Microsurgical breast reconstruction accounts for 22% of breast reconstructions in the UK. Despite thromboprophylaxis, venous thromboembolism (VTE) occurs in up to 4% of cases. Using a Delphi process, this study established a UK consensus on VTE prophylaxis strategy, for patients undergoing autologous breast reconstruction using free-tissue transfer. It captured geographically divergent views, producing a guide that reflected the peer opinion and current evidence base. Methods Consensus was ascertained using a structured Delphi process. A specialist from each of the UK's 12 regions was invited to the expert panel. Commitment to three to four rounds of questions was sought at enrollment. Surveys were distributed electronically. An initial qualitative free-text survey was distributed to identify likely lines of consensus and dissensus. Each panelist was provided with full-text versions of key papers on the topic. Initial free-text responses were analyzed to develop a set of structured quantitative statements, which were refined via a second survey as a consensus was approached. Results The panel comprised 18 specialists: plastic surgeons and thrombosis experts from across the UK. Each specialist completed three rounds of surveys. Together, these plastic surgeons reported having performed more than 570 microsurgical breast reconstructions in the UK in 2019. A consensus was reached on 27 statements, detailing the assessment and delivery of VTE prophylaxis. Conclusion To our knowledge, this is the first study to collate current practice, expert opinion from across the UK, and a literature review. The output was a practical guide for VTE prophylaxis for microsurgical breast reconstruction in any UK microsurgical breast reconstruction unit.

There is extensive discussion regarding method of perineal defect closure extralevator abdominoperineal excision, but little consideration of optimal postoperative management of the flaps, or use of Enhanced Recovery After Surgery in flap reconstruction. Literature review revealed little discussion of optimum postoperative care of perineal flaps following extralevator abdominoperineal excision. We have developed a protocol for postoperative care of perineal flaps for use in conjunction with colorectal Enhanced Recovery After Surgery pathways, easily followed in units not specialising in plastic surgery. The protocol was developed using translatable evidence from guidelines for flap care from other subspecialties, as well as the experience of management of post-extralevator abdominoperineal excision perineal flaps in our trust, with the aim of enabling early detection of deterioration in this complex cohort, with a multidisciplinary enhanced recovery approach.

Background: The transverse upper gracilis flap is an important reconstructive option for patients who desire autologous reconstruction after mastectomy but in whom a deep inferior epigastric perforator flap is unavailable or undesirable. The authors present an analysis of outcomes and patient satisfaction results, from a consecutive series in a single institution. Methods: Using a prospectively populated free flap database, all patients undergoing transverse upper gracilis flap breast reconstruction for a mastectomy defect between January of 2013 and December of 2017 were identified. Retrospective review of clinical notes, admissions, and discharge information was conducted to identify outcomes, secondary operations, and complications. All patients were contacted by letter and invited to take part in a patient satisfaction survey a minimum of 12 months after free-flap surgery. Results: Seventy-eight patients underwent transverse upper gracilis flap breast reconstruction using a total of 103 transverse upper gracilis flaps to reconstruct 99 breast mounds in the 5-year period studied. Patient satisfaction is evidenced by BREAST-Q scores showing 81 ± 19 percent Satisfaction with Breasts, 80 ± 20 percent Psychosocial Well-Being, and 84 ± 19 percent Physical Well-Being of the chest. Forty-six of 53 (87 percent) report satisfaction with the postoperative appearance of their thigh unclothed and 51 of 53 (96 percent) report satisfaction clothed. Conclusions: This is the first consecutive series of transverse upper gracilis flap breast reconstruction outcomes that presents BREAST-Q scores for multiple, postoperative reconstruction modules and details complications stratified by Clavien-Dindo score. The methodology can be easily replicated and benchmarked against. Our donor-site complication rates are lower than previous publications and patient satisfaction data reveal that this is a well-accepted option for patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Introduction The transverse upper gracilis (TUG) flap is a reliable alternative to abdominally based breast reconstruction because of its advantageous anatomy. However, the limited tissue volume prevents reconstruction of large breasts. The bilateral TUG flaps for unilateral breast reconstruction can overcome this problem. Methods A retrospective analysis was performed regarding unilateral breast reconstruction with bilateral TUGs at the Queen Victoria Hospital from 2015 to 2019. Associations between categorical variables were examined with Fisher exact test, and any differences in continuous variables by complication status were evaluated with Mann-Whitney-Wilcoxon test for independent samples. A relevant systematic review was conducted with a meta-analysis of proportions using the Freeman-Tukey arcsine transformation for the estimation of the overall survival rates. Results Ten cases were identified with 6 having a delayed reconstruction. Median age and body mass index were 50.8 years and 23.9 kg/m2, respectively, and average flap weight was 268.3 g. One flap was placed superiorly with its pedicle anastomosed to the retrograde internal mammary vessels, except of half of the cases where a second anterograde vein was used. The mean follow-up was 21.4 months, and all flaps survived. Two patients returned to theater, and 4 experienced donor-site problems. The presence of complications was not associated with age, ever smoking, body mass index, TUG weight, or anastomosis to retrograde internal mammary vein. The systematic review resulted in 8 eligible articles with a total sample of 156 flaps. The overall survival rate was 96.8%. In 6 cases, the indication was Poland syndrome (7.7%), and in 48.7%, axillary vessels were also used as recipient vessels. The estimated overall flap survival rate was 100% (95% confidence interval, 99%–100%), and no significant heterogeneity was noted (I 2 = 0%, P = 0.71). Conclusions The “2-in-1” technique can lead to symmetrical aesthetically pleasant results for both recipient and donor sites. Our case series and the conducted systematic review reiterate the reliability of this approach.

