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Summary Total IntraVenous Anaesthesia is frequently the anaesthetic of choice for enhanced recovery after surgery pathways during breast reconstruction free flap surgery. This relies upon the continuous intravenous infusion of propofol. We describe our experience of two patients where augmentation of a venously congested DIEP flap with a cephalic vein transposition procedure, risked interruption of the intravenous delivery of anaesthesia to the patient. We also share our steps taken to mitigate this risk going forward.

Background Free flap surgery has inherent risks, and the venous drainage of the Deep Inferior Epigastric Perforator (DIEP) flap is particularly vulnerable to congestion. In these cases, an algorithm for flap salvage should be followed and one of the final steps in this process is a cephalic vein transposition. Case Report We describe two patients undergoing mastectomy and immediate bilateral DIEP breast reconstruction, where cephalic vein transposition was required. As part of the Enhanced Recovery After Surgery (ERAS) pathway, patients are anaesthetised with a continuous propofol infusion (Total Intravenous Anaesthesia; TIVA). When the cephalic vein was identified, the propofol infusion was visible within the vein, which would have interrupted TIVA if harvested. To maintain continuous TIVA infusion, the cannula was resited prior to harvest of the cephalic vein. The cephalic vein was anastomosed to the superficial inferior epigastric vein and resolution of the venous congestion was noted. Conclusions These cases although rare highlight the importance of robust preoperative planning and communication between the team and preparation for all eventualities to ensure patient safety and successful outcomes. These cases highlight the potential effects vein harvesting or transposition may have on the safe and effective delivery of anaesthetic agents and other medication. We hope these cases prompt a discussion in the preoperative stage for alternate strategies for monitoring and intravenous access in response to diversions from the standard operating procedure.

Summary 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.

During the recovery restitution phase of the coronavirus pandemic, breast reconstruction teams have faced particular challenges to restarting this essential service. This is due to the length and complexity of the surgery, along with the demands on healthcare staff. The Royal College of Surgeons have classified immediate breast reconstruction as priority 2 and the National Institute for Health and Care Excellence have provided a pre-operative pathway for resumption of elective procedures. We therefore describe our experience in restarting our service for providing a breast reconstruction service from the 29th June 2020.

Therapeutic mammaplasty (TM) may be an alternative to mastectomy, but few well designed studies have evaluated the success of this approach or compared the short-term outcomes of TM with mastectomy with or without immediate breast reconstruction (IBR). Data from the national iBRA-2 and TeaM studies were combined to compare the safety and short-term outcomes of TM and mastectomy with or without IBR.The subgroup of patients in the TeaM study who underwent TM to avoid mastectomy were identified, and data on demographics, complications, oncology and adjuvant treatment were compared with those of patients undergoing mastectomy with or without IBR in the iBRA-2 study. The primary outcome was the percentage of successful breast-conserving procedures in the TM group. Secondary outcomes included postoperative complications and time to adjuvant therapy.A total of 2916 patients (TM 376; mastectomy 1532; mastectomy and IBR 1008) were included in the analysis. Patients undergoing TM were more likely to be obese and to have undergone bilateral surgery than those having IBR. However, patients undergoing mastectomy with or without IBR were more likely to experience complications than the TM group (TM: 79, 21·0 per cent; mastectomy: 570, 37·2 per cent; mastectomy and IBR: 359, 35·6 per cent; P 0·001). Breast conservation was possible in 87·0 per cent of patients who had TM, and TM did not delay adjuvant treatment.TM may allow high-risk patients who would not be candidates for IBR to avoid mastectomy safely. Further work is needed to explore the comparative patient-reported and cosmetic outcomes of the different approaches, and to establish long-term oncological safety.La mamoplastia terapéutica (therapeutic mammaplasty, TM) puede ser una alternativa a la mastectomía, pero hay pocos estudios bien diseñados que hayan evaluado el éxito de esta estrategia o hayan comparado los resultados a corto plazo de la TM con la mastectomía con o sin (+/-) reconstrucción mamaria inmediata (immediate breast reconstruction, IBR). Para comparar la seguridad y los resultados a corto plazo de la TM y la mastectomía +/- IBR se combinaron los datos de los estudios nacionales iBRA-2 y TeaM. MÉTODOS: En el estudio TeaM se identificó el subgrupo de pacientes al que se realizó una TM para evitar la mastectomía y se compararon los datos demográficos, las complicaciones, los resultados oncológicos y el tratamiento adyuvante con las pacientes sometidas a mastectomía +/- IBR del estudio iBRA-2. La variable principal fue el porcentaje de éxito de la cirugía conservadora de mama en el grupo TM. Las variables secundarias fueron las complicaciones postoperatorias y el intervalo de tiempo hasta el inicio del tratamiento adyuvante.Se incluyeron en el análisis 2.916 pacientes (TM n = 376; mastectomía n = 1.532; IBR n = 1.008). La TM era más frecuente en pacientes obesas o en las sometidas a cirugía bilateral en comparación con las pacientes con IBR. Sin embargo, las pacientes sometidas a una mastectomía +/- IBR tenían más probabilidades de desarrollar complicaciones que las del grupo TM (TM n = 79, 21,0%; mastectomía n = 570, 37,2%; mastectomía y IBR n = 359, 35,6%; P 0,001). La conservación de la mama fue posible en el 87% de las pacientes con TM y el procedimiento no retrasó el inicio del tratamiento adyuvante. CONCLUSIÓN: La TM puede permitir que pacientes de alto riesgo que no serían candidatas a IBR eviten la mastectomía de una forma segura. Se necesitan más trabajos para comparar los resultados percibidos por las pacientes y los estéticos de las diferentes estrategias terapéuticas y establecer la seguridad oncológica a largo plazo.

