Bilateral Reconstruction Research Articles

Building Complex Autologous Breast Reconstruction Program: A Preliminary Experience

Autologous breast reconstruction is an increasingly popular method of reconstruction for breast cancer survivors. While deep inferior epigastric perforator (DIEP) flaps are the gold standard, not all patients are ideal candidates for DIEP flaps due to low BMI, body habitus, or previous abdominal surgery. In these patients, complex autologous breast reconstruction can be performed, but there is a limited number of programs around the world due to high technical demand. Given the increased demand and need for complex autologous flaps, it is critical to build programs to increase patient access and teach future microsurgeons. In this paper, we discuss the steps, pearls, and preliminary experience of building a complex autologous breast reconstruction program in a tertiary academic center. We performed a retrospective chart review of patients who underwent starting the year prior to the creation of our program. Since the start of our program, a total of 74 breast mounds have been reconstructed in 46 patients using 87 flaps. Over 23 months, there was a decrease in median surgical time for bilateral reconstruction by 124 min (p = 0.03), an increase in the number of co-surgeon cases by 66% (p < 0.01), and an increase in the number of complex autologous breast reconstruction by 42% (p < 0.01). Our study shows that a complex autologous breast reconstruction program can be successfully established using a multi-phase approach, including the development of a robust co-surgeon model. In addition, we found that a dedicated program leads to increased patient access, decreased operative time, and enhancement of trainee education.

Bilateral network with rich semantic extractor for real-time semantic segmentation

Recently, owing to the requirements of inference speed, most real-time semantic segmentation networks often have shallow network depth, which limits the receptive field size of the model, leading to the limited acquisition of semantic information and resulting in intraclass inconsistency and ultimately a decrease in segmentation accuracy. Additionally, the shallow network depth also restricts the feature extraction capability of the network, reducing its robustness and ability to adapt to complex scenes. To address these issues, a bilateral network with a rich semantic extractor (RSE) for real-time semantic segmentation (BRSeNet) is presented to perform real-time semantic segmentation. First, to solve the problem of insufficient semantic feature information extraction, an RSE is proposed, which includes a multiscale global semantic extraction module (MGSEM) and a semantic fusion module (SFM). The MGSEM can extract rich global semantics and expand the effective receptive field. Simultaneously, the SFM efficiently integrates multiscale local semantics with multiscale global semantics, resulting in more comprehensive semantic information for the network. Finally, based on the characteristics of detail and semantic branches, a bilateral reconstruction aggregation module is designed to reconstruct the contextual information of detail features, model the interdependencies on semantic feature channels, and enhance feature representation. Comprehensive experiments on the challenging Cityscapes and ADE20K datasets are conducted. The experimental results show that the proposed BRSeNet achieves mean intersection over union of 74.9% and 35.7% at inference speeds of 74 and 65 frames per second, respectively, and ensures a favorable balance between segmentation accuracy and inference speed.

The transverse upper gracilis flap for autologous breast reconstruction: patient satisfaction outcomes from a single centre experience.

The transverse upper gracilis (TUG) flap procedure is an alternative procedure for autologous breast reconstruction, that is indicated in patients with a low body mass index (BMI) and small to moderate sized breasts. We investigated patient satisfaction of all TUG flap breast reconstructions at Royal Free Hospital. A retrospective review of all patients who had undergone a TUG flap procedure was performed using Electronic Patient Records between October 2010 and October 2021 in Royal Free Hospital. We collected patient demographic data and surveyed our cohort by telephone, investigating patient satisfaction with a 31-item questionnaire. From 2010 to 2021, 57 TUG procedures for autologous breast reconstruction were carried out on 36 patients. One patient died 6 years postoperatively. Patient age ranged from 29-74 with an average of 49.5 years. Also, 3/57 flaps failed, and 1 patient died 6 years postoperatively. Twenty one out of 35 patients responded to the telephone call survey. Out of the survey respondents 11/21 underwent unilateral breast reconstruction and 10/21 underwent bilateral breast reconstruction. The BODY-Q scale in appraisal of thighs reported an overall patient satisfaction mean score of 75.6±27.4 points. The BREAST-Q scale in breast satisfaction reported an overall patient satisfaction mean score of 61.5±24.1 points. Overall, 19/21 of patients were satisfied with the outcome of the TUG procedure. Royal Free Hospital reported excellent patient satisfaction scores. The TUG procedure is a suitable method for patient's undergoing autologous breast reconstruction. However, patient expectations regarding breast satisfaction should be managed.

