Background: Bilateral breast augmentation has been the top surgical procedure performed worldwide by plastic surgeons for the past 5 years. Complex breast revision patients are challenging, with the cleavage area being one of the most difficult areas to navigate. We present a novel technique for using biological scaffolds in revision breast augmentation surgery. Methods: A step-by-step surgical technique is presented, combined with a series of 11 cases where either SurgiMend (R) acellular dermal matrix (ADM) or GalaFLEX mesh was used specifically in the medial cleavage area to correct a difficult to manage soft tissue contour deformity. Results: Eleven patients underwent revision breast augmentation with the use of the biological scaffolds in the medial cleavage area. The mean age was 43 years with a range of 29-68 years. All replacement breast implants were anatomical-shaped, medium profile, polyurethane-coated implants. GalaFLEX (R) mesh was used in six patients; five patients received SurgiMend (R) ADM. Mastopexy was performed in 8/11 patients. There were two complications in the same patient in this series, one emergency return to theater for bleeding and one minor scar revision. Conclusions: Revision breast augmentation surgery includes a smorgasbord of options that can be used individually or in combination, such as full or partial capsulectomy, removal alone or replacement of the implant, change to the tissue plane of where the implant sits, mastopexy, and fat transfer. In addition to these recognized treatments, we would like to advocate the option of a biological scaffold for extra support of the cleavage area in complex revision cases.

Background: Activation of platelets in platelet-rich plasma may improve growth factor release, thus enhancing regenerative properties. The authors investigated whether different methods of platelet-rich plasma activation affected growth factor release kinetics over time. Methods: Platelet-rich plasma from 20 healthy volunteers was processed by six different methods: (1) control (nonactivated); (2) activation with calcium chloride; (3) activation with calcium chloride and ethanol; (4) activation with calcium chloride and ethanol at 4°C; (5) activation with calcium chloride and ethanol with vitamin C; (6) activation with calcium chloride and ethanol with vitamin C at 4°C. Concentration of secreted vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), and insulin-like growth factor over 24 hours was measured by immunoassay. Results: Calcium chloride–activated platelet-rich plasma produced significantly more insulin-like growth factor at 1 hour compared to cold and vitamin C platelet-rich plasma, and calcium chloride plus ethanol produced significantly more at 24 hours compared to vitamin C platelet-rich plasma. The addition of vitamin C reduced release of PDGF over time. Activation with calcium chloride and ethanol with or without cold temperature produced a gradual PDGF release as opposed to calcium chloride alone, which caused higher PDGF within 4 hours. There were no significant differences between groups for VEGF, although calcium chloride and cooled platelet-rich plasma approached significance for producing more than vitamin C platelet-rich plasma. Conclusions: Activation of platelet-rich plasma does not significantly improve growth factor secretion, which is made worse by the addition of vitamin C, a platelet inhibitor. Ethanol does not negatively impact growth factor production and may offer a more gradual release. Clinical Relevance Statement: These findings will help guide platelet-rich plasma preparation methods where therapeutic growth factors are used. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Background The deep inferior epigastric artery perforator (DIEP) flap is the commonest flap used for breast reconstruction after mastectomy. It is performed as a unilateral (based on one [unipedicled] or two [bipedicled] vascular pedicles) or bilateral procedure following unilateral or bilateral mastectomies. No previous studies have comprehensively analyzed analgesia requirements and hospital stay of these three forms of surgical reconstruction. Methods A 7-year retrospective cohort study (2008–2015) of a single-surgeon’s DIEP-patients was conducted. Patient-reported pain scores, patient-controlled morphine requirements and recovery times were compared using non-parametric statistics and multivariable regression. Results The study included 135 participants: unilateral unipedicled (n=84), unilateral bipedicled (n=24) and bilateral unipedicled (n=27). Univariate comparison of the three DIEP types showed a significant difference in 12-hour postoperative morphine requirements (P=0.020); bipedicled unilateral patients used significantly less morphine than unipedicled (unilateral) patients at 12 (P=0.005), 24 (P=0.020), and 48 (P=0.046) hours. Multivariable regression comparing these two groups revealed that both reconstruction type and smoking status were significant predictors for 12-hour postoperative morphine usage (P=0.038 and P=0.049, respectively), but only smoking, remained significant at 24 (P=0.010) and 48 (P=0.010) hours. Bilateral reconstruction patients’ mean hospital stay was 2 days longer than either unilateral reconstruction (P<0.001). Conclusions Although all three forms of DIEP flap breast reconstruction had similar postoperative pain measures, a novel finding of our study was that bipedicled DIEP flap harvest might be associated with lower early postoperative morphine requirements. Bilateral and bipedicled procedures in appropriate patients might therefore be undertaken without significantly increased pain/morbidity compared to unilateral unipedicled reconstructions.

A middle aged gastroenterologist presented with a two day history of sudden onset and exquisitely painful erythematous swelling around the distal interphalangeal joint of her left ring finger. She had no history of acute trauma but described repetitive hand use while performing four endoscopy sessions weekly for around 25 years: the left hand had been used to manoeuvre the endoscope and the left ring finger to press the control buttons. She was otherwise fit and well, right handed, and a non-smoker. Flexor sheath …

