Myocutaneous Free Flap Research Articles

Short-stay hospital admission after free tissue transfer for head and neck reconstruction.

To show that, for patients with few medical comorbidities and at low risk for airway compromise or fistula formation, early discharge after free tissue transfer for head and neck reconstruction is a safe and viable option. Retrospective chart review. A cohort of patients who underwent free tissue transfer for head and neck reconstruction between February 2010 and December 2014 and who were discharged from the hospital by postoperative day 3 were reviewed. Fifty patients undergoing 51 free-tissue transfer surgeries were discharged by postoperative day 3. The surgeries performed included anterolateral thigh free flaps (ALT) (n = 46), radial forearm free flaps (n = 2), latissimus myogenous and myocutaneous free flaps (n = 1), supraclavicular free flap (n = 1), and serratus free flap (n = 1). All ALT flaps were harvested exclusively as perforator free flaps; and the vast majority used superficial temporal, angular, or facial vessels. All free flaps were viable without evidence of vascular compromise at discharge and the initial follow-up appointment. One patient required take-back for successful flap salvage. One patient experienced late flap failure (between 2-3 weeks postoperatively), requiring another surgery. This resulted in an overall success rate of 98% in this cohort. No other postoperative complications related to early discharge were identified. In a carefully selected subset of patients undergoing free tissue transfer, early discharge has been shown to be possible without compromising patient safety or surgery success rates. 4. Laryngoscope, 126:2679-2683, 2016.

Induced Hypothermia: Implications for Free Flap Survival.

Plastic surgeons may not be aware that the new advanced cardiac life support (ACLS) guidelines released in 2010 include induced hypothermia as an adjuvant treatment to improve neurologic outcomes following cardiac arrest [1]. Induced hypothermia (IH) is thought to mitigate ischemic damage by lowering metabolic demand and preventing noxious byproducts of resuscitation. IH is recommended for patients who experience the return of spontaneous circulation after cardiac arrest, but remain unconscious [2]. The hypothermia protocol involves the reduction of body temperature to 32℃–34℃ for 12 to 24 hours, followed by slow rewarming [1,2]. However, the use of induced hypothermia in microvascular free tissue transfer has not been studied. We present the case of a patient who underwent IH following free-flap reconstruction of a head and neck cancer defect. A 69-year-old male with a history of coronary artery disease and three-vessel coronary artery bypass grafting presented with recurrent basal cell carcinoma of the left ear canal. He underwent total auriculectomy and lateral temporal bone resection, and the defect was reconstructed with a left vertical rectus abdominis myocutaneous free flap. On the second postoperative day, the patient was found unresponsive in pulseless electrical activity cardiac arrest. The ACLS protocol was initiated, including mechanical ventilation and vasopressors for hemodynamic support. The patient was successfully resuscitated but suffered a second cardiac arrest with ventricular fibrillations. He was resuscitated again but remained unresponsive. Hypothermia was induced, with the patient cooled to 32℃ for 48 hours (Fig. 1). The free flap remained well perfused with an audible Doppler signal during the cardiac arrests, vasopressor therapy, hypothermic cooling, and the remainder of his hospitalization (Fig. 2). Unfortunately, the patient had no meaningful neurologic recovery and magnetic resonance imaging showed diffuse hypoxic brain injury. Therefore, the family elected to withdraw care on postoperative day 10. Fig. 1 Temperature curve showing induced hypothermia to 32℃–34℃, from postoperative day three until postoperative day five. Fig. 2 A 69-year-old male underwent composite resection of the left auriculotemporal area and temporal bone for recurrent basal cell carcinoma, and the defect was reconstructed with a left vertical rectus abdominis myocutaneous free flap. The effects of systemic hypothermia on free tissue transfer are not fully understood. Limited animal and human studies have demonstrated conflicting results. Some data have suggested that hypothermia causes decreased perfusion, vasospasm, and thrombosis, while other animal experiments have shown a protective effect of mild hypothermia on free flaps [3,4,5]. Clotting enzymes, platelets, and leukocytes function less effectively in a hypothermic setting; however, no reports have been published on the effect of severe hypothermia (<34℃) on free flap survival in humans. This is the first reported case of induced hypothermia after free tissue transfer. Plastic surgeons should be aware of ongoing changes to the ACLS algorithm and its impact on perioperative care. In this case, a free tissue transfer remained viable despite induced hypothermia and vasopressors, which is a single data point suggesting that free flaps can tolerate such interventions. However, further research is needed to clarify the effects of hypothermia on free tissue transfer.