Bilateral Robot-Assisted Reconstruction of the Ureter with Buccal Graft and Omental Wrapping

Bilateral Robot-Assisted Reconstruction of the Ureter with Buccal Graft and Omental Wrapping

Axillary Hidradenitis Suppurativa: A Comparison between Two Perforator Flap Reconstructive Approaches after Radical Surgical Management.

Axillary hidradenitis suppurativa (HS) can result in significant functional impairment in both personal and professional lives. Stage 3 HS requires radical surgical treatment. Flap reconstruction allows for faster healing and better functional and aesthetic outcomes. We compared the results of thoracodorsal artery perforator (TDAP) and propeller inner arm artery perforator (IAAP) flap reconstructions after radical surgical treatment of axillary HS. We conducted a retrospective study that included 13 consecutive patients who underwent stage 3 axillary HS treatment between August 2015 and January 2023. Seven patients underwent reconstruction by islanded TDAP flaps, whereas six patients underwent reconstruction by propeller IAAP flaps, with one patient undergoing bilateral reconstruction. The data collected from the patient records included age, gender, smoking status, body mass index, comorbidities, operative time, defect size, flap size, hospital stay, and complications. Although not statistically significant (P = 0.1923), a higher rate of flap complications is reported here with propeller IAAP flaps (42.86 %), whereas islanded TDAP flaps had no flap complications (0%). We found a statistically significant difference in operative time (P = 0.0006), defect size (P = 0.0064), and flap size (P = 0.0012) between the two groups. All patients exhibited satisfactory functional and aesthetic outcomes. Fourteen flaps were performed in total; only one case exhibited recurrence (7.14%). After radical surgical management, both islanded TDAP and propeller IAAP flap reconstructions offer excellent outcomes for stage 3 axillary HS. We strongly encourage our peers to consider performing perforator flaps over secondary healing for these patients with a major functional impairment.

Breast Reconstruction With Simultaneous Bilateral Lumbar Artery Perforator Flaps Improves Waistline Definition and Buttock Projection.

The lumbar artery perforator (LAP) flap is a valuable secondary option for autologous breast reconstruction when abdominal donor sites are not available. The aim of this study was to determine how the LAP donor site affects waistline and gluteal proportions, and whether LAP flaps may produce potential secondary benefits concerning donor site aesthetics. A retrospective review of 50 patients who underwent bilateral breast reconstruction with LAP flaps (100 flaps) between 2018 and 2022 was performed. Patient characteristics and postoperative complications were recorded. Pre- and postoperative standardized frontal and lateral patient photographs were analyzed to identify postoperative changes in waist-to-hip ratio (WHR) to assess waistline definition and buttock projection. The patients' individual perception of postoperative aesthetic changes to their waistline and buttocks was determined by an electronic survey. The patients had a mean age of 51 years (range, 24-63 years) and a mean BMI of 26.9 kg/m2 (range, 19.3-37.4 kg/m2). Postoperative donor site complications included seroma (n = 10), wound dehiscence (n = 5), hematoma (n = 4), and wound infection (n = 2). Flap loss rate was 2%. After reconstruction, patients were found to have a more defined waistline, indicated by a significantly decreased WHR on frontal images (mean [standard error of the mean], 0.85 [0.05] vs 0.80 [0.05], P < .005) and a more projected buttocks indicated by a significant reduction in WHR on lateral images (0.92 [0.07] vs 0.87 [0.07], P < .0001). Among the patients who responded to the survey, 73% indicated that their waistline had aesthetically improved, 6.7% felt it had not changed, and 20% felt that it had worsened. An aesthetic improvement of the buttocks was reported by 53%, 40% felt their buttocks had not changed, and 6.7% felt their buttocks appearance had worsened. Bilateral LAP flap breast reconstruction leads to improved waistline definition and buttock projection, bringing patients closer to ideal aesthetic proportions. This reconstructive approach is ideal for patients who are not candidates for abdominal free flaps, but who demonstrate excess flank tissue and seek a more defined waistline and projected buttocks.

Hip reconstruction in cerebral palsy: Lessons from a single center and 137 hips.