INTRODUCTION:The transverse upper gracilis (TUG) flap is a reliable alternative to abdominally based breast reconstruction because of its advantageous anatomy. However, the limited tissue volume prevents reconstruction of large breasts. The bilateral TUG flaps for unilateral breast reconstruction can overcome this problem.METHODS:A retrospective analysis was performed regarding unilateral breast reconstruction with bilateral TUGs at the Queen Victoria Hospital from 2015 to 2019. Associations between categorical variables were examined with Fisher exact test, and any differences in continuous variables by complication status were evaluated with Mann-Whitney-Wilcoxon test for independent samples. A relevant systematic review was conducted with a meta-analysis of proportions using the Freeman-Tukey arcsine transformation for the estimation of the overall survival rates.RESULTS:Ten cases were identified with 6 having a delayed reconstruction. Median age and body mass index were 50.8 years and 23.9 kg/m 2 , respectively, and average flap weight was 268.3 g. One flap was placed superiorly with its pedicle anastomosed to the retrograde internal mammary vessels, except of half of the cases where a second anterograde vein was used. The mean follow-up was 21.4 months, and all flaps survived. Two patients returned to theater, and 4 experienced donor-site problems. The presence of complications was not associated with age, ever smoking, body mass index, TUG weight, or anastomosis to retrograde internal mammary vein. The systematic review resulted in 8 eligible articles with a total sample of 156 flaps. The overall survival rate was 96.8%. In 6 cases, the indication was Poland syndrome (7.7%), and in 48.7%, axillary vessels were also used as recipient vessels. The estimated overall flap survival rate was 100% (95% confidence interval, 99%-100%), and no significant heterogeneity was noted ( I2 = 0%, P = 0.71).CONCLUSIONS:The "2-in-1" technique can lead to symmetrical aesthetically pleasant results for both recipient and donor sites. Our case series and the conducted systematic review reiterate the reliability of this approach.

