1 years (range, 28 to 62 years) and mean body mass index of 32.6 kg/m (range, 23.4 to 49.0 kg/m) underwent reconstruction with 122 flaps. The mean interval between stage 1 and 2 was 16.9 weeks (range, 3 to 31 weeks). Clear margins were obtained in all cases of invasive cancer and in situ disease following stage 1. Complications following stage 2 included partial nipple-areolar complex necrosis (n = 5, 8.2 percent), complete nipple-areolar complex necrosis (n = 4, 6.6 percent), nipple-areolar complex malposition (n = 1, 1.6 percent), and mastectomy skin necrosis (n = 4, 6.6 percent). No flap loss was noted in this series. CONCLUSION Patients with moderate to severe breast ptosis and/or macromastia who wish to undergo mastectomy with reconstruction can be offered nipple-sparing approaches safely if a staged algorithm is implemented. read more CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.BACKGROUND With advances in technology and technique, the goal of microvascular breast reconstruction has transitioned from flap success to minimizing complications and maximizing aesthetic outcome and efficiency. In an effort to evaluate efficiency, the authors implemented a rigorous process analysis in their practice to evaluate deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS A prospective implementation of process analysis was instituted on 147 DIEP flaps. The eight critical maneuvers for a DIEP flap are (1) skin to perforator identification, (2) perforator decision making, (3) perforator dissection, (4) pedicle dissection, (5) flap harvest, (6) preparation for microsurgery, (7) venous anastomosis, and (8) arterial anastomosis. Surgeons with variable experiences (faculty, faculty with senior resident/fellow, and supervised chief resident) used these eight steps to perform DIEP flap reconstruction. The outcomes and time of each maneuver were tracked. RESULTS The total flap harvest time among the three groups was 54.8 minutes for faculty surgeons, 98.3 minutes for senior resident/fellow working with faculty, and 178.8 minutes for supervised chief resident (p less then 0.001). The largest difference was seen in perforator dissection. Increasing the number of perforators resulted in longer flap harvest times. Perforator location did not have an impact on times, but harvesting multiple rows took longer for less experienced surgeons. Body mass index and flap weight did not have an impact on time. CONCLUSIONS The authors share their experience using process analysis for DIEP flap reconstruction. They defined eight critical maneuvers to maximize efficiency and safety. By communicating efficient processes and integrating them into the workflow of a given operation, surgeons can continue to improve throughout the arc of their careers.BACKGROUND The lumbar artery perforator flap is an excellent free flap for breast reconstruction whenever the deep inferior epigastric perforator (DIEP) flap is not an option. The main indication is a lack of abdominal bulk, often seen in young BRCA-positive women seeking prophylactic amputation and immediate reconstruction. METHODS Between October of 2010 and July of 2016, a total of 661 free flap breast reconstructions were performed. The authors retrospectively analyzed patient demographics, perioperative parameters, and secondary corrections. RESULTS Seventy-six lumbar artery perforator flaps were retained and compared with a cohort of 560 DIEP flaps. The average body mass index for lumbar patients was 23.8 kg/m, with a mean age at operation of 46.3 years. Average body mass index for DIEP patients was 25.2 kg/m, with a mean age at operation of 48.8 years old. Lumbar artery perforator flap weight was 504 g (range, 77 to 1216 g) on average versus 530 g (range, 108 to 1968 g) for the DIEP flaps. The amount of corrective procedures performed was very similar in both cohorts 13 percent of the lumbar artery perforator and 12 percent of the DIEP patients underwent no procedures, 62 percent in both groups underwent one procedure, and 25 percent versus 27 percent underwent two or more procedures. Lipofilling was performed in 48 percent of lumbar artery perforator flaps compared with 57 percent of the DIEP flaps (p = 0.14). Mean volume injected was 98.0 cc and 125.1 cc for lumbar artery perforator and DIEP flaps, respectively (p = 0.071). CONCLUSIONS The lumbar flap is a good alternative whenever a DIEP flap is not possible. Bilateral autologous reconstruction is possible even in very thin patients, and secondary corrections are comparable to those for the DIEP.BACKGROUND Capsular contracture is a troublesome and distressing complication in mammaplasty or breast reconstruction involving a prosthesis. Previous studies have indicated that leukotriene antagonists effectively reverse capsular contracture. However, this treatment method lacks comprehensive support from evidence-based medicine and remains considerably controversial. In this study, a meta-analysis was conducted to evaluate the therapeutic and preventive effects of leukotriene antagonists on capsular contracture in patients after breast prosthesis implantation. METHODS A comprehensive literature search was performed in English and Chinese databases. All clinical studies assessing the therapeutic and prophylactic effects of leukotriene antagonists on capsule contracture after breast prosthesis implantation were selected. Risk differences and 95 percent confidence intervals were applied as the final pooled statistics. RESULTS A total of five eligible studies were included, involving 1710 breast prosthesis impy, and exact mechanism of leukotriene antagonists for periprosthetic capsular contracture are warranted.BACKGROUND In deep inferior epigastric perforator flap surgery, the amount of perfusion achievable in the contralateral side over a midline is unclear. Predicting contralateral perfusion preoperatively using computed tomographic angiography will allow efficient breast reconstruction with decreased complications. The authors used computed tomographic angiography to determine whether contralateral perfusion is related to blood vessel status across the midline. METHODS Preoperative computed tomographic angiography scans and intraoperative perfusion in patients who underwent breast reconstruction with a deep inferior epigastric perforator flap between January of 2018 and July of 2018 were checked prospectively. A vessel scoring system was prepared according to vessel density across the flap midline on the scan (grade 0, no visible vessels; grade 1, visible vessels with disconnection or could not be judged as grade 0 or 2; grade 2, definite vessels). Intraoperative flap perfusion was confirmed with indocyanine green angiography.