This large, retrospective, single-center study aimed to compare the outcomes of unilateral hip reconstruction and bilateral hip reconstruction in children with non-ambulatory cerebral palsy and ascertain risk factors for recurrent instability and reoperation. We performed a retrospective review of 137 hip reconstructions performed for patients with cerebral palsy. Preoperative and postoperative clinical and radiological parameters were documented, including hip migration percentage, acetabular index, the Gross Motor Function Classification System, the Melbourne Cerebral Palsy Hip Classification System, hip abduction, and pelvic obliquity. Overall, 49 patients underwent bilateral hip reconstruction, and 37 patients underwent unilateral hip reconstruction. In the unilateral hip reconstruction group, the reconstructed hip remained stable (with a migration percentage < 33%) in 59% of patients compared to 74.4% of the more affected hips in the bilateral hip reconstruction group (p = 0.02). Of the unreconstructed hip in the unilateral hip reconstruction group, 74.4% remained stable (with a migration percentage < 33%), compared to 78.8% of the less affected hips in the bilateral hip reconstruction group. A level pelvis was maintained at final follow-up in significantly more patients in the bilateral hip reconstruction group than the unilateral hip reconstruction group (p = 0.002). Further surgical intervention was performed in 41% of the unilateral hip reconstruction group, compared with 11.5% in the bilateral hip reconstruction group (p = 0.001). Surgery performed under the age of 8 years and not performing an acetabular osteotomy were found to be risk factors for recurrent instability in all groups. Our series suggests that in terms of recurrent instability after hip reconstruction in cerebral palsy, protective factors against this complication include bilateral hip reconstruction, hip reconstruction after 8 years of age, and the use of an acetabular osteotomy.

Do bilateral procedures further increase the complications for autologous breast reconstruction in obese patients?

Obesity is known to be associated with high complication rates. The aim of this study was to evaluate the effect of bilateral procedures on complication rates in obese patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flaps. Medical records of patients undergoing autologous breast reconstruction between January 2017 and December 2019 were retrospectively reviewed. Patients were divided into two groups according to their body mass index (BMI): Group 1 (BMI > 30) and Group 2 (BMI < 30). Group 1 was further divided into 3 subgroups: Group 1a (bilateral reconstruction), Group 1b (unilateral reconstruction), and Group 1c (unilateral reconstruction and contralateral symmetrization). Outcomes and complication rates were compared between groups. Ninety-one patients (with 119 free flaps) were followed up between 6 and 12months. Length of hospital stay, smoking rates, and age were similar in all groups. Group 1 had significantly more rates of wound dehiscence (p = 0.024), mastectomy skin flap necrosis (p = 0.019), and re-operation (p = 0.033). The operation time was significantly higher in group 1 (p = 0.003). There was no significant difference between group 1 and group 2 in terms of hematoma-seroma formation, flap loss, and pulmonary thromboembolism rates. When obese subgroups were compared, no significant difference was observed in terms of complications. In our series, microvascular breast reconstruction was associated with more complication rates in obese patients. However, bilateral procedures in the obese patient group did not significantly increase risk of complications as compared to unilateral procedures. By taking appropriate measures bilateral procedures can be performed in obese patients without additional risks.

Evaluation of Intraoperative Anastomotic Patency with Angiography in Microsurgical Breast Reconstruction.

Microsurgical breast reconstruction is one of the most challenging, yet rewarding procedures performed by plastic surgeons. Several measures are taken to ensure safe elevation of the flap, preparation of recipient vessels, microvascular anastomosis, and flap inset. Reestablishing proper blood flow to the flap tissue after microvascular anastomosis is one of many critical steps for surgical success. Several measures to assess blood flow to the flap have been used; however, the use of indocyanine green angiography (ICGA) of the anastomosis in breast reconstruction has not been well documented. We present a series using ICGA for the evaluation of microvascular anastomosis success in breast reconstruction. Cases from patients who underwent microsurgical breast reconstruction between March 2022 and January 2023 and who had intraoperative ICGA were retrospectively reviewed. We compared the intraoperative findings on ICGA to flap success. Sixteen patients underwent bilateral deep inferior epigastric perforator flap reconstruction with intraoperative ICGA of the microvascular anastomosis, constituting 32 deep inferior epigastric perforator flaps. The ICGA demonstrated return of blood flow in all the flaps after microvascular anastomosis and no flap loss in our sample population. Nine flaps required additional drainage using the superficial inferior epigastric vein, and the superficial circumflex vein was used for additional drainage in one of the flaps. The use of intraoperative ICGA provides reliable visual feedback regarding the patency and direction of the blood flow through the microvascular anastomosed vessels. ICGA can be used as an additional tool in the plastic surgeon's armamentarium for successful breast reconstruction.

