In many centres, the myocutaneous transverse upper gracilis (TUG) flap represents an alternative choice in autologous breast reconstruction when abdominal tissue is unavailable. However, a single TUG flap may be volume deficient, particularly in the upper pole. We describe the application of simultaneous lipofilling to the pectoralis major muscle at the index procedure and present our decision-making algorithm, technique and outcomes. A retrospective review of all TUG flaps between January 2011 and May 2021 was conducted. Patient demographics, volume of primary and any subsequent fat grafting and complications were recorded. A total of 183 patients (242 TUG flaps) were included in this study. Of these; 130 patients were reconstructed with single TUG flaps, 16 patients received a single TUG flap with immediate lipofilling, and 37 patients underwent stacked, double TUG flap reconstructions. Of the 242 flaps, there were 2 flap losses (< 1%), neither of which occurred in the immediate lipofilling cohort. Among the 130 single TUG patients, 28 (21.5%) required a cumulative total of 40, and a mean of 1.4, secondary lipofilling procedures. The immediate lipofilling patients were injected with a mean of 42 ml fat (range: 20-80 ml). In this group, only 2 of 16 patients required secondary lipofilling. The mean follow-up was 67 months (17-141). Primary lipofilling may reduce the need for secondary revisional procedures and appears safe at the index operation, adds little operative time and has negligible donor site morbidity. In patients where a second (stacked) flap would add unnecessary volume and complexity, it can be considered a useful adjunct. (c) 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Background: Despite seasonal variation in malignant melanoma diagnosis being well described, data on the annual variation in high-risk melanomas are scarce. Objectives: We set out to investigate the relationship between seasonality, the incidence of melanoma, and the distribution of melanoma characteristics, including Breslow thickness, ulceration, mitotic rate, lymphovascular and perineural invasion, and the presence of microsatellites. Methods: Primary cutaneous malignant melanomas diagnosed between 2011 and 2019 in Eastern England were identified from our prospectively maintained melanoma database (n = 2199). These were analysed by year and season of diagnosis, patient demographics, and melanoma characteristics. Results: There was a variation in rates of melanoma diagnosis across the year, with Summer having the highest incidence (p < 0.0001). There was a significant trend towards more male than female diagnosis in Winter (p = 0.0354). There were no significant seasonal trends in Breslow thickness, ulceration, tumour infiltrating lymphocytes, or mitotic rate. Multivariate analysis showed that microsatellites were more likely to be diagnosed in the Winter (OR=2.00 (1.19-3.43), p = 0.010), lymphovascular invasion significantly more likely to be diagnosed in Autumn (OR=1.78 (1.16-2.76), p = 0.009), and perineural invasion was more likely to be diagnosed in the Summer (OR=0.44 (0.23-0.79), p = 0.007). Conclusions: These data confirm that high-risk phenotypes are associated with increasing Bres-low thickness and mitotic rate. However, season variability as an independent risk factor for the phenotypes is a novel finding. (c) 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Breast reconstruction can be performed using implants or autologous tissue, either alone or in combination. Implants typically require re-operation during the patient's lifetime, often for adverse capsular contracture. Conversion from implants to autologous tissue may improve symptoms and deliver a definitive reconstruction. This is known as salvage breast reconstruction. In this paper we evaluate the indications, outcomes, complications and cost implications of salvage breast reconstruction in our regional centre and report these in line with the STROBE guidelines. Retrospective casenote analysis of all salvage breast reconstruction patients from January 2018 to January 2020 was performed. Nineteen patients were identified, with a median age of 52 years. Indications were all capsular contracture other than two each of implant rupture and patient request. Thirty-two perforator free flaps; 29 deep inferior epigastric, two profunda artery and one lateral thoracic artery flap were performed. Median time from first implant to free flap reconstruction was nine years. Median hospital stay was five days. No total flap losses and one partial flap loss occurred. Three patients underwent secondary procedures to the breast to improve the aesthetic outcome. All patients reported improvement in symptoms and appearance. For implant-intolerant patients adequately counselled and accepting of the post-operative downtime, salvage reconstruction with autogenous tissue offers a lasting solution. The upfront healthcare costs are higher with a free tissue transfer, but may become comparable longer term given the multiple exchange of implant procedures required over a patient's lifetime.

When autologous breast reconstruction is planned but abdominal tissue is not available, the lumbar artery perforator flap provides an alternative choice with minimal donor site morbidity. The lumbar and posterior intercostal arteries supply adjacent perforasomes on the posterolateral flank. The purpose of this report is to highlight the salvage of an autologous breast reconstruction free flap using a dorsal perforator of the posterior intercostal artery, when the planned lumbar artery perforators were not suitable. The patient was a 74-year-old with recurrent left-sided breast cancer requiring immediate breast reconstruction. A lumbar perforator flap was planned as an oblique ellipse 19 × 10 cm. Intraoperatively, the two identified perforators traveled superiorly up to the 12th rib and therefore originated from the intercostal rather than lumbar arteries. The internal mammary artery and the vena comitants were used as recipient vessels, anastomosed to an interposition graft. Postoperatively, the patient was discharged home after 7 days without complication. Six months later, the patient was pleased with the reconstruction and had negligible donor site morbidity. The dorsal intercostal artery perforator flap therefore provides a salvage option when presumed lumbar artery perforators are dissected and found to be intercostal in origin.