IntroductionOutcome reporting in research studies of breast reconstruction is inconsistent and lacks standardisation. The results of individual studies therefore cannot be meaningfully compared or combined limiting their value. A core outcome set (COS) has been developed to address these issues and identified 11 key outcomes to be measured and reported in all future research and audit studies in reconstructive breast surgery (RBS). A COS represents what key outcomes should be measured. The next step is to determine how and when this should be done. The aim of this study is to develop a core measurement set (CMS) for use in research and audit studies in implant-based breast reconstruction.Methods and analysisThe CMS will be developed in accordance with the guidance developed by the Core Outcome Measures in Effectiveness Trials initiative (COMET) and COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) group for the selection of outcome measurement instruments (OMIs) for relevant outcome domains included in the RBS COS. This will involve three phases with strategies to promote implementation as a final additional phase. The phases are (1) conceptual considerations in which the target population, procedures and settings are defined; (2) systematic reviews to identify existing clinical, patient-reported and cosmetic OMIs and, if appropriate, assess their quality using COSMIN methodology; (3) a modified Delphi process including sequential Delphi surveys involving approximately 100 healthcare professionals and a face to face consensus meeting to agree and ratify which outcome definitions and OMIs should be used and standardised time points for assessment; (4) strategies to promote dissemination and adoption of the CMS.Ethics and disseminationEthical approval has been granted by University of Bristol Faculty Research Ethics Committee FREC ID 60221. Dissemination strategies will include scientific meeting presentations and peer-reviewed journal publications. Implementation activities will include engagement with journal editors and funders to promote uptake and use of the CMS.

To quote Thompson: “all cleft lip surgeons have their favorite surgical technique for repairing the unilateral cleft lip. It is usually a hybrid of training experience and imagination.” [1] Of the ...

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.

