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BACKGROUND: When a single perforator flap does not provide adequate volume or projection for satisfactory breast reconstruction, the addition of an implant may be considered at the time of second-stage revisions. Dissection of an implant pocket beneath the flap may lead to the inadvertent injury of the flap pedicle as the tissue planes have been obscured by tissue ingrowth. The authors present a technique in which the boundaries of the implant pocket are predetermined at the time of flap reconstruction allowing an implant to be inserted at the second stage in ideal position with greater ease of dissection and minimal risk to the flap pedicle. METHODS: Forty patients (80 bilateral perforator flap breast reconstructions) treated with the creation of central under flap pocket technique in anticipation of subsequent sub flap implant augmentation within an 18-month period were assessed retrospectively. RESULTS: Sixty-eight patients with flaps (85%) went on to receive secondary augmentation with silicone implants. The average percentage increase in volume contributed by the implant was 41%. The undersurface of the acellular dermal matrix was readily identified, and its medial most extent safely determined, allowing the expeditious recreation of the predelineated central under-flap implant pocket. No flap pedicles were injured during the process, and the implants were placed in a favorable position providing maximum projection to the reconstruction. No subsequent development of fat necrosis was identified after augmentation. CONCLUSION: The creation of central under flap pocket technique allows for safe, effective, and expedient delayed implant augmentation of perforator flap breast reconstruction.

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INTRODUCTION: Falls are the leading cause of death and third leading cause of non-fatal injuries in construction. In an effort to combat these numbers, The National Campaign to Prevent Falls in Construction began in April 2012. As the campaign gained momentum, a week called the National Safety Stand-Down to Prevent Falls was launched to draw attention to the campaign and its goals. The purpose of this paper is to examine the reach of the Stand-Down and lessons learned from its implementation. METHODS: The Occupational Safety & Health Administration offered a certificate of participation during the Stand-Down. To print the certificate, respondents provided information about their company and stand-down event. CPWR - The Center for Construction Research and Training conducted analyses on the data collected to assess reach and extent of participation. RESULTS: In 2014, 4,882 stand-downs were reported. The total number reported in 2015 was 3,759. The number of participants, however, increased from 770,193 in 2014 to 1,041,307 in 2015. DISCUSSION: The Stand-Down successfully reached the construction industry and beyond. Respondents were enthusiastic and participated nationally and internationally in variety of activities. They also provided significant feedback that will be influential in future campaign planning. CONCLUSION: Numbers of Stand-Downs and participants for both years are estimated to be substantially higher than the data recorded from the certificate database. While we cannot determine impact, the reach of the Stand-Down has surpassed expectations. PRACTICAL APPLICATIONS: The data gathered provide support for the continuation of the Stand-Down. Campaign planners incorporated findings into future Stand-Down planning, materials creation, and promotion. This analysis also provides insight on how organizations can partner to create targeted national campaigns that include activities stakeholders in the construction industry respond to, and can be used to replicate our efforts for other safety and health initiatives in construction and other industries.

