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Background: The process of harvesting and performing microsurgical anastomosis may lengthen deep inferior epigastric artery perforator (DIEP) flap breast reconstruction affecting results and patient safety. The aim of the study was to investigate the associations between predictors and operative time (OT)., Methods: Between 2004 and 2016, 336 immediate and 68 delayed unilateral reconstructions were performed in 404 patients. Age, weight, height, body mass index (BMI), nulliparity, or pluriparity condition were collected to determine the impact of patient characteristics on OT. Flap weight, mastectomy type, flap zone, perforator number, venous anastomoses, recipient vessels selection, reconstruction timing, contralateral symmetrization, and a dedicated anesthesiologist were analyzed as possible predictors., Results: Mean OT was 289 min (range, 150-550 min). Using univariate analysis, for each increment of BMI value and patient weight OT increased, respectively, 3.5- and 1.4 min (97.5% CI: 1.768-5.145, 97.5% CI: 0.739-1.949; P < 0.001). Skin-sparing mastectomy (SSM) (97.5% CI: 2.487-36.637; P = 0.025), perforator number, and venous anastomoses (97.5% CI: 24.468-43.690, 97.5% CI: 24.843-50.492; P < 0.001) negatively influenced OT while nipple-sparing mastectomy (NSM) reduced OT of 22.7-min (97.5% CI: -40.333 to -5.098; P = 0.012). The use of circumflex scapular vessels as recipients reduced OT of 75.4-min while internal mammary vessels (IMV) increased OT of 55.8-min (97.5% CI: -88.631 to -62.209, 97.5% CI: 22.918-88.642; P < 0.001). A dedicated anesthesiologist and the learning curve (LC) reduced OT, respectively, of 39.63-min and of 13-min for every year (97.5% CI: -57.119 to -22.137, 97.5% CI: -14.666 to -11.898; P < 0.001). Using multivariate regression, LC was a negative predictor while SSM, perforators number, superficial epigastric vein, IMV, and flap weight were positive predictors (P < 0.001)., Conclusions: The increase of flap weight, related perforators number, and venous drainage negatively influence OT. LC meaning systematic approach for surgery can optimize DIEP flap surgery efficiency., (© 2017 Wiley Periodicals, Inc.)

The aim of this study was to analyze outcomes of patients who had prior abdominal operations and underwent DIEP flap breast reconstruction and to describe technical strategies to insure well-vascularized flap-harvest minimizing abdominal donor-site complications. All patients who underwent DIEP flap breast reconstruction between 2004 and 2014 were reviewed and divided into a control group (CG) and a scar group (SG). Patient demographics, operative details, flap and donor-site complications were analyzed and compared. For all of the scars, DIEP flap design was not modified, but a standardized approach was developed according to the type and location of the scar, available vascular pedicle, perforator locations, and the required flap tissue for breast reconstruction. Two hundred and eighty patients underwent 292 flaps in CG and 107 underwent 111 flaps in SG. Pfannenstiel, McBurney, laparoscopic, midline and subcostal were the most common previous incisions. There were no significant differences between groups regarding demographics, flap and mastectomy weight, active smoking, or radiation status (P > 0.05). No significant differences were observed in DIEP flap loss (P = 0.909), partial flap loss (P=0.799), or fat necrosis (P=0.871) and in the rate of abdominal donor-site complications between groups (P > 0.05). SG had a significantly higher mean operative time than CG (P=0.034). Medial raw was a negative risk-factor for flap complications, while BMI (>25.1 kg/m 2 ) and smoking-history were significant predictors for donor-site complications. With careful preoperative planning and appropriate technical strategies, successfully DIEP flap breast reconstruction can be performed without increased flap and donor-site complications in patients with preexisting abdominal scars. © 2015 Wiley Periodicals, Inc. Microsurgery 37:282-292, 2017., (© 2015 Wiley Periodicals, Inc.)

Background: Several studies showed the detrimental effect of pedicle torsion on flap survival; however, the impact of hemodilution in this peculiar condition has never been investigated. This study evaluated the effect of acute normovolemic and hypervolemic hemodilution on flap survival in a perforator flap with twisted pedicle model., Methods: Sixty-three female Wistar rats were divided into three groups of 21 rats each: group 1, superficial inferior epigastric artery flap, which was elevated bilaterally and transposed back to the abdominal wall with different angles of rotation (i.e., 90, 180, 270, and 360 degrees); group 2, surgery with previous acute normovolemic hemodilution; and group 3, surgery with previous acute hypovolemic hemodilution. Normovolemic hemodilution was obtained, simultaneously removing 2 cc of blood and replacing it with an equal volume of isotonic sodium chloride 0.9% (two-thirds) plus hydroxyethyl starch 6% (one-third). Hypervolemic hemodilution was obtained by hemodilution and a 20 percent blood volume expansion. Microangiography of the flap and histopathologic analyses were performed., Results: Mean hematocrit values after hemodilution were 27.80 ± 0.04 percent for the acute normovolemic hemodilution group and 27.01 ± 0.03 percent for the acute hypovolemic hemodilution group. Twisting the pedicle at 90, 180, and 270 degrees had no effect on flap survival in all groups. However, 360-degree pedicle torsion showed flap edema, congestion, and necrosis., Conclusions: The authors' hemodilution protocol is an effective and reliable method that could be used to further investigate the impact of the hemodynamic changes that occur during hemodilution on flap microcirculation. The results obtained sustain the existence of a strong correlation between necrosis rate and hemodilution.

