Background Breast deformity is common following lumpectomy. Use of ptotic lower pole tissue for restoration of volume in the upper pole is quite appealing since it allows for a concomitant lift. This study presents the medial pillar island flap technique of oncoplastic breast reconstruction of upper pole defects. Methods Vascular anatomy of the lower pole of the breast was investigated with cadaver study. The medial pillar island flap was designed utilizing the territory of the inferior pole of the breast as an island flap pedicled medially by the internal mammary artery perforators surrounded by the soft tissue of the medial pillar. It was transposed to the upper pole lumpectomy defect as an independent flap from superomedial pedicle which was utilized for nipple transposition. Results The dominant internal mammary artery perforator supplying the medial pillar island flap was consistently found in the fourth interspace at a mean distance of 8.5 cm (range, 8 to 10) from the sternal midline. Thirty patients underwent the procedure, with a mean age of 61 years and mean body mass index of 28.9. The average size of the defect was 170 cm3 (range, 48 to 295 cm3). The majority of the patients (n = 28) underwent opposite breast symmetry surgery as well. The average follow up was 12 months. Complication rate was 23.3%. Reoperation rate was 16.7%. There was no evidence of flap compromise or nipple areola complex necrosis. Patient satisfaction was high, with a mean score of 4.1 (range, 2 to 5) out of 5. Conclusions The medial pillar island flap has reliable vascularity based on the internal mammary artery system. The flap carries lower pole breast tissue as confined by the medial and lateral pillars of a vertical mastopexy design, offering unrestricted arc of rotation for effective reconstruction of upper pole lumpectomy defects as it is completely dissected from the chest wall and the inframammary fold. The two flap design, along with superomedial pedicle, accomplishes versatility for flap inset. The technique was proven to result in safe outcomes without major complications.

Reconstruction of lower back defects is challenging. Since primary repair is often not possible to achieve, there is a need for local or regional flap transfer. This report presents a new technique of reconstruction of lumbosacral defects by deep circumflex iliac artery perforator skin flap based on a propeller flap design. A lower back scar contracture and contour deformity in a 10-year-old female patient required excision and flap reconstruction. Deep circumflex iliac artery perforator flap was marked in the groin region as an elliptical skin paddle and dissected as an island flap based on a dominant musculocutaneous perforator. Following creation of the lumbosacral defect, reconstruction was accomplished by flap rotation based on a propeller flap design around the perforator. Donor site was closed primarily in layers. Complete flap survival was noted with uneventful recovery. Revision was later performed for flap debulking and contour restoration with pleasing result at 1year. Deep circumflex iliac artery perforator flap can be utilized for lower back defect reconstruction by means of a propeller flap design. It is offered as a new flap option for lumbosacral reconstruction. The technique allows well-vascularized tissue transfer while accomplishing primary closure of the donor site with easily hidden scar. The disadvantages include tedious dissection as well as absence of a dominant perforator in some cases.Level of Evidence: Level V, therapeutic study.