The COVID-19 pandemic, has had an unprecedented effect on the NHS, but also across global healthcare systems. This level of disruption and redesigning of plastic surgery services has only been compared to major historical events, such as world wars and other disasters.1Nikkhah M.D. COVID-19 The Great Disruptor.J Plast Reconstr Aesthet Surg. 2020; (S1748-6815-0): 30271https://doi.org/10.1016/j.bjps.2020.05.083Abstract Full Text Full Text PDF Scopus (8) Google Scholar Microsurgery services have had to carry on being available for lower limb injuries and head and neck cancers, even during the peak of the disease.2Ramella V. Papa G. Bottosso S. Cazzato V. Arnež Z.M. Microsurgical reconstruction in the time of COVID-19,.Microsurgery. 2020; 15 (doi: 10.1002/micr.3060)https://doi.org/10.1002/micr.30604Crossref Scopus (6) Google Scholar At the same time, outpatient clinics and elective operating lists were reduced dramatically, due to hospital staff reassignments and to minimise the risk of patient exposure to the virus. Elective surgery, including immediate breast reconstructions, were held back and the guidance from world surgical societies was to delay reconstructive procedures.3Pace B.D. Benson J.R. Malata C.M. Breast reconstruction and the COVID-19 pandemic: a viewpoint.J Plast Reconstr Aesthet Surg. 2020; (S1748-6815-5): 30217https://doi.org/10.1016/j.bjps.2020.05.033Abstract Full Text Full Text PDF Scopus (13) Google Scholar As we enter a long recovery phase in June 2020, the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) published guidance on how to safely resume breast reconstruction services.4http://www.bapras.org.uk/docs/default-source/default-document-library/restarting-breast-recon-pathways.pdf?sfvrsn=2.Google Scholar One of the main highlighted issues, has been the impact on training after this long period of surgical inactivity. This will potentially be aggravated by the policy of strict consultant delivered services during the recovery period. The aim of this study was to quantify the impact of the pandemic on microsurgery fellowships and potentially offer advice on mitigating some of its adverse effects. We developed a questionnaire that was distributed amongst 5 plastic surgery units in London, known for offering microsurgery fellowship programmes: Royal Marsden, Charing Cross, St Thomas', Broomfield and Queen Victoria Hospitals. The information was provided by a Consultant Microsurgeon in each case (Figure 1). All units were affected by the pandemic. The number of fellows employed by each hospital was between 2 and 6. In two units, the microsurgical fellows were relocated to assist with breast and colorectal oncology procedures. In all participating units, breast reconstruction services ceased in March, ranging from the 16th to the 23rd and the recovery plans have not been homogeneous. The Royal Marsden and Charing Cross Hospitals, have slowly restarted offering immediate breast reconstructions in the beginning of June, St Thomas' and Broomfield hospitals by the end of June and Queen Victoria hospital by July. This reflects the different impacts the pandemic has had in the individual hospitals, which needs to be evaluated prior to elective procedures recommencing. The majority of the consultants felt that the fellows were unlikely to achieve their individual goals in microsurgery and programme extensions had been offered. A pleasant surprise during this period of crisis, was the upgrade of teaching reported in all units. As found in the recent literature, lockdown gave rise to virtual teaching which provided an accessible source of highly effective learning.5Sleiwah A. Mughal M. Hachach-Haram N. Roblin P. COVID-19 lockdown learning: the uprising of virtual teaching.J Plast Reconstr Aesthet Surg. 2020; (S1748-6815-X): 30214https://doi.org/10.1016/j.bjps.2020.05.032Abstract Full Text Full Text PDF Scopus (29) Google Scholar Finally, when asked how the negative impact on training could be mitigated, the answer was a combination of programme extensions and more structured webinar teaching opportunities. In conclusion, the impact of COVID-19 pandemic has been significant in microsurgical training. This study highlights the extent of the problem but demonstrates that supervising consultants are aware of this new reality. As microsurgery services resume globally, programme extensions and increased teaching, seem as the best way to compensate for the lost training opportunities. None. None.