The aim of this study was to investigate clinical and aesthetic results of simultaneous contralateral balancing procedures in unilateral DIEP flap reconstructions by means of a symmetrization algorithm. Between 2004 and 2013, 335 patients underwent DIEP flap breast reconstruction with 48 patients (mean age 51.8 years, range 32-69 years) undergoing contralateral procedure. Patients were divided in Group-A including 31 cases who underwent one-stage procedure and Group-B including 17 cases who underwent staged procedure. A symmetrization algorithm was proposed to plan immediate breast reduction/mastopexy. The groups were homogeneous regarding patient's age, BMI, mastectomy and flap weight (P > 0.05). All flaps survived. No complications were observed to the mastectomy skin flaps and to the reduction mammaplasty/mastopexy procedures in both groups. The mean operation time was 5 h in Group-A while 5 h and 37 min in Group-B (P = 0.0682). Contralateral procedures included 23 breast reductions and 8 mastopexies in Group-A, while 10 breast reductions and 7 mastopexies were performed in Group-B. Two and 6 patients required revision of the balancing procedure in Group-A and Group-B, respectively. The follow-up time was 47.3 months (range 14-120 months) in Group-A and 91.3 months (range 41-110 months) in Group-B. Volume, upper/lower pole shape, projection, breast mound placement, IMF, symmetry, overall appearance, and general satisfaction sub-items obtained high-score evaluation without significant difference between the two groups (P > 0.05). One-stage DIEP flap reconstruction by means of the symmetrization algorithm resulted in comparable aesthetic outcomes and patient satisfaction to a staged procedure., (© 2015 Wiley Periodicals, Inc.)

Background: Microvascular reconstruction provides natural, lasting breasts that can be integrated easily into body image but most thin patients are often not ideal candidates because of inadequate donor-site volume. The purpose of this study was to present our experience in delayed augmented DIEP flaps with large fat-volume transfer., Methods: From 2010 to 2014, 20 consecutive patients were prospectively enrolled for delayed fat-graft-augmented DIEP flaps (active group, AG) and matched with a control group (CG) submitted to the same procedure without fat-injection. Patient's age, mastectomy and flap weight, number of take-backs to the theater for secondary procedures, total treatment period (TTP), and complications were collected and analyzed. Patient and surgeon surveys rated aesthetic outcomes. Continuous and categorical variables were analyzed using student t test and Kruskal-Wallis test, respectively. A value of p ≤ 0.05 was considered statistically significant., Results: The groups did not differ in age and mastectomy weight (p > 0.05). The AG had a smaller BMI and flap weight (p < 0.05). Comparison of the mean number of take-backs (1.5 in AG vs. 1.4 in CG) and mean TTP (8.6 months in AG vs. 8.9 months in CG) did not show a significant difference (p > 0.05) between groups. Volume, upper/lower-pole shapes, projection, breast mound placement, IMF, symmetry, overall appearance, and general satisfaction sub-items obtained high-score evaluation without a significant difference between groups (p > 0.05)., Conclusion: Delayed fat-graft-augmented DIEP flaps can be offered to patients with insufficient donor-site volume and medium/large breasts. In comparison with the same technique without fat grafting, no additional take-backs and no prolonged TTP were required to achieve pleasing aesthetic results., Level of Evidence Iii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Recidivating pressure sores are a frequent complication in meningomyelocele patients because of their limitation in motility and their scarce ability to monitor the pressure applied on insensate areas while seated. We report the utilization of the sensate pedicled anterolateral thigh perforator flap for reconstruction of ischiatic sores in meningomyelocele patients. Between May 2011 and September 2013, five patients underwent transfer of a sensate pedicled anterolateral thigh flap, by an intermuscular passageway through the upper thigh, to reach the ischial defect. Flap was properly harvested from the thigh after assessment of the lateral cutaneous femoral nerve sensitive area with the Pressure-Specified Sensory Device. In all cases the flap reached the ischial defect harmlessly, healing was uneventful with no immediate nor late complications. Each patient showed persistence of sensitivity at the reconstructed area and no recurrent ischiatic sore was observed at mean follow-up of 26.4 months. The sensate pedicled anterolateral thigh flap is a valuable solution for coverage of recurrent ischial sores in meningomyelocele patients, in which pressure consciousness is fundamental. The intermuscular passageway allows to reduce the distance between flap's vascular pedicle origin and the ischial defect, hence to use the more reliable skin from the middle third of the anterolateral thigh., (© 2014 Wiley Periodicals, Inc.)

