstruction Including Lymphovenous bypass and Inguinal to Axillary Node Transfer (BRILIANT) demonstrates promising outcomes. Thirty-eight patients (average age: 52.9 years, average BMI: 32.6 kg/m2) who have undergone the BRILIANT approach have all demonstrated improvements in their lymphedema. With an average follow-up of 19.1 months, no patients suffered a post-operative cellulitis, and 81.6% of patients also demonstrated a volume reduction., Conclusion: Our new algorithm combining breast reconstruction with lymphedema surgery represents an evolution in our approach to treatment of breast cancer related lymphedema has demonstrated promising results with long-term outcomes., Competing Interests: Disclosures: The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article at the time of the study. EIC was previously a speaker for Novadaq Inc., but no funding was received for the work presented in this article., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Surgical treatment of lymphedema has expanded in recent years. Lymphovenous bypass and vascularized lymph node transfer are both modern techniques to address the physiologic dysfunction associated with secondary lymphedema. While efficacy of both techniques has been demonstrated in numerous studies, there are several questions that remain. Here, the authors discuss the most pertinent controversies in our practice as well as the current state of surgical management of lymphedema., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

A variety of donor options for vascularized lymph node transfer for the surgical treatment of lymphedema have been described. Intra-abdominal harvest sites including the gastroepiploic nodes within the omental flap and the mesenteric node flap are distinguished from their extra-abdominal counterparts by the absent risk of iatrogenic donor site lymphedema and discrete scar location, as well as the ability to harvest up to 3 vascularized nodal packets from 1 donor site. However, there are also potential morbidities including hernia and intra-abdominal visceral injuries. Patient selection and flap harvest techniques are reviewed., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Lymphedema is a debilitating clinical condition predominantly affecting survivors of cancer. It adversely affects patients' quality of life and results in substantial cost burdens to both patients and the healthcare system. Specialist lymphedema care is optimally provided within integrated clinical programs that align the necessary specialties to provide patient-focused, multidisciplinary, structured, and coordinated care. This article examines our experience building a specialist lymphedema academic program., Methods: We describe the critical components necessary for constructing a multidisciplinary comprehensive academic lymphedema program. Furthermore, lessons learned from our experience building a successful lymphedema program are discussed., Results: Building a comprehensive academic lymphedema program requires institutional support and engagement of stakeholders to establish the necessary infrastructure for comprehensive patient care. This includes the infrastructure for outpatient clinical assessment, diagnostic investigations, radiological imaging, collection of outcomes metrics, non-surgical treatment delivered by lymphedema-specialist therapists, surgical procedures using specialized equipment, and integration of an outpatient framework for comprehensive patient evaluation during follow-up at standardized time intervals., Conclusions: This article examines our experience building a multidisciplinary comprehensive academic lymphedema program and provides a structured roadmap to benefit others that are embarking on this mission., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Volume loss is 1 of the major factors influencing cosmetic outcomes of breast after partial mastectomy (PM), especially for smaller breasts, and therefore, volume replacement is critical for optimizing the final aesthetic outcome. We present a novel technique of raising a pedicled descending branch latissimus dorsi (LD) mini-flap for reconstruction of PM defects via an axillary incision. After PM, the LD mini-flap is harvested through the existing axillary incision of the axillary dissection or the sentinel lymph node biopsy. The descending branches of thoracodorsal vessels and nerve are carefully identified and isolated. The transverse branches are protected to maintain muscle innervation and function. The LD muscle is then undermined posteriorly and inferiorly to create a submuscular pocket and a subcutaneous pocket between LD muscle and superficial fascia. Once the submuscular plane is created, the muscle is divided along the muscle fibers from the deep surface including a layer of fat above the muscle. Finally, the LD mini-flap is transferred to the breast defect. Given the limited length and mobility of the LD mini-flap, this approach is best utilized for lateral breast defects. However, for medial defects, the lateral breast tissue is rearranged to reconstruct the medial breast defect, and an LD mini-flap is then used to reconstruct the lateral breast donor site. This technique can therefore be employed to reconstruct all quadrants of the breast and can provide aesthetic outcomes without scars on the back, with minimal dysfunction of LD muscle., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.