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LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the indications and contraindications for free flap reconstruction. 2. Describe the indications, anatomy, harvest technique, and advantages and disadvantages of the workhorse free flaps. 3. Describe the indications and contraindications for extremity replantation. 4. Describe the techniques and management for extremity replantation. SUMMARY: Microsurgical free flap reconstruction uses a multitude of surgical flaps available to meet the needs of the recipient site. These include cutaneous, muscle, bone, fascia, or some combination of these as available options. Furthermore, sophisticated reconstruction has been enhanced by the development of perforator flaps, enabling multicomponent reconstruction to be performed with reduced donor-site morbidity. It is mandatory that proper debridement of the defect be performed before reconstruction, and that the anastomosis is performed without tension or twisting outside of the zone of injury. There are indications for both musculocutaneous and perforator flaps, and selection is dependent on recipient-site characteristics in addition to function and aesthetics of both the recipient and donor sites. Muscle flaps provide well-vascularized pliable tissue and are used for deep space obliteration, whereas fasciocutaneous flaps are used for flatter, more superficial wounds. Microsurgical replantation of an amputated extremity offers a result that is usually superior to any other type of reconstruction. However, replantation of extremities involves more than microsurgery, as repair of bony and tendon injury must be undertaken as well. This article focuses on the indications, technique, and results of free flap reconstruction and replantation.

Increasing focus on reducing morbidity from latissimus dorsi flaps has led to the evolution of muscle-sparing variants and perforator-based flaps. This study aimed to investigate the vascular anatomy of the muscle-sparing variant and to describe its application as a free flap based on the descending branch of the thoracodorsal artery.Twelve fresh cadavers underwent anatomical dissection and angiographic injection studies of the thoracodorsal arterial system. The musculocutaneous territories of the descending and transverse branches to the latissimus dorsi muscle were identified and assessed using three-dimensional reconstruction software of computed tomography imaging results. In the clinical study, five patients underwent reconstruction of a variety of defects using the free descending branch muscle-sparing latissimus dorsi flap.Three- and four-dimensional (computed tomography) angiography demonstrated perfusion of the latissimus dorsi muscle by the transverse and descending branches, with overlap of vascular territories via cross-linking vessels. The descending branch supplied a slightly greater cutaneous area overlying the muscle, although differences between both branches were not significant (p = 0.76). In the clinical study, the free muscle-sparing latissimus dorsi flap provided excellent coverage with no flap complications or seroma.The free muscle-sparing latissimus dorsi flap based on the descending branch of the thoracodorsal artery is a viable reconstructive option. Significant collateral flow between vessels allows for larger flap harvest than would be expected. The flap is technically simple to harvest, provides a large perfusion area, and is a reliable variant of the full latissimus dorsi flap.Therapeutic, V.