The aim of this study is to present our experience on the use of various recipient sites for deep inferior epigastric perforator (DIEP) flap breast reconstruction and compare them by means of objective data. Two hundred fifty six DIEP flap breast reconstructions, performed between March 2004 and May 2011, were retrospectively analyzed. Only unilateral reconstructions were included in the study and divided into three groups depending on the recipient site choice: internal mammary vessels (IMV) (n = 52), thoracodorsal vessels (TDV) (n = 109), and circumflex scapular vessels (CSV) (n = 95). Clinical records of each patient were reviewed to acquire relevant data such as operative time, postoperative complications, and use of a second vein anastomosis. CSV group showed a statistically significant lower operative time (4.92 ± 0.54 hours) compared to TDV (5.67 ± 1.01 hours) and IMV groups (6.75 ± 1.09 hours) (P < 0.001). Second vein anastomosis was performed in 84 cases (88.1%) of CSV, in 85 cases (77.9%) of TDV, and in 18 cases (35.1%) of IMV groups (P < 0.001). No significant differences were observed among groups regarding risk factors and complications (P > 0.05). The axillary vessels seem to be the ideal recipient site because of reduced operative time and increased possibility to perform a second vein anastomosis. Among them, CSV can be safely used due to following advantages: easy dissection, larger vessel caliber, and optimal flap insetting. Moreover, their location does not expose them completely to radiotherapy consequences., (© 2014 Wiley Periodicals, Inc.)

Although success rate of deep inferior epigastric perforator (DIEP) flap breast reconstruction has greatly improved, complications still occasionally occur. Perfusion-related complications (PRCs) (ie, fat necrosis and partial flap necrosis) are the most frequent concern, affecting aesthetic final result of the reconstructed breast. The aim of our study was to retrospectively investigate 287 consecutive DIEP flap breast reconstructions to investigate predictive and protective factors for PRCs.From May 2004 to February 2012, 287 DIEP flap breast reconstructions were performed on 270 patients; 247 unilateral flaps, including Holm vascular zones I to III, were retrospectively selected and analyzed. Tobacco use, mean blood pressure over the first postoperative 48 hours, superficial epigastric vein drainage, medial/lateral row perforator, nulliparity, crystalloid versus combined crystalloid/colloid intravenous fluid infusion therapy, and learning curve were evaluated by univariate and multivariate logistic regression analyses.Perfusion-related complications occurred 32 (12.9%) times, 79 (31.9%) patients were smokers, 48 (19.4%) showed postoperative mean blood pressure less than 75 mm Hg, 29 (11.7%) were nulliparous, and 173 (70%) had superficial epigastric vein drainage. Selected perforators were 110 (44.5%) from lateral row, 137 (55.5%) from medial row; 91 (36.8%) received crystalloid fluid infusion, whereas 156 (63.2%) combined crystalloid/colloid fluid infusion. From univariate analysis emerged significance of nulliparity, perforator row and intravenous fluid infusion for PRC. Nevertheless, multivariate model confirmed only nulliparity as a significant risk factor (P = 0.029), although variable correlations to other predictors were found: both medial row perforator and combined crystalloid/colloid fluid infusion potentially decrease the PRC risk of 11.6% and 27.6%, respectively. Learning curve did not show significant decrease of PRC risk over time.Our study first proved nulliparity as a statistically significant predictor for PRCs in DIEP flap breast reconstruction, possibly due to different superficial abdominal perfusion between pluriparous and nulliparous women, with potential weaker pattern of perforators and smaller angiosomes in the latter. The choice of medial row perforators and combined crystalloid/colloid fluid infusion might reduce PRC risk.

Background: The thoracodorsal artery perforator flap was described mainly for partial breast reconstruction by Hamdi. The purpose of this article is to describe the use of the pedicled thoracodorsal artery perforator flap for total autologous breast reconstruction without using an implant., Methods: Between January of 2009 and December of 2011, seven patients underwent total breast reconstruction with a pedicled thoracodorsal artery perforator flap. The mean age of the patients was 53 years (range, 43 to 62 years), and the mean body mass index was 27 kg/m (range, 24 to 32 kg/m)., Results: The mean size of the harvested skin paddle was 23.7 × 8.8 cm (range, 15 × 7 cm to 39 × 14 cm). The flaps were based on one to three perforators and successfully transferred with an average operative time of 3 hours. No seroma occurred at the donor site. Average hospital stay was 4 days (range, 3 to 6 days). At an average follow-up of 21.5 months, two patients underwent additional revisions using autologous fat grafting, with overall fat injection volumes of 240 and 280 cc, respectively., Conclusion: The pedicled thoracodorsal artery perforator flap offers an alternative for total autologous breast reconstruction in small to medium breasted patients when abdominal tissues are not available., Clinical Question/level of Evidence: Therapeutic, IV.