977 The Impact of Post-Mastectomy Radiotherapy on Immediate Free Flap Breast Reconstruction

Abstract Aim Radiotherapy following free flap breast reconstruction has historically been thought to increase complication rates, worsen patient reported outcomes (PROs) and lead to poorer cosmetic results. We aim to assess the impact post-mastectomy radiotherapy (PMRT) has on immediate free flap breast reconstruction using these variables, with patients acting as inherent controls. Method We conducted a retrospective cohort study on all patients receiving immediate bilateral free flap breast reconstruction followed by unilateral radiotherapy between 2008 and 2022. Complication rates were assessed by comparing prevalence of fat necrosis, volume depletion requiring lipofilling, and flap loss among irradiated vs non-irradiated breasts. PROs were assessed by comparing “Satisfaction with Breasts” and “Chest Physical Well-Being” (two sections of the Breast-Q survey) among irradiated vs non-irradiated breasts. Cosmetic outcomes were assessed by scoring postoperative pre-radiotherapy and postoperative post-radiotherapy patient images using “Objective Breast Cosmesis Scale” (OBCS) and “Harvard Breast Cosmesis Scale” (HBCS). Results 9 patients underwent immediate bilateral free flap breast reconstruction followed by unilateral radiotherapy. Median age was 40 years (IQR 32-44). Complication rates did not vary significantly between irradiated and non-radiated breasts. “Satisfaction with Breasts” did not vary significantly between irradiated and non-radiated breasts; however, “Chest Physical Well-Being” did vary significantly between both breasts. Cosmetic outcomes did not vary significantly between pre-radiotherapy and post-radiotherapy images. Conclusions PMRT following immediate free flap breast reconstruction does not have significant deleterious effects on complication rates, patient satisfaction with breasts or cosmetic outcomes. However, radiotherapy has a significant effect on patient’s chest physical well-being, hence we aim to study this further.

1231 Radical Vulvectomy and Reconstruction for Severe, Refractory Crohn's Disease of the Vulva: A Case Report

Abstract Vulval Crohn’s disease (VCD) is rare and can arise from direct infiltration, through fistulae or as non-contiguous lesions, so called metastatic disease. We present a case of a 32-year-old female with severe, refractory vulval Crohn’s disease (VCD), requiring radical vulvectomy and reconstruction. She had a subtotal colectomy for Crohn’s disease 8 years previously, and for one year had experienced vulval swelling and pain associated with perianal fistulae for which she underwent an abdomino-perineal resection. Though she achieved long term remission of her gastrointestinal disease, she continued to experience severe vulval symptoms with recurrent infections and abscesses despite treatment with immunomodulators and biologics over a period of 10 years. She then underwent a radical vulvectomy with bilateral gluteal fold flap reconstruction and skin grafting. She made an uncomplicated post-operative recovery. Histopathology showed active non-caseating granulomatous vulvitis. At 1 year follow up, there were no further disease flares, with significant improvement of her pain. Further plastic surgery is being considered. Our case demonstrates the value of surgical management in refractory VCD to improve symptoms, function and quality of life. Though medical therapy with immunosuppressive agents is recommended as first-line treatment, the course of VCD is unpredictable and often relapses on treatment cessation. VCD may persist for long after remission of gastrointestinal disease and may require more aggressive surgery using a multispecialty approach even in the context of active infective disease.

Minimally Invasive and Innovative Management of Prosthesis Infections in Endoscopic-Assisted Breast Reconstruction.

Implant infection continues to be the most common complication of breast reconstruction, and it can lead to serious consequences of implant loss. Recently, endoscopic-assisted nipple-sparing mastectomy with direct-to-implant breast reconstruction is being performed more frequently, with similar prostheticinfection incidence compared to conventional techniques. But there is little information published in the literature on the management of periprosthetic infection in endoscopic-assisted breast reconstruction. A retrospective review was performed of patients who underwent endoscope-assisted breast reconstruction and developed periprosthetic infection between January 2020 and December 2022. Prosthesis infection was defined as any case where antibiotics were given, beyond the surgeon's standard perioperative period, in response to clinical signs such as swelling, pain, erythema, increased temperature, fever, etc. We summarized our clinical approach and treatment protocol for periprosthetic infection patients. Collected data include preoperative basic information, surgical details, postoperative data, and outcomes. A total of 580 patients (713 reconstructions) underwent endoscopic-assisted immediate breast reconstruction. There were 58 patients developed periprosthetic infection, 14 of whom had bilateral prosthesis reconstruction with unilateral prosthesis infection. The incidence of infection was 10.0%. Average follow-up was 17.3 ± 8.9 months (range = 2-37 months). Of the 58 patients, 53 (91.4%) patients successful salvaged implant and 5(8.6%) patients removed prosthesis. During follow-up, Baker III capsular contracture occurred in 2 patients (3.8%) who had radiotherapy. Our management of prosthesis infections in endoscopic-assisted breast reconstruction is easy, minimally invasive, and inexpensive. This method can be repeated if the implant infection does not improve after the first drainage. What's more, our data suggest that our prosthesis salvage of periprosthetic infection is effective. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Long-Term Outcomes following Hybrid Breast Reconstruction.