Background: The use of abdominal tissue in post-mastectomy autologous breast reconstruction is a popular choice among reconstructive surgeons. This is the first study to evaluate donor complications comparing unilateral, bilateral, and bipedicled DIEP breast reconstructions. Methods: A retrospective chart review was conducted of all women undergoing rib-preserving DIEP free flap breast reconstruction at a University Hospital between 2008 and 2015 by the senior surgeon (CMM). Results: A total of 130 patients were included in this study and were divided into three groups: unipedicled unilateral (n = 93), unipedicled bilateral (n = 19), and bipedicled unilateral (n = 18). Relative to the unipedicled unilateral group, the age and BMI-adjusted odds of complication were almost two-fold higher in the bilateral group [Odds ratio (95% CI): 1.97 (0.63, 6.19)] and approximately halved in the bipedicled group [Odds ratio (95% CI): 0.59 (0.22, 1.61)]; however, these associations were not statistically significant. Overall, 75% of complications were managed conservatively. The majority of ClavieneDindo grade 3 complications were observed in participants from the unipedicled unilateral group (84%), whereas no patients in the bipedicled group developed morbidity that required recourse to surgery or readmission to hospital. Conclusions: Although further research with greater statistical power will be valuable, the results of this investigation provide evidence that donor site morbidity of bipedicled DIEP free flap breast reconstructions does not increase when compared with those of unipedicled unilateral and unipedicled bilateral surgical procedure types. (C) 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

An 82-year-old man was referred to the gastroenterology outpatient department on the fast-track cancer pathway with iron-deficiency anemia (hemoglobin, 87 g/L; mean corpuscular volume, 68.8) and melena. His clinical examination was normal. He was referred for urgent gastroscopy and computed tomography (CT) colonography. Gastroscopy showed a potentially fungating mass protruding into the posterior wall of the esophagus (Figure A). Wires were visible on the surface of the mass, suggesting that the patient’s endovascular stent had eroded into the esophagus. Remaining gastroscopy showed only occasional erosions and CT colonography was normal. Sixteen months previously the patient had a mycotic saccular aneurysm of the distal descending thoracic aorta repaired using an endovascular stent graft (Valiant Captivia Thoracic Stent Graft; Medtronic, Minneapolis, MN). Long-term flucloxacillin was commenced because blood cultures taken during stent grafting grew Staphylococcus aureus. He was considered unfit for surgery. Eight months after the repair, the patient had an episode of chest pain with pyrexia, hypotension, and possible hematemesis. CT initially reported no abnormality of the stent graft repair and the patient was treated for angina. In light of the endoscopy findings, the CT scan was re-reviewed at the multidisciplinary meeting, and in retrospect a small defect in the esophageal wall adjacent to the stent graft was identified (Figure B, the row of arrowheads denotes the location of the stent graft, the white arrow points to air within the distal esophagus). A further CT scan performed 3 weeks after endoscopy showed gas surrounding the stent graft. Absent previously, the gas confirmed the presence of an aorto-esophageal fistula (AEF) (Figure C, the radio-opaque struts of the stent graft are marked as SG, the white arrow points to air within the esophagus and to the defect in the esophageal wall, the arrowhead points to air between the aortic wall and wall of the stent graft). AEF may develop secondary to thoracic endovascular aortic repair, infected aneurysms are a risk factor. Possible presenting features include chest pain, hematemesis, fever, and shock.1Czerny M. Eggebrecht H. Sodeck G. et al.New insights regarding the incidence, presentation and treatment options of aorto-oesophageal fistulation after thoracic endovascular aortic repair: the European Registry of Endovascular Aortic Repair Complications.Eur J Cardiothorac Surg. 2014; 45: 452-457Google Scholar, 2Luehr M. Etz C.D. Nozdrzykowski M. et al.Emergency open surgery for aorto-oesophageal and aorto-bronchial fistulae after thoracic endovascular aortic repair: a single-centre experience.Eur J Cardiothorac Surg. 2015; 47: 374-383Google Scholar The incidence of AEF formation after thoracic endovascular aortic repair has been reported at 1.5%.1Czerny M. Eggebrecht H. Sodeck G. et al.New insights regarding the incidence, presentation and treatment options of aorto-oesophageal fistulation after thoracic endovascular aortic repair: the European Registry of Endovascular Aortic Repair Complications.Eur J Cardiothorac Surg. 2014; 45: 452-457Google Scholar The diagnosis of AEF may prove challenging with its low incidence and nonspecific presentation. However, it is crucial to note the past medical history in such patients when performing gastroscopy. This patient was remarkably well and hemodynamically stable. Biopsy of the mass would have resulted in fatal hemorrhage. Conservative management has been associated with a high mortality rate.1Czerny M. Eggebrecht H. Sodeck G. et al.New insights regarding the incidence, presentation and treatment options of aorto-oesophageal fistulation after thoracic endovascular aortic repair: the European Registry of Endovascular Aortic Repair Complications.Eur J Cardiothorac Surg. 2014; 45: 452-457Google Scholar Aggressive surgical treatment has been shown to improve mortality,1Czerny M. Eggebrecht H. Sodeck G. et al.New insights regarding the incidence, presentation and treatment options of aorto-oesophageal fistulation after thoracic endovascular aortic repair: the European Registry of Endovascular Aortic Repair Complications.Eur J Cardiothorac Surg. 2014; 45: 452-457Google Scholar, 2Luehr M. Etz C.D. Nozdrzykowski M. et al.Emergency open surgery for aorto-oesophageal and aorto-bronchial fistulae after thoracic endovascular aortic repair: a single-centre experience.Eur J Cardiothorac Surg. 2015; 47: 374-383Google Scholar therefore patients should be referred for review. In this case, review of the patient concluded that he was unfit for further surgical intervention. His iron-deficiency anemia was treated with ferrous sulfate tablets, and after a month of therapy his anemia had improved (hemoglobin, 127 g/L; MCV, 77.2). He was advised to stop his antiplatelet therapy and to continue with long-term antibiotics.

Introduction: Primary bilateral breast augmentation is the commonest aesthetic procedure in the UK and USA. Occasionally revision breast implant surgery is warranted. Multiple indications and complexity of surgery make it difficult to generalise the approach and patients present with a gamut of implant generations. We present a practical approach based on the senior author's experience.