Venous congestion is the principle cause of flap failure after microsurgical breast reconstruction. We aim to correlate preoperative computed tomography angiography (CTA) findings with postoperative venous congestion to predict patients at risk of congestion.All patients undergoing deep inferior epigastric perforator (DIEP) breast reconstruction between August 2009 and August 2013 underwent preoperative CTA and prospectively entered the study. Patients with postoperative venous congestion were matched with a similar cohort of complication-free patients. Preoperative CTAs were randomized and re-interpreted by a radiologist, blinded to the subsequent clinical outcome. Inter-group comparisons were performed.Two hundred and forty DIEP flaps were performed in 202 patients over the 4-year study. Venous congestion affected 15 flaps (6.3%). Preoperative CTA showed significantly more atypical venous connections between deep and superficial systems in congested flaps compared to controls (66.7% vs. 8%; P .0001), with a positive predictive value of 83%. Atypical connections were narrow, tortuous, or incomplete. Patients with congestion-free flaps had more normal connections (80% vs. 26.7%; P .001) and more cranial perforators (P = .02). Similar CTA findings between groups included perforator size and lateral position, superficial inferior epigastric vein size, crossing of midline, and absent connections (P .05).Preoperative CTA identifies atypical venous connections between deep and superficial systems that increase the risk of postoperative DIEP congestion five-fold. Identifying atypical venous connections maximizes the chances of flap survival and minimizes complications for patients considering DIEP breast reconstruction.

Summary 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.

Background: Breast reconstruction (BR) may improve psychosocial and cosmetic outcomes after mastectomy for breast cancer but currently, few women opt for surgery. Reasons for this are unclear. The aim of this qualitative study was to explore access to care and the provision of procedure choice to women seeking reconstructive surgery. Methods: Semi-structured interviews with a purposive sample of patients who had undergone BR and professionals providing specialist care explored participants' experiences of information provision before BR. Interviews were transcribed verbatim and analysed using the constant comparative technique of grounded theory. Sampling, data collection and analysis were performed concurrently and iteratively until data saturation was achieved. Results: Both patients and professionals expressed concerns about the provision of adequate procedure choice and access to care. Lack of information and/or time, involvement in decision making and issues relating to the evolution and organisation of reconstructive services, emerged as potential explanations for the inequalities seen. Interventions to improve cross-speciality collaboration were proposed to address these issues. Conclusion: Inequalities in the provision of choice in BR exist, which may be explained by a lack of integration between surgical specialities. Pathway restructuring, service reorganisation and standardisation of training may enhance cross-speciality collaboration and improve the patient experience.

This retrospective study reviews the demographics, morphology and management of paediatric hand fractures. Notes of all children with hand injuries attending a plastic surgery paediatric trauma clinic over a one-year period were reviewed. Non-bony injuries were excluded. A total of 303 fractures in 283 patients were included. Fracture incidence rose after the age of seven, peaking at 14 years of age; 76% of fractures occurred in males. Sporting injuries accounted for 47% of fractures. Physeal fractures were present in 39% of cases. Open fractures accounted for only 4% of all fractures. Management was primarily conservative. Only 5% of cases required surgical fixation; 6% of patients experienced complications.

Avulsion injuries of the flexor digitorum profundus (FDP) tendon are common and widely reported [1-3].

Summary 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.

PurposeThe purpose of this article to study referrals to our hand service to find out how long they had been waiting and with what sort of clinical conditions. The Department of Health monitors outpatient's waiting time as the percentage of patients seen within a 13‐week target. This target does not include patients referred by consultants or other health professionals.Design/methodology/approachAll the referral letters from other consultants or healthcare professionals still awaiting appointments were collected. The referrals were read and studied to ascertain the most likely diagnosis. This was recorded along with the source of the referral and the details to whom the referral was made. The date of the referral letter being received by the department (date stamped) was also noted.FindingsA total of 157 referrals from consultants or healthcare professionals were waiting outpatient dates. The median waiting time was 448 days (range 20‐952 days). The most frequent source of referrals was from the orthopaedic department. Carpal tunnel syndrome was the most common problem awaiting an outpatient appointment.Originality/valueThe wait for a clinic appointment for these patients is long. This has come about as the result of the fact that the government targets for outpatient waiting times have been set for GP referrals alone and exclude referrals that have been made by other consultants or other healthcare professionals. This is a clinical governance issue for the Hospital Trust, the Primary Care Trust and for general practitioners.