Hybrid breast reconstruction combines free tissue transfer with implant placement. Various mesh products have been successfully used to secure the implant position in these reconstructions. In this study, the authors investigate the impact of mesh type on long-term outcomes following hybrid breast reconstruction. A retrospective analysis of all patients with at least 24 months of follow-up after immediate bilateral prepectoral hybrid breast reconstruction was performed. Univariate and multivariable regression analyses were used to evaluate long-term outcomes and compare breasts reconstructed with polyglactin mesh versus acellular dermal matrix (ADM). Thirty-nine patients (78 breasts) who underwent hybrid breast reconstruction with an average follow-up period of 50.4 months (range, 27 to 73 months) were included in the study. Postoperative complications included hematoma ( n = 2 [2.6%]), mastectomy skin necrosis ( n = 12 [15.4%]), and fat necrosis ( n = 6 [7.7%]). There were no instances of implant infection, implant exposure, or flap failure. Polyglactin mesh and ADM were used in 24 breasts and 54 breasts, respectively. Implant malposition and capsular contracture occurred more frequently in the polyglactin cohort leading to 10 (41.7%) instances of reoperation for implant replacement compared with only 1 (1.9%) in the ADM cohort ( P < 0.001). On multivariable regression analysis, polyglactin mesh was associated with a 36-fold greater probability of requiring implant replacement compared with ADM ( P = 0.006). ADM (versus polyglactin mesh) is associated with lower rates of capsular contracture and implant malposition in the context of hybrid breast reconstruction. Therapeutic, III.

Aesthetic Implications of Bilateral Profunda Artery Perforator Flaps on Thigh and Buttock Proportions.

The profunda artery perforator (PAP) flap has emerged as an excellent secondary option for autologous breast reconstruction. Despite the increased acceptance, potential secondary benefits concerning aesthetic proportions of proximal thigh and buttock at the donor site have never been systematically investigated. A retrospective review of 151 patients who underwent breast reconstruction with horizontally designed PAP flaps (292 flaps) from 2012 to 2020 was performed. Patient characteristics, complications, and numbers of revision surgeries were collected. In bilateral reconstructions, pre- and postoperative standardized patient photographs were analyzed to identify postoperative changes in proximal thigh and buttock contour. The patients' own perception of postoperative aesthetic changes was determined by an electronic survey. The patients had a mean age of 51 and a mean body mass index of 26.3 kg/m2. The most common complications were minor and major wound complications affecting 35.1% of patients, followed by cellulitis (12.6%), seroma (7.9%), and hematoma (4.0%). A total of 38 patients (25.2%) underwent revision of the donor site. After reconstruction, patients were found to have aesthetically improved proximal thigh and buttock proportions, indicated by a wider thigh gap (thigh gap-hip ratio: 0.05 ± 0.04 vs. 0.13 ± 0.05, p < 0.0001) and reduction in lateral thigh-to-buttock ratio (0.85 ± 0.05 vs. 0.76 ± 0.05, p < 0.0001). Among the 85 patients who responded to the survey (56.3% response rate), 70.6% felt that PAP surgery had aesthetically either improved their thigh contour (54.12%) or not changed it (16.47%), whereas only 29.4% reported that the surgery negatively impacted their thigh contour. PAP flap breast reconstruction leads to improved aesthetic proportions of the proximal thigh and buttock. This approach is ideal for patients with ptotic tissue of the inferior buttocks and medial thigh, a poorly defined infragluteal fold, and inadequate anterior-posterior buttock projection.

Poster 340: Return to Sport and Psychological Readiness to Return to Sport in Individuals who Have Undergone Bilateral vs Unilateral ACL Surgeries