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BACKGROUND: Patients with moderate to severe ptosis are often considered poor candidates for nipple-sparing mastectomy. This results from the perceived risk of nipple necrosis and/or the inability of the reconstructive surgeon to reliably and effectively reposition the nipple-areola complex on the breast mound after mastectomy. METHODS: A retrospective review identified patients with grade II/III ptosis who underwent nipple-sparing mastectomy with immediate perforator flap reconstruction and subsequently underwent a mastopexy procedure. The mastopexies included complete, full-thickness periareolar incisions with peripheral undermining around the nipple-areola complex to allow for full transposition of the nipple-areola complex relative to the surrounding skin envelope. RESULTS: Seventy patients with 116 nipple-sparing mastectomies met inclusion criteria. The most common complications were minor incisional dehiscence (7.7 percent) and variable degrees of necrosis in the preserved breast skin (3.4 percent) after the initial mastectomy. There were no cases of nipple-areola complex necrosis following the secondary mastopexy. CONCLUSIONS: The authors demonstrate that full mastopexy, including a complete full-thickness periareolar incision and nipple-areola complex repositioning on the breast mound, can be safely performed after nipple-sparing mastectomy and perforator flap breast reconstruction. The underlying flap provides adequate vascular ingrowth to support the perfusion of the nipple-areola complex despite complete incisional interruption of the surrounding cutaneous blood supply. These findings may allow for inclusion of women with moderate to severe ptosis in the candidate pool for nipple-sparing mastectomy if oncologic criteria are otherwise met. These findings also represent a significant potential advantage of autogenous reconstruction over implant reconstruction in women with breast ptosis who desire nipple-sparing mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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BACKGROUND: Advances in autologous breast reconstruction continue to mount and have been fueled most substantially with refinement of perforator flap techniques. METHODS: For patients with a desire for autogenous breast reconstruction and insufficient abdominal fat for conventional abdominal flaps, secondary options such as gluteal perforator flaps or latissimus flaps are usually considered. Patients who also have insufficient soft tissue in the gluteal donor site and preference to avoid an implant, present a vexing problem. The authors describe an option that allows for incorporation of four independent perforator flaps for bilateral breast reconstruction when individual donor sites are too thin to provide necessary volume. The authors present their experience with this technique in 25 patients with 100 individual flaps over 5 years. RESULTS: The body lift perforator flap technique, using a layered deep inferior epigastric perforator/gluteal perforator flap combination for each breast, was performed in this patient set with high success rates and quality aesthetic outcomes over several years. Patient satisfaction was high among the studied population. CONCLUSIONS: The body lift perforator flap breast reconstruction technique can be a reliable, safe, but technically demanding solution for patients seeking autogenous breast reconstruction with otherwise inadequate individual fatty donor sites. This sophisticated procedure overcomes a limitation of autogenous breast reconstruction for these patients that otherwise results in a breast with poor projection and overall volume insufficiency. The harvest of truncal fat with a circumferential body lift design gives the potential added benefit of improved body contour as a complement to this powerful breast reconstructive technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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BACKGROUND: Breast reconstruction continues to evolve. The deep inferior epigastric perforator (DIEP) flap is a well-described means of providing natural tissue reconstruction with an attendant goal of minimizing damage in the abdominal donor site. METHODS: For patients with the need for autogenous reconstruction of a single breast and insufficient abdominal fatty volume for routine DIEP flap reconstruction, the authors present an option that allows for incorporation of the entire abdominal fatty composite with sequential linkage and stacked inset of two individual abdominal flaps. The ability to take advantage of the entirety of the abdominal donor volume allows those with a relatively thin body habitus to enjoy candidacy for DIEP flap reconstruction. This sophisticated microsurgical procedure overcomes some of the limitations of other techniques with similar goals such as the bipedicled transverse rectus abdominis musculocutaneous flap by avoiding muscle sacrifice and allowing precise, independent flap inset. The authors describe their experience with this technique in 55 patients with 110 flaps over 3 years. RESULTS: The authors' experience reviews the use of the stacked DIEP flap in a large number of patients with high success rates and superb aesthetic outcomes over a relatively short period of time. Of the 55 patients who underwent reconstruction, all enjoyed successful outcomes. Patient satisfaction was high in the studied population. CONCLUSION: Stacked DIEP free flap breast reconstruction is a reproducible, safe, and innovative yet technically demanding solution for patients seeking autogenous breast reconstruction with otherwise inadequate abdominal fatty volume.

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Muscle and musculocutaneous flaps have been used reliably in reconstruction of soft-tissue defects for many years. Previous experimental studies have shown musculocutaneous flaps to be superior to the random pattern and fasciocutaneous flaps in the management of infected wounds. Over the past decade, perforator flaps have gained acceptance as alternative methods of reconstruction in the clinical setting that can decrease donor-site morbidity and hospital stay, and increase patient satisfaction. The authors theorized that perforator flaps may be able to handle infected wounds better than random pattern and fasciocutaneous flaps because their blood supply is essentially the same as many of their musculocutaneous counterparts. The goal of this study was to compare the S1 perforator-based skin flap and latissimus dorsi musculocutaneous flap in the dorsal flank of the rabbit with the introduction of bacteria to simulate both superficial and deep wound infection. Measurements of oxygen tension and regional perfusion index were performed on both types of flaps to ascertain their viability and capacity to heal. The authors found no statistical significance between latissimus dorsi musculocutaneous and S1 perforator flaps in the rabbit with respect to superficial and deep wound infections. The regional perfusion index was calculated for postoperative days 1, 2, and 4. No statistically significant difference between the two flaps using the regional perfusion index could be identified. Additionally, regional perfusion for both types of flaps was greater than 0.6, indicating that their capacity to heal wounds is similar.

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