Multiple options

Interosseous epidermoid cysts of the phalanges are rare, particularly at the base of the phalanx and if the lesion is tender. We report a case of a tender interosseous epidermoid cyst at the base of the distal phalanx of a young man.

Resume La synostose congenitale isolee a ete decrite entre presque tous les os du carpe. Elle peut etre unique et dans ce cas, c’est la liaison entre le lunatum et le triquetrum qui est la plus frequente. Elle peut egalement etre multiple et s’associer alors a d’autres syndromes malformatifs. Nous rapportons un cas rarement decrit de synostose scaphotrapezienne bilaterale, restee quasiment asymptomatique chez une patiente de 63 ans.

Summary Introduction Free tissue transfer for breast reconstruction is widely practiced in the UK and its availability forms part of the NICE guidelines in treating breast cancer. Free flap reconstruction scores highly on patient reported outcome measures for both immediate and delayed procedures. However there are significant resource implications and a concern that the financial burden is not adequately met by the fixed price tariff system (Payment by Results). This study aims to compare the cost of treatment with both local financial estimates and reimbursement. Method We conducted a prospective costing analysis for 10 consecutive delayed unilateral DIEP breast reconstructions from August 2011 by a single surgeon in Frenchay Hospital, Bristol. Comparison was made to both the hospital's costing estimates and the Health Resource Group (HRG) tariffs received for 27 similar cases performed by the same surgeon in the 2010–11 financial year. Results The mean treatment cost for performing a delayed unilateral DIEP procedure was £7628 (±£754 Standard Deviation). This compared to an estimate from the financial department of £8072 ± (£1683 SD). These values were not significantly different ( p = 0.27). The HRG tariff was £8792 (±£423 SD). There was an average net income of £720 per case. Personnel in theatre represented the largest cost area at an average of 73% of total cost. Conclusions This study highlights that the costs of this procedure have been estimated accurately by the financial department and that the current HRG code provides adequate reimbursement. The new HRG code for 2012–13, HRG JA14z, provides significantly less reimbursement at £7012 and measures need to be taken to address this. This study has identified that personnel costs are the greatest contributor to overall cost and allowed us to recognise and implement changes to improve efficiency.