Emergency Transplantation of Free Flap between Separated Thoraco-Omphalopagus Conjoined Twins.

Emergency Transplantation of Free Flap between Separated Thoraco-Omphalopagus Conjoined Twins.

Tissue flap repair strategy for severe defects of skin and soft tissue around the knee joints

To explore selection and method of tissue flaps for the repair of severe defects of skin and soft tissue around the knee joints. Fifty-four patients with wounds around the knee joints, all accompanied by exposure or necrosis of tendon or bone and exposure of prosthesis, were hospitalized in our burn center from June 2008 to December 2014. Five of them were with knee joint injury. After thorough debridement or tumor resection, the wound area ranged from 5 cm × 5 cm to 46 cm × 22 cm. Three patients were repaired with free latissimus dorsi myocutaneous flaps, 7 were repaired with modified sartorius myocutaneous flaps, 8 were repaired with gastrocnemius myocutaneous flaps, one was repaired with gastrocnemius muscle flap, two were repaired with posterior leg flaps combined with gastrocnemius muscle flaps, one was repaired with femoral biceps muscle flap combined with gastrocnemius muscle flap, 13 were repaired with reverse anterolateral thigh island flaps, two were repaired with reverse anterolateral thigh island flap combined with gastrocnemius myocutaneous flaps, two were repaired with superior lateral genicular flaps, 4 were repaired with reverse posterior thigh island flaps, 11 were repaired with saphenous artery flaps. Patellar ligament was reconstructed in 4 patients. The tissue flap size ranged from 5 cm × 5 cm to 38 cm × 19 cm. Some donor sites were sutured directly, and the others were closed by split-thickness skin grafting obtained from ipsilateral or contralateral legs. Among 59 tissue flaps of 54 patients, 55 tissue flaps of 50 patients survived, while necrosis of the distal part was observed in 4 tissue flaps, including one saphenous artery flap, two reverse anterolateral thigh island flaps, and one free latissimus dorsi myocutaneous flap. Among them, 3 flaps with necrosis at the distal part healed after debridement followed by skin grafting, one myocutaneous flap healed by transplanting gastrocnemius myocutaneous flap. During the follow-up period of 6 to 36 months, the tissue flaps were in good appearance and texture, and knee joint function was good in most cases. In 4 patients the knee joint function was satisfactory after patellar ligament reconstruction, while stiffness was observed in 4 out of 5 patients with knee joint injury. Free latissimus dorsi myocutaneous flaps are preferred to repair extensive defects around the knee joints. Reverse anterolateral thigh island flaps followed by saphenous artery flaps are preferred to repair wounds around the anterior knee. Wounds of the lateral knee are mainly repaired with reverse anterolateral thigh island flaps, and for small wounds the use of the superior lateral genicular flaps may be considered. Wounds of the medial knee can be repaired with modified sartorius myocutaneous flaps or saphenous artery flaps. Wounds of the posterior knee can be repaired with reverse posterior thigh island flaps or superior lateral genicular flaps. Wounds with severe infection or large space can be repaired with gastrocnemius myocutaneous flaps or muscle flaps or modified sartorius myocutaneous flaps. Anterolateral thigh flaps and gastrocnemius myocutaneous flaps are preferred in cases with indication of patellar ligament reconstruction.

メビウス症候群の顔面神経麻痺に対する，遊離広背筋移植による動的再建術において，動力源となる神経の選択に難渋した1例

メビウス症候群の顔面神経麻痺に対する，遊離広背筋移植による動的再建術において，動力源となる神経の選択に難渋した1例

Breakthrough Technique for Free Tissue Transfer of Poorly Vascularized Lower Extremity: Arteriovenous Loop Revisited

Breakthrough Technique for Free Tissue Transfer of Poorly Vascularized Lower Extremity: Arteriovenous Loop Revisited

Reconstruction of maxillary defect with musculo-adipose rectus free flap.