Objectives: Prior studies report lower return to preinjury level of sport in patients who undergo bilateral anterior cruciate ligament (ACL) reconstructions compared to unilateral reconstructions, with the most common cited reason being fear of reinjury. The purpose of our investigation was to compare subsequent return rates and psychological readiness to return to sport (RTS) in patients who underwent bilateral versus unilateral ACL reconstructions. Methods: A retrospective review of patients who underwent ACL reconstruction at a single academic institution between 2012-2021 with a minimum of 1-year follow-up was conducted. Patients were divided into bilateral and unilateral cohorts. Those who underwent bilateral ACL reconstruction were matched 1:3 to unilateral reconstruction based on age, sex, BMI, and primary sport. Primary outcomes included return to sport, level of RTS and psychological readiness to RTS, assessed by the validated ACL- Return to Sport after Injury (ACL-RSI) scale. Within the ACL-RSI questionnaire, fear and confidence to return to sport were specifically analyzed. Fear to RTS was measured on a scale of 0-100 with 0 equal to extremely fearful and 100 equal to no fear at all. Confidence to RTS was measured on a scale of 0-100 with 0 equal to not at all confidence and 100 equal to fully confident. Statistical analysis was performed in R studio, with chi-square used for categorical values and two-sided t-test for continuous. Results: One hundred eighty-one patients were included, forty-three bilateral ACL reconstructions and one hundred thirty-eight unilateral. The unilateral cohort included 69 (50.0%) males and 69 (50.0%) females and the bilateral cohort included 22 (51.2%) males and 21 (48.8%) females. Mean age was 26.0 (14-56) in the unilateral cohort and 25.2 (14-50) in the bilateral cohort. Mean BMI was 25 (15.3-39.2) in the unilateral cohort and 28 (15.1-39.7[SM1] ) in the bilateral cohorts (p=.08). The percentage of individuals who returned to sport in the bilateral reconstruction cohort was not significantly different from those who returned in the unilateral cohort (79.6% vs 76.7%, p=0.85). There was no significant difference in psychological readiness to RTS (mean score 52.6 for bilateral and 47.4 for unilateral, p=0.31). There was also no significant difference between the level at which bilateral versus unilateral patients returned to sport. 59.6% unilateral returned to the same or higher level and 60.6% bilateral returned to the same or higher level, p=0.92. There was no significant difference in the reported scale of psychological readiness to return to sport (52.6 for bilateral and 47.4 for unilateral, p=0.31). When asked about fear to RTS, the mean scale response was 42.2 in the unilateral cohort and 46.5 in the bilateral (p=0.45). Conclusions: There is no difference in RTS and level of sport returned to between patients who undergo bilateral ACL reconstructions compared to patients who undergo unilateral ACL reconstructions. Psychological readiness, fear and confidence to return to sport were not different between unilateral and bilateral injuries.

Poster 251: Patients who Undergo Bilateral Medial Patellofemoral Ligament Reconstruction Return to Sport at a Similar Rate to Unilaterals: A Matched Cohort Study

Objectives: Lateral patellar instability is a debilitating condition not only to athletes, but also a broad range of highly active individuals. Many of these patients experience instability symptoms bilaterally. Medial patellofemoral ligament reconstruction (MPFLR) is indicated to prevent future recurrence and ideally facilitate a complete return to sports (RTS). While RTS has been examined following MPFLR, the rate and timing of RTS in patients that undergo MPFLR bilaterally is unknown. The purpose of this study is to compare patients who have received bilateral MPFLR to a matched unilateral cohort, to elucidate potential differences and eventually allow better prognostication of this unique population’s ability to return to sports. Methods: Patients who underwent primary MPFL reconstructions with minimum 12-months clinical follow-up were identified from a single institution from the years 2011 to 2021. Those who underwent non-simultaneous primary MPFL reconstruction of bilateral knees were identified, as well as cohort of unilateral MPFLR. Surveys were then disseminated, including the Visual Analog Scale (VAS) for pain and satisfaction, the Kujala Anterior Knee Pain Scale, the Tegner Activity Scale, and the MPFL-RSI assessing psychological readiness to RTS. Detailed baseline sport activity and RTS information was collected, which was modified for bilateral patients to report on each procedure. For analysis, bilateral and unilateral MPFLRs were matched in a 1:2 ratio based on age, sex, BMI, and status of concomitant tibial tubercle osteotomy (TTO). A sub-analysis was performed comparing patients who underwent concomitant TTO compared to isolated MPFLR. Outcomes were compared between cohorts using T-tests and Chi-square analyses when required. Bivariate linear regression and logistic regression were performed to assess correlation between RTS and outcome scores, as well as psychological readiness. Results: Surveys were completed by 24 patients who underwent bilateral MPFL reconstruction and 105 unilateral patients with a total mean follow-up time of 4.2 ± 2.4 years. Among the bilateral patients, average time between MPFL procedures was 19.3 ± 16.9 months; notably, 71.4% of patients had symptoms in the contralateral knee at the time of index procedure. Three bilateral patients were unable to be matched, resulting in a 21:42 match with respective bilateral and unilateral cohorts having a mean age (22.5 ± 5.7 vs 23.3 ± 6.6 years; p = 0.65), sex (males 9/21 vs 18/42; p = 1.00), BMI (25.87 ± 6.39 vs 25.21 ± 4.78 kg/m2; p = 0.65), and concomitant TTO (9/18 vs 18/42; p = 1.00) that did not significantly differ, indicating successful matching. When comparing matched cohorts, bilateral MPFLR patients returned-to-sport at a similar rate to unilaterals following both their first (61.1% vs 63.2%; p = 0.98) and second MPFLR (72.7% vs 63.2%; p = 0.82). After undergoing both procedures, 33.3% of the bilateral cohort was able to return to their preinjury level of sport, compared to 26.3% of unilaterals (p = 0.82). The mean time for bilateral patient to RTS following their first procedure was 24.3 ± 7.5 weeks and 22.5 ± 12.9 weeks after their second, compared to the unilateral time-to-return taking 38.5 ± 23.0 weeks, though this difference at each time point (bilateral index vs unilateral; bilateral contralateral vs unilateral) did not reach significance (p = 0.06; p = 0.08). All patients scored highly with respect to VAS surgery satisfaction (85.4 vs 82.8; p = 0.44). There were no significant differences found between bilateral and unilateral cohorts for the Kulaja score (79.0 vs 86.1; p = 0.14) or in psychological readiness to RTS as indicated by the MPFL-RSI (49.7 ± 24.2 vs 58.8 ± 26.7; p = 0.24). Regression analysis found both the Kujala score (β = 0.06, p = 0.01) and MPFL-RSI (β = 0.06, p &lt; 0.01) to be weakly, but significantly associated with rate of RTS. Sub-analysis of MPFLR with and without concomitant TTO did not demonstrate any significant differences with respect to RTS, psychological readiness, or any other outcome score (p &gt; 0.05). Conclusions: The results of this study suggest that patients who undergo MPFLR bilaterally are able to return to sports at a similar rate and to a similar level compared to a matched unilateral comparison group with equivalent satisfaction and functional outcome scores. These findings are particularly important due to the high prevalence of simultaneous bilateral symptomatic patellar instability. With no demonstrable differences in rate and timing of return-to-sport, knee function, and psychological readiness between patients who have undergone unilateral versus bilateral MPFLR, surgeons can more confidently report equivalent outcomes to patients particularly with respect to RTS rates.