BACKGROUND Techniques in breast reconstruction have vastly improved with natural feeling, aesthetically pleasing breasts created through transfer of free or pedicled tissue. Traditional flap designs incorporate a skin paddle that leaves a "patch," which can be fairly large on the nouveau breast, clearly delineating the boundaries between the reconstruction and the native skin. In this article, the authors discuss the operative technique and present a clinical series of patients undergoing the periareolar advancement flap procedure. This technique reduces the skin paddle either to a circumferential areola-size area onto which the nipple can be simultaneously reconstructed (type I) or a single linear scar (type II) across the breast mound, thus enhancing the aesthetic appearance of the reconstructed breast. METHODS A retrospective review of all patients between 2007 and 2009 undergoing periareolar advancement flaps under the care of the senior author (M.S.C.) was performed. Type of reconstruction, staging of procedures, additional operations, and complications were recorded. RESULTS Fifteen patients had a type I procedure and six patients had a type II procedure. There were no major complications. One patient had minor nipple scabbing that resolved. All type I patients had concomitant nipple reconstructions at the time of their periareolar advancement flap. CONCLUSIONS The periareolar advancement flap is a useful technique to include in the range of secondary revision procedures for further refinement of autologous breast reconstruction. It results in a sensate, more aesthetically pleasing breast. It has low complication rates and can be performed at the same time as a nipple reconstruction in type I patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Despite many modifications to the extended latissimus dorsi flap, its use in autologous breast reconstruction remains limited because of insufficient volume and donor-site morbidity. Through a detailed analysis of the deposition of back fat, this study describes a low transverse extended latissimus dorsi flap harvest technique that increases flap volumes and improves donor-site aesthetics.Eight fresh cadaver hemibacks were used to identify the anatomical location of the fat compartments. Correlation between the fat compartments and the fat folds was made using photographic analysis of 216 patients. Retrospective case note review was conducted of all patients who had a low transverse extended latissimus dorsi flap performed by the senior author (M.S.-C.).Cadaveric dissection and photographic analysis confirmed the presence of the four distinct fat compartments in the back. The lower compartments 3 and 4 were the most frequently identified and the largest, with mean values of 367 cm and 271 cm, respectively. The clinical series comprised eight high-body mass index patients who underwent 12 pure autologous breast reconstructions using the low transverse skin paddle harvest technique. Donor-site complications included partial dehiscence (n=2) and minor infection (n=3). There were no instances of seroma, and fat necrosis (5 percent) occurred in one breast.The low transverse skin paddle extended latissimus dorsi flap is reliable and provides sufficient volume for purely autologous breast reconstruction with low donor-site morbidity and improved body contouring for a select group of patients. The authors' initial experience with high-body mass index patients shows promising results with this flap in a challenging group.

Breast reconstruction using the deep inferior epigastric perforator (DIEP) flap is becoming more common and can help reduce donor site morbidity. The authors proposed that dissection of the deep inferior epigastric artery (DIEA) and vein (DIEV) to their external iliac source may not be required for safe flap transfer.Sixteen whole fresh cadaveric hemiabdomens were used to dissect transverse abdominal-based flaps. Latex injection of the DIEA system was carried out, and the diameters of the DIEA/DIEV vessels were assessed at various points along the course of the pedicle from the origin to the perforator. A clinical study of 26 patients who underwent a short and ultrashort pedicle DIEP flaps was carried out.The average DIEA and DIEV vessel diameters were relatively similar from the external iliac origin to a point just caudal to the bifurcation. At the lateral rectus edge, the average DIEA diameter was 3.2 mm, and the DIEV diameter was 3.1 mm. The average pedicle length obtained with classic DIEP dissection was 16.9 cm, short-pedicle DIEP dissection 10.4 cm, ultrashort technique 8.1 cm, and free TRAM technique 6.5 cm. Venous injection study demonstrated rich venous interconnections between both venae comitantes. In their clinical study, the authors were able to achieve average pedicle lengths of 11.0 cm when transecting cranial to the lateral edge of the rectus, with average diameters of 2.5 mm (artery) and 2.9 mm (vein).Transection of the DIEA/DIEV pedicle at the lateral rectus edge or more proximally is safe and can help reduce operative time and donor-site morbidity.Therapeutic, IV.

The technique of autologous fat transplantation has been dramatically improved since its first introduction in 1893. This surgical approach has more recently been used in both the reconstructive and cosmetic setting, and has subsequently been the subject of much controversy. We sought to compose a detailed and systematic literature review of recent literature on the topic in order to provide surgeons with the data in an organized and easily accessible manner. We selected 19 studies and systematically documented trends in their methods, follow-up procedures, and outcomes, paying particular attention to complications. We chose to include studies that analyzed the outcomes of the surgical procedure in both reconstructive and cosmetic cases. Most authors reported satisfactory or greater results, and we concluded that it appears as though autologous fat transplantation to the breast is a safe option for patients seeking both reconstructive and cosmetic surgery.