The rectus myocutaneous free flap (RMFF) is used for medium to large maxillectomy defects. However, in patients with central obesity the inset could be difficult due to the bulk from excessive layer of adipose tissue. We describe a modification of the RMFF for patients with excessive central obesity with a flap consisting of adipose tissue with minimal rectus muscle; the musculo-adipose rectus free flap (MARF). Five cases of MARF reconstruction were performed between 2003 and 2013, with patients' body mass indexes ranging from 29.0 to 41.2 kg/m2 . All patients had sinonasal tumor, of which three were adenoid cystic carcinoma, one squamous cell carcinoma, and one melanoma. Four patients had Codeiro IIIb defects and one had Codeiro II defect. Using the MARF technique, the maxillectomy defect was obliterated with vascularized adipose tissue overlying the rectus muscle and was trimmed to fit the maxillectomy defect. The adipose tissue was allowed to granulate and mucosalize. The volume of adipose tissue harvested was between 120 and 160 mL. All flaps survived with no requirement for re-exploration. Complete oro-nasal separation was achieved in all patients. The time to commencement of oral intake ranges from 5 to 15 days. One patient developed seroma and one developed wound breakdown on the donor site. The length of stay at the hospital ranges from 9 to 22 days. On follow-up ranging 7.5-32.8 months, two patients died from their malignancies. The other three patients were able to tolerate oral soft diet. The MARF may be considered as an alternative to myocutaneous rectus free flap particularly for the reconstruction of maxillary defects in patients with central obesity. © 2015 Wiley Periodicals, Inc. Microsurgery 37:137-141, 2017.

Does the use of an acellular dermal graft in abdominal closure after rectus flap harvest impact the occurrence of post-operative hernia?

Patients with rectus free flap harvest extending below the arcuate line are predisposed to postoperative hernia formation. As such, many authors have advocated the use of closure adjuncts to increase the integrity of the closure and prevent hernia or abdominal wall bulging. Busy level 1 public trauma center in metropolitan Fort Worth, Texas Following harvest of the rectus free flap, 48 patients underwent primary closure; 24 of these patients had defects extending below the arcuate line. Forty patients were closed with an acellular dermal graft; 22 of these patients had defects extending below the arcuate line. Postoperative hernia formation and local infection rate were examined in a minimum follow-up period of 1 year. Regardless of closure method, no hernias were observed in the postoperative period. Using an unpaired t test and an alpha value of 0.05, there was no statistically significant difference in the infection rate between the two groups. Following rectus abdominis myocutaneous free flap harvest, the use of an acellular dermal graft in abdominal wall closure may not be of any further advantage in the prevention of hernia. Retrospective (Level III).

Application of 909 anterolateral thigh myocutaneous flaps in the reconstruction of oral and maxillofacial defects

To summarize the application of 909 anterolateral thigh myocutaneous flaps in the repair of oral and maxillofacial defects and to examine their benefits in maxillofacial reconstruction of these defects. Patients were recruited from January 2004 to December 2012 in the Department of Oral and Maxillofacial Surgery of the Second Xiangya Hospital of Central South University. All patients underwent reconstructive surgery with anterolateral thigh myocutaneous flaps, and patient age ranged from 19 to 81 years with a mean of 51.2 years. There were 761 flaps showing single lobe and 148 flaps showing a multi-island pedicle. The largest area among the single flaps was 28 cm × 12 cm, and the smallest was 4 cm × 2 cm. Among the 909 transferred flaps, 882 survived and 27 showed necrosis, with a survival rate of about 97.0%. The common complications at flap donor site were poor wound healing 9.6% (87/909), localized paresthesia 61.0% (500/820), and altered quadriceps force 15.0% (123/820). No case was presented with local serious complications, and 90% of the patients achieved good functional recovery and aesthetically acceptable results after the reconstruction by anterolateral thigh myocutaneous flaps. The anterolateral thigh myocutaneous free flaps are more suitable for oral and maxillofacial defects than other flaps and should be preferred.