s / International Journal of Surgery 10 (2012) S53–S109 S66 ABSTRACTS and post-discharge antibiotic use to identify the infection rate. Themedical notes of the respondents were then reviewed to identify co-morbidities, operative data and antibiotic administration. Results: 161 patients were contacted and we received 96 responses (response rate 59.6%). Data collection was completed for 89 cases. The overall infection rate was 24%. 46% patients (41/89) had no prophylactic antibiotics; 27% (11/41) developed a wound infection. 42% patients (37/89) had a full course of prophylactic antibiotics; 22% (8/37) developed awound infection. This difference was not statistically significant. Route of administration: Patients who received intravenous antibiotics had an infection rate of 12.5% (1/8), compared to 30% (3/10) for oral antibiotics and 16% (3/19) for topical chloramphenicol ointment. Conclusion: The use of prophylactic antibiotics in elective plastic surgery does not significantly reduce postoperative wound infection rates. However, topical chloramphenicol ointment use may be beneficial and should be investigated further. 0304: INITIATING A TRANSFUSION PROTOCOL FOR FREE DIEP FLAP BREAST RECONSTRUCTION IN NORTH BRISTOL NHS TRUST James Smith, James Warbrick-Smith, George Filobbos, Sherif Wilson. North Bristol NHS Trust, Bristol, UK Aims: The authors aimed to identify the transfusion rate for patients having freedeep inferior epigastric perforator (DIEP)flapbreast reconstruction and highlight the role of pre-operative blood transfusion cross matching. Methods: A retrospective note review was performed between March 2007 and November 2011 of all patients undergoing free DIEP flap breast reconstruction post mastectomy. Patient demographics, pre-operative and post-operative haemoglobin and haematocrit, operative time, blood transfusion and post-operative complications were compared. Results: A total of 174 free DIEP breast reconstructions were performed on 145 patients; 116 unilateral and 29 bilateral procedures. 113 patients had delayed breast reconstruction whilst 32 patients underwent mastectomy and immediate reconstruction. The overall transfusion rate was 26.9%, 24 patients were transfused despite having a post-operative haemoglobin of more than 7g/dl. 44 patients had a valid group and hold and 20 of these patients had a cross-matched sample pre-operatively but did not receive a blood transfusion. Conclusions: The authors concluded that unilateral and bilateral free DIEP operations should not be cross-matched prior to surgery. This has fiscal implications for the trust and a clear protocol for staff to follow. This process might be applied to other general and plastic surgical operations. 0381: BCC EXCISION AUDIT IN PLASTIC SURGERY Luke Lintin. Derriford Hospital, Plymouth, UK Aims: To re-audit the incomplete excision rate of Basal Cell Carcinomas (BCCs) by a single plastic surgery department to monitor performance. Introduction: Excision margins were analysed from 115 consecutively excised BCCs between 09/09/2011 and 31/10/2011. Analysis: Of the 115 BCCs excised 6 (5.2%) were incompletely excised (where the lesions were involved at the the surgical margins). All incompletely excised lesions involved the circumferential margin and none involved the deep margin. Discussion: Guidelines form The British Association of Dermatologists published in 2008 suggest that a 4-5mm margin will completely excise approximately 95% of BCCs. An incomplete excision rate of 5.2% is comparable to studies from other British plastic surgical units. Data collected from a similar audit in September 2010 showed a 7.4% incomplete excision rate for BCCs in the same plastic surgery department, suggesting that the department's performance has remained consistent with no statistical difference between the two sets of data (p1⁄40.5722). Conclusion: In order to minimise incomplete excision rates surgeons should assure that they are excising lesions with standardised 4-5mm circumferential margins regardless of anatomical position, wherever possible. This may require an increase in the number of local flaps or grafts performed in order to reconstruct defects. 0409: AN AUDIT OF ANTIBIOTIC PROPHYLAXIS IN PLASTIC SURGERY: A SINGLE-CENTRE EXPERIENCE George Lye, Amar Ghattaura. The Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea, UK Aim: Incorrect antibiotic usage is financially expensive and may harm individuals. The SIGN Guidelines 104 stipulate “best-practice” in antibiotic prescriptions to prevent surgical-site infections. This audit aimed to establish the appropriateness of antibiotic prescriptions in the department. Method: A retrospective-study of acute (n1⁄458) and elective (n1⁄420) admissions to the plastic surgery department over a period of 1 week was performed using the SIGN 104 guidelines for antibiotic usage in surgical wounds. Results: Antibiotics were prescribed in trauma (79%) and elective (55%) cases. Co-Amoxiclav was prescribed in 60% of trauma and 45% of elective cases. 38% of trauma prescriptions and 20% of elective cases were inappropriate. Co-Amoxiclav was inappropriately prescribed in 51% of trauma and 33% elective cases. In clean-contaminated trauma cases a 2:1 inappropriate: appropriate prescription ratio existed. Inappropriate prescriptions for trauma cases included 19 post-op antibiotic courses for cleancontaminated wounds; 2 IV antibiotic courses for clean-contaminated wounds; and 1 contaminated case with short-course antibiotics. Inappropriate prescriptions for elective cases included 3 post-op courses of antibiotics for clean wounds; and 1 post-op course for a clean-contaminated wound. Conclusion: There is a high inappropriate antibiotic prescription rate in plastic surgery. Guidelines should be established to prevent this in the future. 0466: PREDICTING MULTI-FOCALITY IN NECROTISING FASCIITIS: A PARADIGM CHANGER OR PARALYSIS BY ANALYSIS? Ussamah El-khani , Jean Nehme , Ammar Darwish , Nicholas Bennett , Simon Heppell , Godwin Scerri . Queen Alexandra Hospital, Wessex Deanery, UK; Manchester Royal Infirmary, Manchester, UK Introduction: Multifocal Necrotising Fasciitis is defined as more than one non-contiguous area of necrosis. Current management guidelines of necrotising fasciitis pertain to single-focus disease, with no recognition of the implications of multi-focality. Aim: To conduct the first ever systematic review onmulti-focal necrotising fasciitis. Materials andMethods: A PRISMA-guided systematic review of MEDLINE, OLD MEDLINE and Cochrane Collaboration was performed from 1966 to March 2011 using sixteen search terms. Of the papers that demonstrated multi-focality, the following data was extracted: patient demographics, inciting injury, presentation time-line, microbial agents, sites affected, objective assessment scores, treatment and outcome. Results: 33 individual cases of Multifocal Necrotising Fasciitis were included in the quantitative analysis. 52% of cases were Type II Necrotising Fasciitis. 42% had identifiable inciting injuries. 21% developed multifocal lesions non-synchronously, of which 86% were Type II. 94% of cases had incomplete objective assessment scores. One case identified inflammatory imaging findings prior to clinically detectable necrosis. Conclusions:Multifocality in Necrotising Fasciitis is likely to be associated with Type II disease. We postulate that validated objective tools will shape management pathways and identify high risk groups. We recommend adoption of regional Multifocal Necrotising Fasciitis registers and consideration of early pre-emptive imaging in select cases. 0484: REDUCING ABDOMINAL COMPLICATIONS FROM BREAST RECONSTRUCTION USING DIEP FLAPS R.L. Tillett, J. Rees-Lee, S.M. Wilson. Plastic & Reconstructive Surgery Department, Frenchay Hospital, Bristol, UK Introduction: Abdominal wound complications can cause significant post operative morbidity. A retrospective review of 61 patients, undergoing DIEP breast reconstruction over a 26 month period, by a single surgeon, showed delayed wound healing requiring conservative treatment in 16 (26.2%) and operative treatment in 4 (6.6%) patients. 3 patients (4.9%) developed a seroma and 4 patients (6.6%) developed an abdominal bulge (6.6%). Junior team members had been performing abdominal wounds closure. These results were compared to a large meta-analysis of 1997 patients undergoing abdominal flap breast reconstruction (Salgarello et al, 2011). Methods:Anewregimeof abdominal closure involving3 layersofmonocryl, with either the senior author supervising a senior trainee or performing the procedure himself, was instituted. Data was collected retrospectively on subsequent consecutive patients undergoing DIEP reconstruction.