Sir: As surgical education evolves toward more outcome-based measures, methods for objective and accurate evaluation of residents will be increasingly necessary.1 In microsurgical education, there is currently no standardized method of training and evaluation; however, global rating scale assessment instruments have been validated.2 These require senior microsurgeons to grade live or video-recorded operations performed by residents in simulation laboratories. Recent Plastic and Reconstructive Surgery Viewpoints have discussed software tools that facilitate assessment by simultaneously displaying recorded video and the evaluation form to be completed.3 Smartphone coupling to microscopes or other optical instruments has been used in pathology, ophthalmology, dermatology, and hematology, and for global health and teleconsultation. Although photography is commonplace is plastic surgery, the literature includes few applications of smartphone cameras, such as an app for postoperative free flap perfusion monitoring.4 The senior author (M.A.) has previously experimented with consumer digital cameras in microstructural photography.5 We present a simplified and cost-effective method for video recording of microsurgical operations using a smartphone's high definition camera coupled to an operating microscope. During the annual microsurgery training course at our institution, we experimented with coupling smartphones to an operating microscope with an additional monocular viewing eyepiece (Fig. 1). After developing prototype adapters, which were functional albeit cumbersome, we discovered the many commercially available adapters for this purpose. We selected the Snapzoom (HI Resolution Enterprises, Honolulu, Hawaii) adapter because it is low cost, universally adjusts to different phone models with or without a protective case, and is designed to attach to either binocular or monocular eyepieces in the widescreen mode. Once positioned properly, the smartphone camera recorded high-quality video while displaying video on the screen (Fig. 2). (SeeVideo, Video Supplemental Digital Content 1, which demonstrates a rat femoral artery anastomosis recorded using a smartphone coupled to an operating microscope. The quality has been reduced to ease online access; however, the original quality is high-definition 1080p video, https://links.lww.com/PRS/B287.) It was possible to broadcast live video to a computer using video-sharing programs such as Skype (a division of Microsoft Corp., Redmond, Wash.). Typically, a black rim was visible, even when properly positioned, which could be easily removed by digital zoom on a camera app.Fig. 1: Smartphone (iPhone; Apple, Inc., Cupertino, Calif.) attached to Snapzoom adapter, coupled to a monocular third viewing eyepiece, displaying and recording residents performing a rat femoral vessel anastomosis.Fig. 2: A single frame from video captured using a smartphone (iPhone) during a rat end-to-end femoral artery anastomosis demonstrates the high quality and clarity of video output possible using this technique.Video: Supplemental Digital Content 1 demonstrates a rat femoral artery anastomosis recorded using a smartphone coupled to an operating microscope. The quality has been reduced to ease online access; however, the original quality is high-definition 1080p video, https://links.lww.com/PRS/B287.As smartphones with high-definition cameras are ubiquitous among plastic surgery trainees and faculty, this method presents an affordable alternative to expensive clinical-grade video solutions for the recording of microsurgical simulations. Multiple adapters can be used for recording multiple residents simultaneously. Disadvantages of this method include limited storage space on many consumer smartphones and that, unless a third eyepiece is available (Fig. 1), the second microscope eyepiece must be used for the camera instead of by an assistant. Future developments should focus on directly recording video to a networked location where it can easily be stored, accessed, and evaluated by attending surgeons. In conclusion, a simple and affordable smartphone method for capturing high-definition video recordings of microsurgery training operations is presented. Access to recorded video is essential for microsurgical education, allowing later review and evaluation with previously described assessment tools.2,3 Methods that are simple, cost-effective, and validated will enable surgical training programs to easily implement competency-based curricula designed to objectively evaluate resident aptitude in performing simulation exercises. DISCLOSURE This work was funded by the University of Massachusetts Division of Plastic Surgery as part of the annual microsurgery course. The authors have no financial disclosures or commercial associations that might create a conflict of interest related to this communication, including the following products mentioned: Snapzoom smartphone-microscope adapter, Apple iPhone, and the Skype program. Dylan Perry, B.A. Mark Albert, M.D. Mustafa Akyurek, M.D., Ph.D. Division of Plastic Surgery Department of Surgery University of Massachusetts Medical School Worcester, Mass.

Background: Abdominoplasty is one of the most commonly performed cosmetic operative procedures. Few large studies have examined outcomes of cosmetic abdominoplasty in a community setting. The authors explored postoperative outcome and the preoperative and intraoperative factors that may contribute to these complications. Methods: A retrospective review of consecutive patients undergoing abdominoplasty over an 11-year period was performed. Baseline patient demographics, intraoperative technique, and postoperative outcomes were recorded. Preoperative and intraoperative characteristics were analyzed to determine characteristics that predispose patients to complications and undesirable outcomes. Results: The 1008 study patients underwent either a full or modified abdominoplasty with a total complication rate of 32.6 percent. The most common complication was seroma (15.4 percent). Liposuction of the abdominal flap was performed in 469 patients (46.5 percent) and liposuction of the flanks was performed in 555 patients (55.1 percent). Chi-square analysis followed by logistic regression revealed that liposuction of the flanks and abdomen was independently associated with seroma formation in addition to major and minor complications (p < 0.05). Conclusions: Seroma formation following abdominoplasty is the most common complication. Concomitant liposuction of the flanks and abdomen with the addition of aggressive undermining leads to higher seroma rates. This association is likely multifactorial and may be secondary to increased resorptive demands placed on the abdominal lymphatics in the setting of greater dead space and larger fluid shifts as a result of liposuction. To reduce seroma rates, surgeons should avoid aggressive liposuction and undermining, particularly in high-risk patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Neaman, KC MD; Armstrong, SD; Baca, ME; Albert, M; VanderWoude, DL; Renucci, JD Author Information

Armstrong, SD MD; Neaman, KC; Baca, M; Vanderwoude, DL; Renucci, JD; Albert, M Author Information