Closure of a large bronchopleural fistula by omentoplasty and free myocutaneous latissimus dorsi muscle flap

The treatment of post-pneumonectomy bronchopleural fistula requires both closure of the fistula and control of the infection usually by obliteration of the thoracic cavity. A 53-year-old man developed a large airway defect (4 × 2 cm) after right pneumonectomy performed for lung cancer. To close such a large defect a two-stage operation consisting of omentoplasty and free lattisimus dorsi muscle flap transposition was performed. This report illustrates the feasibility of overcoming this demanding complication with collaboration of plastic surgery.

Reconstruction of Chronic Complicated Scalp and Dural Defects Using Acellular Human Dermis and Latissimus Dorsi Myocutaneous Free flap.

We present reconstruction of a complicated scalp-dura defect using acellular human dermis and latissimus dorsi myocutaneous free flap. A 62-year-old female had previously undergone decompressive craniectomy for intracranial hemorrhage. The cranial bone flap was cryopreserved and restored to the original location subsequently, but necessitated removal for a methicillin-resistant Staphylococcal infection. However, the infectious nidus remained in a dermal substitute that was left over the cerebrum. Upon re-exploration, this material was removed, and frank pus was observed in the deep space just over the arachnoid layer. This was carefully irrigated, and the dural defect was closed with acellular dermal matrix in a watertight manner. The remaining scalp defect was covered using a free latissimus dorsi flap with anastomosis between the thoracodorsal and deep temporal arteries. The wound healed well without complications, and the scalp remained intact without any evidence of cerebrospinal fluid leak or continued infection.

Reconstruction Using Locoregional Flaps for Large Skull Base Defects.

We present a modified locoregional flap for the reconstruction of large anterior skull base defects that should be reconstructed with a free flap according to Yano's algorithm. No classification of skull base defects had been proposed for a long time. Yano et al suggested a new classification in 2012. The lb defect of Yano's classification extends horizontally from the cribriform plate to the orbital roof. According to Yano's algorithm for subsequent skull base reconstructive procedures, a lb defect should be reconstructed with a free flap such as an anterolateral thigh free flap or rectus abdominis myocutaneous free flap. However, our modified locoregional flap has also enabled reconstruction of lb defects. In this case series, we used a locoregional flap for lb defects. No major postoperative complications occurred. We present our modified locoregional flap that enables reconstruction of lb defects.

The super thin external pudendal artery (STEPA) flap

The need for improved microsurgical reconstructive techniques is ongoing given the "ideal" free flap still does not exist. When reconstruction requires a thin flap, options have remained limited and flaps with minimal donor site morbidity that do not require secondary de-bulking have been elusive thus far. The importance of a thin and supple flap cannot be understated when dealing with challenging cases such as the dorsum of the hand or foot. This also applies to other areas such as the head and neck and over the large joints of the knee and elbow. The authors propose a previously un-described free tissue transfer based on the external pudendal artery that fulfills many of the aforementioned goals. An anatomical cadaveric study has been performed describing the super thin external pudendal artery (STEPA) flap. Six fresh cadavers were used in the raising of eight hemiscrotal flaps and two bipedicled scrotal flaps based on the external pudendal vessels. 2 hemipelvises underwent cannulation of the external pudendal artery followed by injection of a barium sulphate/gelatin mixture and three-dimensional computed tomographic angiography to evaluate vascular anatomy. Colored-latex was injected into two raised hemiscrotal flaps. Measurements were made on the cadaveric dissections and on a computed tomography workstation. The average external diameter of the external pudendal artery measured 2.81mm at its origin from the femoral artery, the vein 4.44mm. The mean pedicle length measured 11cm (range, 10-12cm). The mean thickness of the flap measured 1.1mm. A new free flap, the STEPA flap, has been described that is the thinnest myocutaneous free flap with over 80% of the thickness of the flap less than 1.1mm. It has been demonstrated to have reliable anatomy with more than adequate vessel caliber. It has a large surface area and a generous pedicle length for free tissue transfer. Donor site morbidity is favorable. It is accepted that there may be cosmetic issues regarding flap pigmentation and a variable degree of hair in patients where the reconstruction is visible. We would contend that there exist many successful techniques which address pigmentation and depilation, and that this trade-off is acceptable given the functionality and characteristics of this uniquely thin flap. It has the potential to be used in many clinical scenarios where thin supple reconstruction is a high priority.