Introduction: The use of abdominal flaps is recognized as a very advantageous approach for breast reconstruction with gradual refinements leading from the pedicled transverse rectus abdominis musculocutaneous flap to the criterion standard deep inferior epigastric perforator (DIEP) flap and its several variations. A systematic review with meta-analysis attempts to investigate the safety of the bipedicled DIEP flap for unilateral breast reconstruction. Methods: The literature search used "PubMed" database, and a relevant study conducted at the Queen Victoria Hospital was also included. The extraction of data included study type, follow-up, patients' age, body mass index, preexisting abdominal scars, timing of reconstruction, operating time, flap inset, pedicles' configuration, flap failure, revision, and complication rates. Proportions were pooled with Freeman-Tukey arcsine transformation, and meta-regression was performed to evaluate whether complication rates were modified by different variables. Results: Fourteen eligible articles provided an overall sample of 486 flaps, with a median follow-up of 18.5 months. In most cases, immediate reconstruction with undivided flap was performed, with equal use of extraflap and intraflap pedicles' configuration. Only 4 cases of flap failure (0.82%) were documented, with 18% overall complications and 3% fat necrosis rate. The forest plot showed significant between-study heterogeneity, and meta-regression revealed marginal positive association between older patient and complication rate. Conclusions: Bipedicled DIEP flap for unilateral breast reconstruction is a technique that maintains the complications rate relatively low in challenging postmastectomy cases. Further comparative studies are needed to substantiate the findings of this study.

Background The deep inferior epigastric perforator (DIEP) flap is currently the flap of choice for autologous breast reconstruction. When the amount of tissue transferred needs to be maximised, a bi-pedicled DIEP flap allows harvesting the entire lower abdomen. Methods A retrospective analysis was conducted including patients who had unilateral breast reconstruction with bi-pedicled DIEP flaps between January 2013 and December 2017. Demographic information, operation notes and post-operative course were reviewed. Mann-Whitney-Wilcoxon and Fischer's exact tests were used to look for a statistically significant association between complications and intra-operative modalities. Results Forty-four cases were reviewed. Half of these patients underwent delayed breast reconstructions, 40.9% underwent immediate reconstructions and 10% were salvage cases. The majority of the cases (52.3%) had an initial anastomosis of the secondary pedicle to either a side branch (38.6%) or the superior continuity (13.6%) of the primary pedicle (intra-flap anastomosis). Twenty-seven percent of the intra-flap arterial anastomoses were performed using vessel couplers. The remaining 47.7% of the cohort had anastomoses of both pedicles to the internal mammary (IM) vessels anterogradely and retrogradely. There were no flap failures. The cases in which both pedicles were anastomosed with IM vessels had an overall higher complications rate, but were not related to flap failures or anastomotic issues. Intra-flap anastomosis on the other hand is a reliable alternative including the possibility of vessel coupler application to smaller arteries of this approach. Conclusions In our experience, bi-pedicled DIEP flaps are a safe alternative for unilateral breast reconstruction when the amount of harvested tissue needs to be maximised. Level of evidence: Level III, therapeutic study.