Posterior Tibial Slope in Patients Undergoing Bilateral Versus Unilateral ACL Reconstruction: MRI and Radiographic Analyses

Background: An increased posterior tibial slope (PTS) is a risk factor for primary anterior cruciate ligament (ACL) tears and graft failure, but the PTS has not been well-defined in those who have experienced bilateral ACL injuries. Purpose: The primary aim was to compare the PTS, as well as the rate of an elevated PTS (>12° on lateral radiography; >7° on magnetic resonance imaging [MRI]), between patients who have undergone bilateral ACL reconstruction (ACLR) versus unilateral ACLR. A secondary purpose was to examine whether these associations remained consistent on both plain radiography and MRI. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We retrospectively identified patients who underwent primary ACLR at our institution from the years 2012 to 2020. Patients who underwent nonsimultaneous bilateral ACLR (n = 53) were matched to those who underwent unilateral ACLR (n = 53) by age, sex, and body mass index. Exclusion criteria were rotated lateral radiographs, MRI scans of inadequate quality, and concomitant ligament injuries or fractures. Those who had undergone unilateral ACLR with <5-year follow-up were further excluded. There were 3 blinded readers who measured the PTS on lateral radiographs, while the medial PTS (MPTS) and lateral PTS (LPTS) were measured on MRI scans. Bivariate regression was performed to determine the correlation between radiographic and MRI measurements. Results: The PTS on radiography (11.26° vs 10.13°, respectively; P = .044) and the LPTS on MRI (7.32° vs 6.08°, respectively; P = .012) in the bilateral ACLR group were significantly greater than those in the unilateral ACLR group but not the MPTS on MRI (4.55° vs 4.17°, respectively; P = .590). The percentage of patients in the bilateral group with a radiographic PTS >12° was 41.0% compared with 13.2% in the unilateral group (P = .012). The bilateral group had a significantly higher rate of an LPTS >7° compared with the unilateral group (53.8% vs 32.1%, respectively; P = .016) but not for an MPTS >7° (P = .190). On MRI, the LPTS (6.90°± 2.73°) was significantly greater than the MPTS (4.41°± 2.92°) (P < .001). There was a weak correlation between MPTS and radiographic PTS measurements (R = 0.24; P = .021), but LPTS and radiographic PTS measurements were not significantly correlated (R = 0.03; P = .810). Conclusion: Patients who underwent bilateral ACLR had a significantly greater PTS on radiography and a significantly greater LPTS on MRI compared with those who underwent unilateral ACLR. The rate of a radiographic PTS >12° was 2.4 times greater among patients undergoing bilateral ACLR compared with those undergoing unilateral ACLR. PTS measurements on radiography demonstrated a weak to negligible correlation with PTS measurements on MRI, suggesting that future normative PTS values should be reported specific to the imaging modality.

The Delay Procedure in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction.