Anterolateral thigh myocutaneous flaps as the preferred flaps for reconstruction of oral and maxillofacial defects

BackgroundThe anterolateral thigh myocutaneous flap is one of the most commonly used flaps in reconstructive procedures, but its application in oral and maxillofacial defects has not been fully determined. Herein, we summarize the application of 1212 anterolateral thigh myocutaneous flaps in the repair of oral and maxillofacial defects and examine their benefits in maxillofacial reconstruction of these defects. MethodsPatients were recruited from February 2002 to June 2013 in the Department of Oral and Maxillofacial Surgery of Central South University. All patients underwent reconstructive surgery employing anterolateral thigh myocutaneous flaps. Patient ages ranged from 6 to 82 years with a mean age of 51.2 years. There are 1015 flaps showing single lobe and 197 flaps showing a multi-island pedicle and one of which carries the iliac bone. The largest area among the single flaps was 28 × 12 cm2, and the smallest was 3 × 2 cm2. ResultsAmong the 1212 transferred flaps, 1176 survived and 36 showed necrosis, a survival rate of about 97.0%. The common complications at flap donor site were poor wound healing (10.1%), localized paraesthesia (50.1%), and altered quadriceps force (11.0%). No cases presented with local serious complications, and 90% of patients achieved good functional recovery and aesthetically acceptable results after reconstruction of oral and maxillofacial defects at various locations using anterolateral thigh myocutaneous flaps. The time (23–121 min; average 51 min) for anastomosis of one vein and one artery was significantly less than that for two veins and one artery (45–153 min, average 83 min; p = 0.0003), which indicates one vein anastomosis can significantly reduce the operating time. ConclusionThe anterolateral thigh myocutaneous flaps can be easily obtained and can provide a good amount of muscle for filling dead space and fascia lata. These flaps can be prepared into a separate fat flap, multi-island fascia with iliac bone, and other composite pedicle flaps to meet the various requirements of oral and maxillofacial defects. The subcutaneous fat thickness of the anterolateral area can vary considerably and thus can be used to repair defects requiring different flap thickness. Therefore, the anterolateral thigh myocutaneous free flaps are more suitable for oral and maxillofacial defects than other flaps.

Free myocutaneous flap transfer to treat congenital Volkmann’s contracture of the forearm

The purpose of this study is to report our experience with free functional muscle transfer procedures for the late sequelae of the rare condition of congenital Volkmann's ischaemic contracture of the forearm. Four children, with an average age of 9.5 years (range 1.5-17), were treated and were followed for a mean of 6 years (range 1-14). Two patients had dorsal forearm contractures, and two had both flexor and extensor forearm contractures. We carried out free functional muscle transfers to replace the flexor or extensor muscles. The functional result was assessed according to the classification system of Hovius and Ultee. All patients had wrist contractures and skeletal involvement with limb length discrepancy that influenced the outcome. All five transferred muscles survived and improved the function of the hand in three of the four patients. LEVEL OF EVIDENCE 4.

Discussion on reconstruction of the postoperative defect after oral floor carcinoma resection

