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Background: Preoperative planning with CT-angiography (CTA) in deep inferior epigastric perforator (DIEP) flap reconstruction is an essential preoperative tool. The aim of this study was to describe the management of the incidental findings following the introduction and further modification of a combined CTA and CT-staging preoperative protocol which includes chest, abdomen, pelvis, and musculoskeletal system., Material and Methods: A retrospective case series of 292 patients (Group 1) with breast cancer who underwent DIEP flap between 2015 and 2019. This was followed by a re-assessment between 2019 and 2021 of 101 patients (Group 2) following modification of the staging-CT protocol to include only those patients who received chemotherapy. Group 1 included immediate and delayed reconstruction; whereas Group 2 included only the high-risk delayed reconstruction cases. Both groups had CT staging., Result: Overall, 30% of Group 1, most likely those who had the delayed reconstruction, had findings which were recommended for further follow-up. This led to a change in staging of the high-risk patients only at the end of 2019 to those who underwent chemotherapy and had delayed reconstruction. Briefly, 56.4% of Group 2 demonstrated incidental findings, 42.1% of them required repeat scanning, 7% were referred to other specialties, and 47.4% did not require further action. There were no cases of occult metastatic breast cancer in either series; however, 1% were diagnosed with de novo primary cancers at non breast sites only in the first series., Conclusion: The screening of patients with asymptomatic breast cancer as part of CTA scanning prior to autologous reconstruction is not universally practiced and not supported by the NICE guidelines. This unit changed the practice to stop preoperative staging for low-risk patients by the end of 2019, and reserved it for the high-risk patient groups to reduce cost., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Microsurgical breast reconstruction accounts for 22% of breast reconstructions in the UK. Despite thromboprophylaxis, venous thromboembolism (VTE) occurs in up to 4% of cases. Using a Delphi process, this study established a UK consensus on VTE prophylaxis strategy, for patients undergoing autologous breast reconstruction using free-tissue transfer. It captured geographically divergent views, producing a guide that reflected the peer opinion and current evidence base., Methods: Consensus was ascertained using a structured Delphi process. A specialist from each of the UK's 12 regions was invited to the expert panel. Commitment to three to four rounds of questions was sought at enrollment. Surveys were distributed electronically. An initial qualitative free-text survey was distributed to identify likely lines of consensus and dissensus. Each panelist was provided with full-text versions of key papers on the topic. Initial free-text responses were analyzed to develop a set of structured quantitative statements, which were refined via a second survey as a consensus was approached., Results: The panel comprised 18 specialists: plastic surgeons and thrombosis experts from across the UK. Each specialist completed three rounds of surveys. Together, these plastic surgeons reported having performed more than 570 microsurgical breast reconstructions in the UK in 2019. A consensus was reached on 27 statements, detailing the assessment and delivery of VTE prophylaxis., Conclusion: To our knowledge, this is the first study to collate current practice, expert opinion from across the UK, and a literature review. The output was a practical guide for VTE prophylaxis for microsurgical breast reconstruction in any UK microsurgical breast reconstruction unit., Competing Interests: Conflicts of interest None of the authors hold any conflicts of interest., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The longevity and durability of implant-based reconstruction is limited and many patients who develop complications seek alternative reconstruction. Recent studies have shown tertiary reconstruction with autologous tissue to be safe in the short term. But no study has looked in-depth at the motivation for seeking referral and its long-term outcome., Methods: This was a retrospective study using patient case-notes and a prospectively-collated database. One hundred and fifteen patients underwent tertiary breast reconstruction with a Deep Inferior Epigastric Perforator (DIEP) flap between 1998 and 2016., Results: Mean age was 49 (23-67). The predominant initial reconstruction was expander (71%). Twenty nine percent received a definitive reconstruction (implant with acellular dermal matrix or pedicled latissimus dorsi). The proportion of patients who received post-mastectomy radiotherapy (PMRT) to their implant was 72%. Thirty four percent underwent surgical salvage prior to referral for autologous tissue and this was significantly higher in the group that did not receive PMRT (29% vs 40, p = 0.04). Predominant motivation for autologous reconstruction was poor cosmesis (62%) and/or grade III/IV capsular contracture (27%). Mean time from implant to DIEP was 4 years 5 months. Ten percent had complications requiring re-operation. Flap loss was 0.7%. Fifty five percent required an additional ipsilateral procedure and 47% required symmetrization. Median follow-up was 20-months (6-months to 7-years)., Conclusions: We present the largest UK series of tertiary breast reconstruction. Tertiary reconstruction is safe with a surgical outcome comparable to delayed autologous reconstruction. Patients with implant complications often had multiple failed attempts at salvage prior to referral. We advocate careful consideration of implants in the setting of PMRT and early referral for autologous tissue once complications become apparent., (Copyright © 2019 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: Women considering reconstructive breast surgery (RBS) require adequate information to make informed treatment decisions. This study explored patients' and health professionals' (HPs) perceptions of the adequacy of information provided for decision-making in RBS., Methods: Semi-structured interviews with a purposive sample of patients who had undergone RBS and HPs providing specialist care explored participants' experiences of information provision prior to RBS., Results: Professionals reported providing standardised verbal, written and photographic information about the process and outcomes of surgery. Women, by contrast, reported varying levels of information provision. Some felt fully-informed but others perceived they had received insufficient information about available treatment options or possible outcomes of surgery to make an informed decision., Conclusions: Women need adequate information to make informed decisions about RBS and current practice may not meet women's needs. Minimum agreed standards of information provision, especially about alternative types of reconstruction, are recommended to improve decision-making in RBS., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

A common cause for loss of a deep inferior epigastric perforator (DIEP) flap is venous congestion secondary to inadequate outflow via the deep perforating vessels. Further anastomosis of the superficial venous system provides effective outflow and salvage of the congested DIEP. Multiple methods have been described requiring dissection of additional recipient venous systems or around the perforating vessels in order to provide a vein onto which the superficial system may be anastomosed. These are potentially associated with increased morbidity and risk of damage to the pedicle. We describe an alternative technique of harvesting an additional length of deep inferior epigastric pedicle cranial to the perforator onto which an anastomosis may be performed. This avoids the need for additional dissection of recipient vessels or further handling of the perforator, its venae comitantes and the main pedicle of the flap thus reducing the risk of damage., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Familial Partial Lipodystrophy (or Dunnigan-Kobberling syndrome) is characterised by the progressive loss of peripheral subcutaneous fat, with or without truncal involvement. The resultant physical changes in appearance may be dramatic, especially in women, and their psychological impact underestimated. There are limited reports regarding the role of reconstructive procedures to address the physical defects imposed by the various lipodystrophy syndromes, and much of the work to date has focused around facial lipoatrophy in patients with HIV-1 protease inhibitor induced disease. We, however, present a single case report pertaining to the role of breast augmentation in patients with truncal lipoatrophy, as in Familial Partial Lipodystrophy., (Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)