Background: The free transverse upper gracilis flap is well described for breast reconstruction and is the authors’ second choice. Medial thigh soft tissue creates a durable, pliable, aesthetic breast; however, it has been criticized for modest volume and short pedicle. This demands frequent use of bilateral flaps for unilateral reconstructions, sacrifice of thoracodorsal vessels, and/or use of vein grafts. The authors have overcome these issues by modifying their microvascular techniques. Methods: The authors describe several maneuvers that they have introduced, including excision and replacement of costal cartilage, using nontraditional internal mammary arterial anastomoses, and using adductor branches for flap-to-flap anastomoses to allow double flap reconstructions. The authors describe their case series of 30 transverse upper gracilis flaps to reconstruct 20 breasts in 18 patients. Results: All flaps have survived. Seventy-five percent of the reconstructions were unilateral, although of these, 67 percent used two flaps to reconstruct one breast. The mean reconstructed breast was 360.9 g. Of 10 breasts reconstructed with double flaps, six used available adductor branches, whereas the others used internal mammary perforators, end-to-side anastomoses, or retrograde arterial flow. To complement this clinical approach, an anatomical study of the branching patterns from the gracilis pedicle has been carried out on 33 cadaveric specimens. Conclusions: The authors’ study has allowed a new classification system to be defined and demonstrates suitable branching patterns to allow flap-to-flap anastomoses in 75 percent of patients; in those 25 percent where this is not possible, alternative strategies for double flaps can be sought and have been used successfully in our clinical series. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Introduction: Residual limb infection following amputation is a devastating complication, resulting in delayed rehabilitation, repeat surgery, prolonged hospitalisation and poor functional outcome. The aim of this study was to identify variables predicting residual limb infection following non-salvageable lower limb trauma.Methods: All cases of non-salvageable lower limb trauma presenting to a specialist centre over 5 years were evaluated from a prospective database and clinical and management variables correlated with the development of deep infection.Results: Forty patients requiring 42 amputations were identified with a mean age of 49 years (+/- 19.9, 1SD). Amputations were performed for 21 Gustilo IIIB injuries, 12 multi-planar degloving injuries, seven IIIC injuries and one open Schatzker 6 fracture. One limb was traumatically amputated at the scene and surgically revised. Amputation level was transtibial in 32, through-knee in one and transfemoral in nine. Median time from injury to amputation was 4 days (range 0-30 days). Amputation following only one debridement and within 5 days resulted in significantly fewer stump infections (p = 0.026 and p = 0.03, respectively, Fisher's exact test). The cumulative probability of infection-free residual limb closure declined steadily from day 5. Multivariate analyses revealed that neither the nature of the injury nor pre-injury patient morbidity independently influenced residual limb infection.Conclusion: Avoiding residual limb infection is critically dependent on prompt amputation of non-salvageable limbs. (C) 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The incidence and mortality due to malignant melanoma has increased three-to four-fold across males and females in England and Wales over the past thirty years. 1 Ninety percent of patients with primary melanoma have no clinical evidence of lymphadenopathy at presentation. 2 In this paper we describe our management of impalpable axillary melanoma deposits in a patient with a pedicled latissimus dorsi (LD) flap reconstruction to the ipsilateral breast. No such case has been previously described in the literature. (C) 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Over the last few decades, there have been many important advances in the treatment of severe lower limb injuries. This article looks at a few of the more widely used classification systems and Injury Severity Scores to examine their utility in a practical setting.Gustilo and Anderson formulated their landmark classification system in 1976 (J Bone Joint Surg Am. 1976; 58: 453-458). For the Gustilo classification system to serve any useful purpose, it is necessary to include supplemental information, whenever discussing these injuries, that includes the mechanism and energy of the injury and the presence of any other concomitant injuries or comorbidities.Byrd et al (Plast Reconstr Surg. 1985; 76: 719 -728) recognized some of the shortcomings of the Gustilo-Anderson system and proposed a classification system of their own in 1985. The Byrd-Spicer classification is less commonly used, mainly because of a large degree of interobserver variability, but it includes energy and presence of devitalized tissue.The Predictive Salvage Index, devised in 1987, recognized the importance of vascular injury as a prognostic indicator and was formulated in an attempt to avoid not only unnecessary amputations, but also to avoid protracted attempts at salvage that might eventually be converted into a delayed amputation.The Mangled Extremity Severity Score looked at 4 variables: patient age; the presence and duration of shock; ischemia time; and the energy of the injury. Critics question the relevance of its parameters.The 7 components of the Limb Salvage Index include injury to an artery, deep vein, nerve, bone, skin, and muscle as well as warm ischemia time. However, predictive results have not been reproduced.The Hanover Fracture Scale was initially developed on the basis of 13 weighted variables to quantify risk factors for amputation and complications in high-energy trauma to a limb. This included index bacteriology, and was weighted heavily toward the presence of vascular injury.Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score attempted to address criticized weaknesses of the Mangled Extremity Severity Score.These scores can be useful tools in the decision-making process when used cautiously, but should not be used as the principal means for reaching difficult decisions.

Necrotising fasciitis (NF) can complicate varicella zoster virus in children. This is rare and has not previously been reported in the plastic surgery literature. We report a case of a female toddler who developed necrotising fasciitis secondary to chicken pox. Her presentation and progress are reported, the diagnosis of necrotising fasciitis in children and the small number of case series and case control studies are discussed.