To explore the reconstruction approaches and indications in repairing of postoperative defect after resection of oral floor carcinoma. To review the clinical data of 106 patients with oral floor carcinoma treated by radical resection with simultaneous reconstruction in the Department of Head and Neck Surgery at our hospital from July 2003 to March 2013, and to evaluate the advantages and disadvantages of various repair methods. The patients were followed up for 2 months to 10 years. Their 3-year survival rate was 63.6% (42/66) and 5-year survival rate was 57.7% (30/52). One case had sternocleidomastoid myocutaneous flap necrosis, and was successfully repaired with elective pectoralis major myocutaneous flap. Another one case showed partial strap muscle flap necrosis, and the wound was well healed after debridement and dressing changes. Three cases of free flap crisis because of poor blood supply were successfully cured by flap emergency exploration. The rest were well healed. The eating and language function of the patients could meet the general needs of life. At the time of radical resection of oral floor carcinoma, an appropriate repair method should be selected according to many factors such as disease conditions, defect size, patients' physical constitution, etc. Generally, adjacent pedicle flap is not recommended. Prosthodontics membrane, free forearm flap, free anterolateral thigh flap, pectoralis major myocutaneous flap and free fibula flap can basically meet the need of repair of the postoperative defect after resection of oral floor carcinoma, therefore, are recommended.

Oculo-facial rehabilitation after facial cancer removal

Leaving open or closing the oculo-facial defect by means of a myocutaneous flap mainly depends on maxillofacial surgical considerations. For those cases that present a closed defect, the authors aim to evaluate an innovative method of ocular bulb positioning using a magnetic resonance imaging dataset. Following cancer removal and plastic reconstructive surgery, a Digital Imaging and Communications in Medicine format magnetic resonance imaging dataset was used to determine the volume and position of the left ocular bulb. The exact location of the prosthetic bulb was determined by mirroring this position on the affected side. Images of the eyeglasses were imported into the virtual environment, and the designs of the substructure and facial prosthesis were projected using computer-aided design/computer-aided manufacture (CAD/CAM) technology. The updated method presented here enables restoration with a facial prosthesis, even when a myocutaneous flap is used to close the defect, thereby resolving the problem of ocular bulb positioning and enabling the rapid and easy design of a retention system connected to eyeglasses. The proposed protocol aims to develop and describe a viable method for the construction of a facial prosthesis for a patient whose face had been reconstructed using a myocutaneous free flap.

Patient access to immediate breast reconstruction following cancer surgery. Learning from the National Mastectomy and Breast Reconstruction Audit (NMBRA)