The delay procedure in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction, in which the reduced-caliber choke vessels play a major role, can provide more well-perfused tissue than a standard DIEP flap. The aim of this study was to review the authors' experience with this technique, evaluate the indications, and analyze the surgical outcomes. A retrospective study was conducted of all consecutive DIEP delay procedures performed between March of 2019 and June of 2021. Patient demographic characteristics, operative details, and complications were registered. Patients had preoperative imaging by magnetic resonance angiography to select dominant perforators. The surgical technique involves a two-stage operation. During the first operation, the flaps were pedicled on a dominant perforator and a lateral skin bridge extending toward the lateral flank and lumbar fat; in a second stage, the flap was harvested and transferred. A total of 82 extended DIEP delay procedures were performed to reconstruct 154 breasts. The majority were bilateral breast reconstructions (87.8%). The delay procedure was used for 38 primary reconstructions (46.3%) and 32 tertiary reconstructions (39.0%). The primary indication was the need for additional volume (79.3%), followed by extensive abdominal scarring and liposuction. After the first operation, seroma was the most frequently observed complication (7.3%). After the second operation, three total flap losses (1.9%) were observed. The delay procedure in DIEP flap breast reconstruction results in the harvest of a good amount of abdominal tissue by adding a preliminary procedure. This technique can convert cases previously considered unsuitable into suitable candidates for abdominal-based breast reconstruction. Therapeutic, IV.

Bilateral Simultaneous Lumbar Artery Perforator Flaps in Breast Reconstruction: Perioperative Outcomes Addressing Safety and Feasibility.

The lumbar artery perforator (LAP) flap has emerged as an excellent option for breast reconstruction, but its steep learning curve makes it less approachable. Furthermore, length of the operation, flap ischemia time, need for composite vascular grafts, complex microsurgery, multiple position changes, and general concern for safety has led experienced surgeons to stage bilateral reconstructions. In the authors' experience, simultaneous bilateral LAP flaps are feasible, but overall perioperative safety has not been fully explored. Thirty-one patients (62 flaps) underwent simultaneous bilateral LAP flaps and were included in the study (excluding stacked four-flaps and unilateral flaps). Patients underwent two position changes in the operating room: supine to prone and then supine again. A retrospective review of patient demographics, intraoperative details, and complications was performed. The overall flap success rate was 96.8%. Five flaps were compromised postoperatively. The intraoperative anastomotic revision rate was 24.1% per flap (4.3% per anastomosis). The significant complication rate was 22.6%. The number of sustained hypothermic episodes and hypotensive episodes correlated with intraoperative arterial thrombosis ( P < 0.05). The number of hypotensive episodes and increased intraoperative fluid correlated with flap compromise ( P < 0.05). High body mass index correlated with overall complications ( P < 0.05). The presence of diabetes correlated with intraoperative arterial thrombosis ( P < 0.05). Simultaneous bilateral LAP flaps can be performed safely with an experienced and trained microsurgical team. Hypothermia and hypotension negatively affect the initial anastomotic success. In this complex operation, a coordinated approach between the anesthesia and nursing team is paramount for patient safety. Therapeutic, IV.

The Effect of Body Mass Index on Free Flap Breast Reconstruction.

Literature addressing the risks associated with increasing body mass index (BMI) for patients undergoing free flap breast reconstruction is limited. Often, an arbitrary BMI cutoff (i.e., BMI of 30 kg/m2) is used to determine candidacy for a free flap without substantial backing evidence. This study utilized a national multi-institutional database to analyze outcomes of free flap breast reconstruction and stratified complications by BMI class. Using the 2010 to 2020 National Surgical Quality Improvement Program database, patients who underwent free flap breast reconstruction were identified. Patients were divided into six cohorts based on the World Health Organization BMI classes. Cohorts were compared by basic demographics and complications. A multivariate regression model was created to control for age, diabetes, bilateral reconstruction, American Society of Anesthesiologists class, and operative time. Surgical complications increased with each BMI class, with the highest rates occurring in class I, II, and III obesity, respectively. In a multivariable regression model, the risk for any complication was significant for class II and III obesity (odds ratio [OR]: 1.23, p < 0.004; OR: 1.45, p < 0.001, respectively). Diabetes, bilateral reconstruction, and operative time were independently associated with an increased risk of any complication (OR: 1.44, 1.14, 1.14, respectively, p < 0.001). This study suggests that the risks of postoperative complications following free flap breast reconstruction are highest for patients with a BMI greater than or equal to 35 kg/m2, having nearly 1.5 times higher likelihood of postoperative complications. Stratifying these risks by weight class can help guide preoperative counseling with patients and help physicians determine candidacy for free flap breast reconstruction.