Dermatofibrosarcoma protuberans is a rare cutaneous malignant tumor associated with a high cure rate but with a high incidence of local recurrence. Because of its tentacle-like subcutaneous infiltrating pattern that extends far beyond the clinically visible skin lesion, a wide resection margin is recommended. Hence, its localization to the head-and-neck regions, although rare, represents a real challenge for both the oncologic surgeon and the reconstructive surgeon, who aim to achieve a radical resection of the tumor with the best possible aesthetic outcome.A case of a 21-year-old Mediterranean man who presented with a 7-month history of a slowly growing subcutaneous lesion of the left preauricular region is reported. A diagnosis of dermatofibrosarcoma protuberans CD34+ was confirmed through surgical biopsy, and the patient subsequently underwent a wide en bloc local surgical resection, followed by anterolateral thigh perforator free flap reconstruction. Healing was uneventful. Initially, there was some facial nerve neurapraxia; however, this completely subsided within 3 months after the surgery. At the 13-month follow-up, the patient was completely well and free from the disease.

Introduction: Combined hemiglossectomy and floor-of-the-mouth defects need accurate reconstructive planning to restore swallowing and speech function. The aim of this prospective study was to evaluate outcomes of the bilobed design applied to perforator free flaps for combined hemitongue and floor-of-the-mouth defects., Patients and Methods: Twelve patients with a mean age of 71 years (range, 60-84) addressed to combined hemiglossectomy and floor-of-the-mouth resection and bilobed-shaped perforator free-flap reconstruction were prospectively enrolled. Defects were classified as follows: type 1, including only the anterior mobile portion of the tongue (n = 3); type 2, involving both mobile tongue and tongue base (n = 6); and type 3, including segmental mandibulectomy combined with a type 1 or type 2 defect (n = 3). The Kruskal-Wallis and Bonferroni post hoc tests were used to compare outcomes., Results: Type 1 defects were reconstructed by three anterolateral thigh (ALT) perforator flaps; type 2 defects were reconstructed by four ALT flaps and two vertical deep inferior epigastric perforator flaps; and type 3 defects were restored by three osteocutaneous fibula flaps. Eleven flaps (91.6%) healed uneventfully, while one (8.4%) suffered a small area of skin necrosis whose revision did not compromise functional results. Six patients achieved normal intelligible speech, five had acceptable intelligible speech and one had unintelligible speech (p = 0.356). Swallowing function was considered normal in eight patients and with mild impairment in four (p = 0.178). Cosmesis resulted excellent in seven patients and good in five (p = 0.855)., Conclusion: The bilobed-shaped perforator free flaps were shown to be a safe and predictable solution for combined hemitongue and floor-of-the-mouth defects providing optimal aesthetic and functional outcomes., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Reconstruction of a functional tongue with proper motility and sensation after subtotal resection is a demanding procedure. The authors describe the reinnervated mushroom-shaped anterolateral thigh perforator flap for subtotal tongue reconstruction., Methods: Thirteen patients (mean age, 54.8 years; range, 49 to 71 years) diagnosed with T3 and T4 squamous cell carcinomas were allocated prospectively to anterior total mobile (n = 7) or subtotal tongue resection (n = 6). All patients received the mushroom-shaped anterolateral thigh perforator flap. A Likert scale ranging from 1 to 4 was used to assess speech intelligibility, swallowing function, and cosmetic results. Epicritic and proprioceptive sensitivity testing was performed with the Pressure-Specified Sensory Device on the tip of the tongue preoperatively, on the neotongue at the donor site preoperatively, and at the recipient site 12 months postoperatively; protopathic thermoreceptor and nociceptors were clinically investigated. Outcomes were analyzed, and values of p < 0.05 were considered significant., Results: All flaps healed uneventfully (mean follow-up, 18 months). Six patients (46.2 percent) recovered a nearly natural deglutition, whereas seven (53.8 percent) had mild impairment (p = 0.274). Normal intelligible speech was achieved in seven cases (53.8 percent), and acceptable intelligible speech was achieved in six (46.2 percent) (p = 0.286). Aesthetic results were excellent in eight patients (61.5 percent) and good in five (38.5 percent) (p = 0.592). All patients recovered epicritic, proprioceptive, and protopathic sensitivity; cortical upgrading phenomena of the recipient nerve were observed., Conclusion: The reinnervated mushroom-shaped anterolateral thigh perforator flap was found to be an innovative and effective option for subtotal tongue reconstruction.