A review of the described methods of attachment of flexor tendon grafts to the distal phalanx is presented. The authors advocate the previously described method of attachment consisting of passage of the tendon graft through the pulp with anchorage to the nail. A new modification of this technique is presented, facilitating accurate dissection and placement of the graft with minimal trauma.

Background Abdominal CT angiography (CTA) has become an integral part of the pre-operative evaluation of patients undergoing free Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction. It aids accurate delineation of perforator anatomy, assists pre-operative decision making and reduces operative time. However, such detailed imaging invariably yields a variety of incidental findings, with quoted figures of 13–36% in this setting. The purpose of this study was to identify the rate of “incidentalomas” when using DIEP CT angiography and, review how such findings influence our management. Method A retrospective review was performed, looking at pre-operative scan reports of 154 consecutive patients undergoing free DIEP flap breast reconstructions between July 2008 and June 2012. Results Of 154 CTA's reviewed, 116 (75.3%) demonstrated incidental findings. In 71 patients (46.1%), these “incidentalomas” were inconsequential. However, in 37 patients (24.0%) the CTA prompted further investigations, and notably in a further 8 patients (5.2%) metastatic disease or other significant pathology was discovered which changed the operative plan. Conclusion The overall rate of “incidentalomas” presented in this study is substantially higher than other similar published series, and most importantly, significantly altered the surgical management plan in 5.2% of cases. As such we would advocate that a pre-operative “staging” CTA, imaging the chest, abdomen and pelvis is useful for more than just delineation of vascular anatomy in patients undergoing DIEP flap reconstruction.