Summary Fullness in the lateral thoracic area following breast reconstruction can be a source of concern for patients. This redundant tissue creates disharmony between the newly reconstructed breast, the lateral mammary fold, and the lateral thoracic compartment. In this article we present the results of our anatomical/histological study, discuss the operative technique and present a clinical series of patients who underwent this procedure. Methods Cadaveric Anatomical study: Dye injection studies on 4 hemi-chests to determine if the lateral thoracic fold is a separate anatomic fat compartment. Tissue from the boundaries between identified compartments was also submitted for routine H&E histological analysis. Clinical study: Retrospective case note analysis of all patients undergoing dermolipectomy performed by the senior author. Results In the analyzed cadavers, a clear line of delineation was found separating the lateral thoracic fold from the breast and adjacent structures, this was confirmed histologically. Forty patients underwent 64 dermolipectomy procedures. The average dimension of the resected specimen was 13.37 cm (range 3.0–25.0 cm) × 5.44 cm (range 1.0–12.0 cm). The mean time of dermolipectomy following initial reconstruction was 15.4 months. As the BMI increased the average resection size increased both in length ( p = 0.002) and width ( p = 0.006). There were no postoperative complications. Conclusion The lateral thoracic fold is a distinct fat compartment. Dermolipectomy following breast reconstruction is a useful adjunct and should be considered in any patient with excess skin/subcutaneous tissue in the lateral thoracic region. The procedure has a low complication rate and can be performed in conjunction with other post reconstruction refinement procedures.

Breast reduction is a commonly performed procedure by plastic surgeons in Canada, with well-established safety and aesthetic results. Outcome studies of breast reduction surgery reveal that the procedure improves health-related quality of life (1) and that the vast majority of women (more than 94%) are satisfied with the results (2). Breast reduction techniques have evolved in recent years, particularly with regard to pedicle choice and incision placement. Traditionally, the classic inferior pedicle technique, first described by Aufricht (3), in combination with the inverted T scar (4), is ubiquitous because it has been shown to provide safe and consistent results (5). However, this technique and its modifications may be associated with problems such as infra-mammary fold hypertrophic scarring and pseudoptosis (6). A survey by Hoffman in 1987 (7) showed that the inframammary scar was the most common reason for litigation against plastic surgeons following breast reduction. Vertical breast reduction was first described by Dartigues in 1925 (8) and reintroduced by Lassus in 1969 (9), defining a technique that avoided the inframammary fold scar. Lejour modified Lassus’ technique (10,11), thereby popularizing the procedure in Europe and South America; however, North American surgeons have been more reluctant to adopt the vertical technique. Explanations include lack of training in vertical techniques, fear of complications, uncertainty regarding perfusion of the superior pedicle, potential for legal action due to substandard results, and apprehension about completing surgery without seeing the final breast shape (11,12). In a survey of breast reduction techniques among 190 members of the American Society of Plastic and Reconstructive Surgeons, Hidalgo et al (13) found that 74% of surgeons favored inferior/central pedicle with inverted T scar techniques. Breast reduction surgery was performed on an inpatient basis 57% of the time. In a later study, performed in 2002, Rohrich et al (14) surveyed 554 members of the American Society for Aesthetic Plastic Surgery. They found that 75.5% used primarily inferior pedicle and inverted T scar techniques, while only 15.5% of surgeons used limited incision techniques, including short scar and vertical scar methods. Although 89% of surgeons regarded limited incision techniques and liposuction as new trends that were here to stay, only a fraction of these surgeons were actually using them in practice. In North America, newer modifications such as the Hall-Findlay technique, which uses a medial pedicle and vertical scar, have been shown to be safe and efficient (15). Despite these reassurances, comfort with the vertical techniques lag behind Europe. Menke et al (16) retrospectively reviewed data from 799 breast reduction patients that had been prospectively entered into a database as a form of quality control. They showed that German plastic surgeons performed 99% of their reductions as inpatient surgery, and that most reductions were less than 1000 g per side. The majority of reductions (52%) were performed using vertical scar techniques, followed by inverted T scar techniques (45%). Complication rates were 21.5%, the most common of these being wound dehiscence. There was no difference in complication rates between vertical and inverted T scar techniques. In the United Kingdom (UK) and Ireland, Iwuagwu et al (17) reported that 67% of surveyed consultant surgeons use an inferior pedicle technique, mostly on an inpatient basis. There has been no study to date examining the practice profiles of Canadian plastic surgeons and the types of breast reduction techniques employed. The goal of the present study was to determine which breast reduction techniques Canadian plastic surgeons are using in their practices, and to review complications, outcomes and differential admission costs.