The result of an extra-levator abdominoperineal excision of the rectum (ELAPE) is a composite three-dimensional defect. This is performed for locally advanced anorectal cancer, and may involve partial excision of the vagina. The aim of reconstruction is to achieve wound healing, restore the pelvic floor and to allow micturition and sexual function. We aim to evaluate the concurrent use of profunda artery perforator (PAP) and bilateral gracilis flaps for vaginal and pelvic floor reconstruction. We performed a retrospective case note review of patients undergoing pelvo-perineal reconstruction with combined gracilis and PAP flaps between July 2018 and December 2019. Eighteen pedicled flaps were performed on six patients with anal or vulval malignancies. All underwent pre-operative radiotherapy. Four patients had extended abdominoperineal tumour resections, while two patients underwent total pelvic exenteration. The median age was 57 (range 47-74) years, inpatient stay was 22 (11-47) days and the follow-up was 10 (5-21) months. Four patients developed partial perineal wound dehiscence, of which one was re-sutured. One patient had a post-operative bleed requiring radiological embolisation of an internal iliac branch and had subsequent 1cm PAP flap loss. All other flaps survived completely. Median time to heal was 4 (1-6) months. This is the first series reporting combined bilateral gracilis and PAP flaps for pelvic reconstruction. The wound dehiscence rate and healing times were expected in the context of irradiation and radical pelvic tumour resection. This is a reliable technique for perineal and vaginal reconstruction with minimal donor site morbidity. (C) 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

When performing breast reconstruction, reduction of the contralateral breast is often required to achieve symmetry. The tissue that would otherwise be discarded from the reduced breast has been utilized as a free flap. This has the benefit of minimizing donor site morbidity, and combining the principles of "spare-part-surgery" and replacing "like-with-like." The purpose of this paper is to report the procedure, outcome, and potential controversies of using a free lateral thoracic artery perforator flap for contralateral breast reconstruction. We present a 32-year-old with congenital breast asymmetry previously corrected with an implant. The patient required tertiary breast reconstruction for capsular contracture, and a simultaneous left breast reduction. There was no history of breast cancer. The reconstruction proceeded as follows; the right sided breast implant was removed. On the left breast, a wise pattern reduction with a superomedial pedicle was instigated. Intraoperatively, four perforating arteriovenous pedicles perfusing the reduced tissue were identified; of which the lateral thoracic artery perforator was selected. The flap weight was 296 g. The lateral thoracic pedicle was anastomosed to the right internal mammary vessels. The flap survived completely. The post-operative course was uneventful and without complication. The patient was followed up for 1 year and was pleased with the final result. The application of the LTAP free flap may cautiously be extended to oncological breast reconstruction. For patients to be suitable, they would need a large remaining breast to provide adequate tissue for reconstruction, up-to-date breast screening and a low risk of developing breast cancer in the future.

Globally, there has been a measured response to rationalise elective operating during the Coronavirus disease 2019 (COVID-19) pandemic. In terms of breast cancer care, this has led to a restricted provision of reconstruction with autologous free tissue transfer. A primary concern is the risk of mortality in elective surgery patients who develop COVID-19. The aim of this report is to describe the observed physiological impact of the virus on our patient, and to address how outpatient care after autologous free tissue transfer can be delivered to COVID-19 positive patients.

True occipital artery aneurysms are exceptionally rare. To our knowledge only five reports of true occipital artery aneurysm have been previously described.1-5 We present a rare case of a 70-year-old gentleman with a true occipital artery aneurysm associated with alopecia areata. This case report adds to the current lack of literature on true occipital artery aneurysms and summarises their presentation, investigation and management.