Over the last thirty years the internal mammary system has become the recipient of choice when performing free tissue transfer breast reconstruction. The cranial ends of the internal mammary artery and vein are safely and reliably used for anastomosis following division. Using these cranial vessels maintains their normal antegrade direction of flow. As the complexity of reconstruction has increased, use of the caudal end of the internal mammary vein (IMV) has been cited as a convenient option for additional venous drainage. This requires blood flow in a retrograde fashion. The literature to date suggests that this is possible based on the principle that there are no valves in the internal mammary vein. This will be shown to be incorrect. In this study, the internal mammary veins of 32 formalin-preserved cadavers were dissected to specifically look for and to map valves. 21 valves were discovered in the internal mammary veins of 14 of the 32 cadavers (99 internal mammary veins and major branches). 20 of these were bicuspid in nature, one being tricuspid. Valves were found before or after the branching point of the IMVs, and at multiple sites within some individuals. The significance of valve position relative to rib-space and arborisation of parent IMVs is discussed. Whereas existing data support the use of retrograde IMVs to provide a source of additional venous drainage, we would urge caution in using them exclusively. A proportion of IMVs appear to have valves between the commonly used 2nd or 3rd rib-spaces, and the next draining side-branch.

As techniques of microsurgery continued to develop and become more widespread, surgeons were able to counter problems of donor morbidity and improve flap viability with use of the “free TRAM flap.” This method of autologous reconstruction completely separates abdominal wall tissue from the lower abdomen, which is then transferred to the anterior chest wall. Microvascular techniques with anastomosis of the deep inferior epigastric vessels to the internal mammary or thoracodorsal vessels are used to restore blood supply to the TRAM flap. The free TRAM flap is based on the deep inferior epigastric vessels rather than the superior epigastric vessels on which the pedicled TRAM flap is based. Anatomic and functional studies have clearly demonstrated that the deep inferior epigastric system provides the dominant arterial and venous supply to the lower abdomen. Studies have also demonstrated that the superior epigastric system can only perfuse the lower abdomen via collateral supraumbilical “choke” vessels, and that the caliber, pressure and flow of blood through the superior epigastric arteries are less that that of the deep inferior epigastric arteries. Thus, the area of the lower abdomen perfused by each superior epigastric system is smaller than the area supplied by each deep inferior system (6-8). This partiallyaccounts for the higher frequency of venous congestion and partial flap loss witnessed in the pedicled TRAM group when compared with the free TRAM group of patients (9-11). A further benefit of the free TRAM flap is that the integrity of the inframammary fold can be better preserved; thus with a pedicled TRAM flap it is necessary to tunnel through to the chest wall from the upper abdomen to create a passage for the flap. The body of the rectus muscle lies within this tunnel and may allow the inframammary crease to drift inferiorly. Moreover, the rectus muscle can produce an unsightly prominence in the epigastrium, especially with a contralateral pedicled TRAM flap.

We wish to highlight an interesting case treated at our Burns Centre recently. A 25-year-old man sustained a rectangular shaped full thickness burn to the lateral aspect of his left thigh whilst inebriated. Upon waking the patient found his mobile telephone damp and functionless in his left trouser pocket. There are many reports of mobile telephone induced injuries in the literature including mobile telephone explosion and acute ear trauma. We purport that although the mobile telephone has become an important means of communication worldwide, care must be taken in its use as there is potential to cause serious injury. Language: en

&NA; The authors have indicated no significant interest with commercial supporters.

As yet no qualitative research studies looking at return to work following burns have been published. The aim of this study was to investigate the “hows” and “whys” of return to work, by purposively selecting a cross-section of burns patients who returned to the same/similar job, those who returned to work but either on a part-time basis or in a different role/job and those who became or remained unemployed, and using semi-structured interviews to explore their experiences. Using matrix analysis methodology, and with the general themes that emerged from these transcripts, it was possible to place patients into 5 broad groups, the “defeated”, the “burdened”, the “affected”, the “unchanged” and the “stronger”. We anticipate that use of these general groups will be useful in targeting multi-disciplinary return to work strategies, and discuss how this qualitative research has changed practice at the Queen Victoria Hospital Burns Centre.