s / International Journal of Surgery 11 (2013) 589e685 605 ABSTRACTS 0329: PATIENT ACCESS TO IMMEDIATE BREAST RECONSTRUCTION FOLLOWING CANCER SURGERY. LEARNING FROM THE NATIONAL MASTECTOMY AND BREAST RECONSTRUCTION AUDIT (NMBRA) Senthurun Mylvaganam, Niraj Vethirajan, Khalid Boussouara, George Metaxas, Hemant Ingle. Good Hope Hospital, Heart of England NHS Trust, Sutton Coldfield, Birmingham, UK. Introduction: NICE guidance requires breast reconstruction discussionwith all patients requiring mastectomy. The national mastectomy and reconstruction audit showed significant variation in accessibility and practice in NHS Trusts offering breast reconstruction. Our trust service has evolved since the audit combining breast and dedicated plastic surgeons on site. Aims: Assess current local accessibility and practice for offering immediate breast reconstruction following mastectomy. Methods: Retrospective analysis of patients undergoing mastectomy for cancer at Heart of England NHS trust (HEFT) between September 2011 to July 2012. Data collected on tumour biology, whether reconstruction options offered and if not performed why. Results: N1⁄476. Mean Nottingham Prognostic Index(NPI)1⁄44.03. Mean age1⁄461(31-90) Immediate reconstruction offered 1⁄446%. Immediate reconstruction performed 1⁄425%. Reconstruction techniques; immediate with expander(2), immediate delayed with expander(5), Transverse Rectus Abdominis Myocutaneous(TRAM) free flap(7), Lattissimus Dorsi(LD) pedicled flap(2), LD with implant(2), Deep Inferior Epigastric Perforator(DIEP) free flap(1). Reasons reconstruction not performed; patient choice(8), patient choosing delayed(6). Conclusion: Our trust breast cancer service is a partnership between breast and plastic surgeons with joint MDT and clinic services. The trust rate of discussion of immediate reconstruction is greater than the published NMBRA local cancer network rate(36%). An integrated oncoplastic service is a key measure towards fulfilling NICE guidance. 0331: THE IMPORTANCE OF NEEDLE CORE BIOPSY IN THE DIAGNOSIS OF PHYLLOIDES TUMOURS Senthurun Mylvaganam, Lucinda Frank , Clare Toro , Sarah Vestey , Steven Thrush . Worcester Royal Hospital, Worcestershire Acute NHS Trust, Worcester, Worcestershire, UK; Gloucestershire Hospitals NHS Trust, Gloucester, Gloucestershire, UK. Introduction: Phylloides tumours are rare fibroepithelial breast tumours and are usually clinically and radiological indistinguishable from fibroadenomas. This makes core biopsy the main method of diagnosis. Only small studies have looked at the diagnostic histological accuracy of needle core biopsy(NCB) and none have addressedwhether there is any variability of NCB accuracy between institutions. Aims: To assess the diagnostic accuracy of NCB compared to the gold standard excision biopsy report in 2 separate hospitals trusts. Methods: Multicentre retrospective analysis of all cases of phylloides tumours on core and/or excision biopsy from March 2006 to July 2012 at Worcestershire Acute NHS Trust (WAHNST) and Gloucestershire hospitals NHS Trust (GHNHST). Results: N1⁄494. Mean age1⁄448. Mean clinical size1⁄431.7mm, mean radiological size1⁄435.4mm. WAHNST n1⁄442. NCB Sensitivity1⁄487% and Positive Predictive Value(PPV)1⁄490%. GHNHST n1⁄452 NCB Sensitivity1⁄474% and PPV1⁄4100%. Conclusion: The high sensitivity of NCB shown demonstrates its importance in the diagnosis of Phylloides tumours (comparative study in literature 63%). There does appear to be variation between pathologists in interpretation of NCB, which may be caused by the interpretation of the criteria for diagnosing Phylloides. NCB is not 100% sensitive at diagnosing these tumours so there must be local protocols to ensure tumours are not missed. 0434: BREAST CANCER SURGERY IS SAFE IN THE ELDERLY PATIENT Ramesh Yap Kannan, Nadi Khaldoun, Khawaja Saira, Sumrien Haytham, Holt Simon, Sharaiha Yousef. Prince Philip Hospital, Llanelli, Carmarthenshire, UK. Aims: To assess the safety of surgical resection of breast cancer in patients over 70 years Methodology: A retrospective study of 188 consecutive patients diagnosed with breast cancer at the age of 70 or older (2004 to 2008). Notes were examined for demographics, treatment, complications and final outcome. Patients received surgery with an intent to cure (SC) or conservative treatment (C). Results: 68 patients received C and 120 patients underwent SC. SC was performed in 63.8%(120 of 188), of whom 93.3% had a general anaesthetic. Mastectomy (M) was performed in 51.6%, M following a wide local excision (WLE) in 4.2% and WLE in 44.2%. Axillary surgery (n1⁄493) was either an axillary sampling (AS) in 5%, AS and clearance (AC) in 1%, primaryAC in87.1%, sentinel node biopsy (SNB) in 3.2% and SNB followed by AC in 3.2% (3 of 93). 30 day mortality was 0.008% (1 of 120) following a myocardial infarction. 10 patients had minor complications. Median follow up (SC) was 24 months versus 20 months (C). Overall survival was 89%(SC) versus 50% (C). Conclusion: Elderly patients with breast cancer, can be treated surgically with an intent to cure, safely and this has an impact on survival. 0470: A RETROSPECTIVE ANALYSIS OF PHYLLODES TUMOURS AND B3 LESIONS ON CORE BIOPSY Lucinda Frank, Sarah Vestey, Richard Bryan. Gloucester Royal Hospital,

Nipple-Sparing Mastectomy in Patients with a History of Reduction Mammaplasty or Mastopexy