The Royal College of Surgeons (RCS) guide to surgical prioritisation during the coronavirus (COVID-19) pandemic states that breast reconstruction is Priority level 4 Surgery, meaning it can be delayed for over three months.1Federation of Surgical Specialty Associations (FSSA). Guide to surgical prioritisation2020.Google Scholar The 30-day mortality in elective surgery patients diagnosed peri-operatively with COVID-19 may be as high as 19.1%.2COVIDSurg CollaborativeMortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study.Lancet. 2020; PubMed Google Scholar In view of the associated mortality risk, and potential complications such as return to theatre, autologous free tissue transfer for breast reconstruction was withheld in our unit from the 12th March. It is the view in our regional centre that free tissue transfer for breast reconstruction should not be viewed as complex surgery. We believe in performing the correct operation, for the right patient, at the right time and we strive to adhere to the NHS improvement program GIRFT (getting it right first time). After widespread consultation with stakeholders both locally and nationally, as of June 3rd we re-started autologous free flap reconstruction. We describe our experience as the first unit in resuming this service during the COVID-19 pandemic. Stage 1- Discussion stage with key stakeholders With limited resources and time available, it was important to prioritise patients and maintain discussion of reconstruction on a trust director level agenda. Cases were discussed on an individual basis using the RCS prioritisation as a guideline. Categories of patients that we felt would require reconstruction during Phase 1 were reviewed regularly and highlighted to surgical directors. Our exclusion criteria were adapted according to both the emerging situation within our unit and in the medical literature. Stage 2- Development of pathway We developed an evidence based pathway that selected low risk patients and then minimised their potential pre-operative and inpatient COVID-19 exposure. The commitment and approval of our nursing and physiotherapist colleagues has been central to the service re-opening. Multidisciplinary ownership of the pathway was key to engaging the senior management team. Furthermore, the nursing staff provided data on the practical availability of trained theatre and ward staff. The enthusiasm of a large group of motivated individuals created momentum to restart the service. Theatre lists were reduced and pooled. Low risk patients attend a pre-operative virtual forum consultation with surgeons, specialist nurses and physiotherapists. This is where most information is provided, in order to reduce the length of the subsequent face-to-face consultation. Prioritisation of cases on a Divisional Operations level was based on clinical needs as well as requirement and availability of resources. We expected four hours of operating and did not plan to take breaks or change scrub nurse intraoperatively, thereby reducing personal protective equipment usage. Two plastic surgery consultants were supported by an experienced scrub team. We presented this streamlined theatre plan to theatre managers. This was particularly important as during Phase 2 the theatre workforce was reduced by 30%. Our enhanced recovery protocol includes patient discharge on day two. Our pathway for restarting DIEPs was presented to the hospital executive board. Whilst the trust directors were considering the proposal, potential low risk surgical candidates were identified. Stage 3- National consensus and support from colleagues On May 15th, our unit chaired an online meeting to gauge the national viewpoint on breast reconstruction and initiate discussion. This concluded 72% (22/30) plastic surgeons were ready to resume reconstruction within three months. There was particular concern regarding the growing waiting list for delayed DIEPs, safety of surgery and implications for training. There was also recognition of the national variation of COVID-19 effects on hospitals. Our unit had 40% inpatient capacity. Through this meeting we gained support from key stakeholders such as BAPRAS which was essential to resuming our reconstruction service. Stage 4- Safety and consent In line with the Montgomery ruling,3Montgomery v Lanarkshire Health Board. AC 1430. SC 112015Google Scholar all forms of reconstruction and associated additional COVID-19 risks were discussed with patients. Our exclusion criteria, shown in Table 1, is based on current best evidence, and our own experience of a DIEP patient with COVID-19.2COVIDSurg CollaborativeMortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study.Lancet. 2020; PubMed Google Scholar,4Sharp O, Masud, D. Breast reconstruction with immediate autologous free tissue transfer in a peri-operative COVID-19 positive patient: a case report illustrating feasibility of aftercare. Publication pending, June2020.Google Scholar Our initial protocol criteria utilises age, comorbidity and body mass index, although we expect to move to using the clinical frailty score as our experience grows.Table 1Exclusion criteria.Age > 60 yearsAll smokers and recent ex-smokers (< 2 years)Patients with a cancer history other than the breast cancerPre-operative lymphopenia countPre-operative low vitamin DCardiovascular disease (AF and previous MI/ stroke/TIA)Hb < 10Patients who live in a household with 1) high risk individuals 2) key workers whom are unable to isolatePatients unable to accept 72-hour hospital stayBMI > 30Bilateral (for June)Poor perforators on CT angiogramActive respiratory diseaseWe select low risk patients at a virtual reconstruction MDT jointly lead by breast and plastic surgeons. Any attendance to the hospital is mapped on a 'green route' whereby patients are able to enter and pass through our pre-screened, lowest risk ward. AF, Atrial fibrillation; MI, Myocardial infarction; TIA, Thromboembolic event; Hb, Heamoglobin; BMI, Body mass index; CT, Computerised tomography. Open table in a new tab We select low risk patients at a virtual reconstruction MDT jointly lead by breast and plastic surgeons. Any attendance to the hospital is mapped on a 'green route' whereby patients are able to enter and pass through our pre-screened, lowest risk ward. AF, Atrial fibrillation; MI, Myocardial infarction; TIA, Thromboembolic event; Hb, Heamoglobin; BMI, Body mass index; CT, Computerised tomography. Our legal team was consulted to discuss how risks of exposure and complications were presented and provided us with patient information leaflets. As a result, we have a dedicated section in our reconstruction virtual forum discussing the risks of COVID-19. We have also devised a procedure-specific consent form for our DIEPs which includes a section on COVID-19 risks and complications. Stage 5- Service recommenced We recommenced operating on June 3rd. Initially we booked low-risk patients whom were accepting of the additional hazard of COVID-19. A powerful tool for resuming reconstruction was the reconstruction forum to discuss cases for immediate autologous reconstruction this allowed categorisation to level 2. We are closely monitoring our service, and depending on the future epidemiology of COVID-19, we will continue to adapt our pathway. None.