To evaluate the effect of technical modifications to pancreaticoduodenectomy (PD) on postoperative outcome, we established a register of all patients undergoing PD at Victoria General Hospital (Queen Elizabeth II Health Sciences Centre), a tertiary care, university-affiliated hospital.Data from 78 consecutive patients who underwent PD from January 1998 through November 2000 were collected for univariate and multivariate analyses of clinical and technical factors on early outcome after PD, including duration of gastric stasis, development of complications and length of hospital stay.Two patients (2.6%) died; complications were recorded in 43 (55%). Upon univariate analysis, 3 factors (a diagnosis of chronic pancreatitis, pylorus preservation, and route of the jejunal limb) significantly affected duration of gastric stasis; but on multivariate analysis, only pylorus preservation and jejunal-limb route remained significant. Retromesenteric jejunal-limb placement was associated with longer periods of gastric stasis (mean 11.9 d, standard deviation [SD] 8.1 d) than the antemesenteric (retrocolic) route (mean 7.2, SD 3.6 d; p0.05); likewise pyloric preservation (mean gastric stasis 10.4 d, SD 5.9 d) compared with resection of the pylorus (mean 7.0 d, SD 3.2 d; p0.05). Pancreatic leaks occurred in 18% of retromesenteric and 8% of antemesenteric reconstructions (p = 0.3). Fewer patients with mucomucosal pancreaticojejunostomy suffered complications than those with invaginated anastomoses, but their hospital stays were similar in length.Route of the jejunal efferent limb and preservation of the pylorus are independent technical variables affecting early outcome after PD.

Although sirolimus (SRL) binds the immunophilin FK506-binding protein-12 (FKBP-12) with greater avidity than tacrolimus (TAC), animal studies have shown that SRL and TAC act synergistically to prevent rejection. Dose-related toxicity is more often the cause of TAC discontinuation than rejection. We hypothesized that SRL would allow for a substantial reduction in the concomitant dose of TAC after liver transplantation to levels less than the threshold for toxicity. A series of 56 liver transplant recipients were administered a combination of SRL and TAC (target trough levels, 7 and 5 ng/mL, respectively). Planned weaning of steroids commenced after 3 months. Pharmacokinetic (PK) studies were undertaken. Patient and graft survival were 52 patients (93%) and 51 grafts (91%), with a follow-up of 23 months (range, 6 to 35 months). One episode (1.8%) of hepatic artery thrombosis was seen. The rate of acute cellular rejection was 14%. No extra treatment was administered in 3 of 8 patients, and the other 5 episodes responded to a single course of steroids. Cytomegalovirus infection occurred in 4 patients (7%). Renal function, glucose control, and lipid metabolism are near normal in 47 patients (84%) without additional medication. Steroid elimination is completed in 51 patients (91%). Bioavailability of SRL and TAC varied between transplant recipients, but trough levels strongly correlated with the area under the curve (r(2) = 0.82 and r(2) = 0.84, respectively). Simultaneous administration did not affect the PK profile of the drugs at this dose. The ratio of trough level to daily dose correlated between SRL and TAC. The synergistic effect seen in animal models also occurs in clinical liver transplant recipients on SRL-TAC combination immunosuppression. A low-dose combination of SRL and TAC should be compared with conventional immunosuppression in a multicenter, randomized, controlled trial.

INTRODUCTION: The inferior pedicle, Wise-pattern reduction mammaplasty is the most popular technique for breast reduction because of its reproducible results and reliability. However, complication rates in obese patients or large volume reductions are high, ranging from 35 to 78%. This study aimed to determine whether a modification to the standard Wise-pattern reduction technique, an expanded inframammary fold skin triangle, produces improved outcomes in high-risk large volume breast reduction patients.