INTRODUCTION: Nipple-sparing mastectomy has gained popularity, but the question remains whether it can be offered safely to women with prior history of reduction mammaplasty or mastopexy. Presented is our updated experience with offering nipple-sparing mastectomy to this patient population. METHODS: Patients at our institution who had reduction mammaplasty or mastopexy prior to nipple-sparing mastectomy were identified and their records reviewed. Outcomes measured include nipple-areolar complex viability, mastectomy flap necrosis, infection, cancer in the nipple-areolar complex and breast cancer recurrence. RESULTS: The records of our nipple-sparing mastectomy patients from 2006 through 2012 were reviewed. We present eleven patients (n=19 breasts) who underwent nipple-sparing mastectomy following reduction mammaplasty or mastopexy. Seventeen breasts had reduction mammaplasties while the remaining two had mastopexies. In all cases, reduction mammaplasty or mastopexy were in the patient’s surgical history and not performed as part of a planned two stage nipple-sparing mastectomy procedure. The mean age of the patients was 47.5 and the mean BMI was 27.6. None of the patients in this subset were diabetic, and one patient was a smoker. Twelve breasts had therapeutic resections, and seven were for prophylactic indications. Average time elapsed between reduction mammaplasty or mastopexy and nipple-sparing mastectomy was 104.3 months (range, 33 days to 40 years). Fourteen patients were reconstructed immediately with tissue expanders, one with a latissimus dorsi flap with immediate implant and four with immediate transverse rectus abdominis myocutaneous free flaps. Prior reduction mammaplasty or mastopexy incisions were used in all cases. Complications included one hematoma requiring evacuation, one breast with mastectomy flap necrosis, and one displaced implant requiring revision. There were no positive subareolar biopsies. Nipple viability complications included a partial necrosis rate of 15.8% (3/19). Mean follow-up time was 14.5 months. CONCLUSION: Our updated experience demonstrates that the outcomes of nipple-sparing mastectomy in patients with a history of reduction mammaplasty or mastopexy are comparable to the standards for patients who undergo nipple-sparing mastectomy alone.

The Super Thin External Pudendal Artery (STEPA) Flap

INTRODUCTION: The need for improved microsurgical reconstructive techniques is ongoing given the “ideal” free flap still does not exist.1 When reconstruction requires a thin flap, options have remained limited and flaps with minimal donor site morbidity that do not require secondary de-bulking have been elusive thus far. The importance of a thin and supple flap cannot be understated when dealing with challenging cases such as the dorsum of the hand or foot, the head and neck or over joints. The authors propose a previously un-described free tissue transfer based on the external pudendal artery that fulfills many of the aforementioned goals (Figure 1). An anatomical cadaveric study has been performed describing the super thin external pudendal artery (STEPA) flap.Figure 1: Location and pertinent anatomy of the STEPA flap.METHODS: Six fresh cadavers were used in the raising of eight hemiscrotal flaps and two bipedicled scrotal flaps based on the external pudendal vessels. Two unipedicled and both bipedicled flaps underwent cannulation of the external pudendal artery followed by injection of an iodinated contrast medium, iohexol (Omnipaque) and three-dimensional computed tomographic angiography to evaluate vascular anatomy. Colored-latex was injected into one raised hemiscrotal flap. Measurements were made on the cadaveric dissections and on a computed tomography workstation. RESULTS: The average external diameter of the external pudendal artery measured 2.81mm at its origin from the femoral artery, the vein 4.44 mm. The mean pedicle length measured 11cm (range, 10 to 12 cm). The mean thickness of the flap measured 1.1mm. CONCLUSION: A new free flap, the STEPA flap, has been described that is the thinnest myocutaneous free flap with over 80% of the thickness of the flap less than 1.1mm (Figure 2). It has been demonstrated to have reliable anatomy with more than adequate vessel caliber. It has a large surface area and a generous pedicle length for free tissue transfer. Donor site morbidity is favourable. It is accepted that there may be cosmetic issues regarding flap pigmentation and a variable degree of hair in patients where the reconstruction is visible. We contend that there exist many successful techniques which address pigmentation and depilation, and that this trade-off is acceptable given the functionality and characteristics of this uniquely thin flap.2,3 It has the potential to be used in many clinical scenarios where thin supple reconstruction is a high priority.Figure 2: Demonstration of thinnest of the STEPA flap.