The Hall-Findlay mammaplasty pattern for skin-sparing mastectomy: case report

We present an application of the Hall-Findlay mammaplasty skin pattern for skin-sparing mastectomy (SSM). This is a simplified vertical reduction mammaplasty. Vertical reduction mammaplasty is the procedure advised for patients with moderator or large ptotic breasts, who wish to have a simultaneous contra-lateral breast reduction/mastopexy at the time of SSM for cancer or prophylactic mastectomy. It is particularly suitable for breast reconstruction with autologous tissue in the form of free transverse rectus abdominis myocutaneous (TRAM), deep inferior epigastric artery perforator (DIEP) and extended latissimus dorsi (ELD) flaps.     

An application of the LeJour vertical mammaplasty pattern for skin-sparing mastectomy: a preliminary report

An application of the LeJour vertical mammaplasty skin pattern for skin-sparing mastectomy is presented. The approach provides adequate access for the mastectomy, axillary dissection, and immediate breast reconstruction. The technique is ideal for patients with large or ptotic breasts undergoing a simultaneous contralateral breast reduction or mastopexy. It is particularly suitable for autogenous tissue reconstruction. Its use in mastectomies for cancer and prophylactic subcutaneous mastectomies is described.     

Immediate versus delayed free TRAM breast reconstruction: an analysis of perioperative factors and complications.

Immediate breast reconstruction provides superior psychological benefit to the patient compared with delayed reconstruction, and has a financial advantage. Smokers undergoing immediate free TRAM breast reconstruction have a higher incidence of flap necrosis than smokers undergoing delayed free TRAM reconstruction. Whereas the differences in psychological benefit, effects of smoking and cost are well addressed in the literature, the differences in morbidity between immediate and delayed free TRAM breast reconstruction are still unknown. Knowledge of any differences would help to determine the best timing for reconstruction, and would support surgical decision making and preoperative patient advice. We present a retrospective review of 105 consecutive free TRAM breast reconstructions performed in 97 patients (89 unilateral and eight bilateral reconstructions). There were 48 immediate reconstructions and 57 delayed reconstructions. In the immediate-reconstruction group six flaps required revision of the anastomosis, and three flaps (6%) were lost. In the delayed-reconstruction group five flaps required revision of the anastomosis, and only one flap (2%) could not be salvaged. Delayed healing of the chest-wall skin flaps only occurred in immediate reconstructions (16%, P = 0.017).     

A safe approach to sparing the rectus muscle in abdominal-based microvascular breast reconstruction—TRAM, MS-TRAM, DIEP or SIEA?

There has been an international drive towards the use of abdominal-based perforator (deep inferior epigastric perforator (DIEP) or superficial inferior epigastric artery (SIEA)) flaps for breast reconstruction as they provide the ideal tissue whilst minimizing donor site morbidity, post-operative pain and recovery times. Ultimately, what is desired is a safe and reliable reconstruction. We retrospectively reviewed 245 consecutive abdominal-based free flaps performed by three surgeons at a single institution between January 2002 and March 2008. Primary breast reconstructions were planned as DIEPs, but a safe, flexible approach to flap selection was adopted with the most appropriate flap performed depending on the perforator anatomy at the time of surgery. Chest wall resurfacing procedures for extensive recurrent disease, inflammatory breast carcinoma or following radionecrosis were planned as transverse rectus abdominis myocutaneous (TRAM) flaps. The incidence of flap complications was compared including total and partial flap loss, returns to operating room, seroma, abdominal hernia/bulge, fat necrosis and delayed wound healing. Patient age, body mass index (BMI), smoking status, co-morbidity and pre- and post-operative radiotherapy were recorded. Two hundred patients, mean age 48?years (range, 26–74?years), underwent a total of 245 abdominal-based microvascular breast reconstructions. Twelve salvage TRAM flaps were performed for chest wall resurfacing. Of the remaining 233 flaps, 151 (65%) were immediate and 82 (35%) were delayed reconstructions. Flaps included 171 DIEPs, 38 muscle-sparing (MS)-TRAMs, 2 TRAMs and 22 SIEA flaps. Of the 233 reconstructions, 39 flaps (16.7%) in 31 patients received radiotherapy. Mean follow-up was 2.6?years. There were three (1.3%) complete flap losses and three (1.3%) partial flap losses. Rates of fat necrosis were 3.0% and abdominal hernia/bulge 1.7%. We present an algorithm to aid decision-making in autologous breast reconstruction that reflects our safe flexible approach. We have achieved excellent success rates in autologous breast reconstruction and conclude that in order to minimize complications, a safe flexible approach towards muscle harvest must be maintained in our drive to use perforator flaps.     

Immediate breast reconstruction after salvage mastectomy: Case control outcome comparisons of DIEP flap and DTI reconstruction

BackgroundCancer recurrence after breast-conserving therapy is most often managed by salvage mastectomy. Successful breast reconstruction immediately after salvage mastectomy, however, remains challenging because the reconstruction is performed on previously irradiated breast tissue.MethodsRecords of patients who underwent breast reconstruction from June 2010 to June 2019 were reviewed, including their demographic characteristics, methods of breast reconstruction, and early and late outcomes. Deep inferior epigastric perforator (DIEP) flaps and direct-to-implant (DTI) reconstructions following salvage mastectomies were compared with reconstructions following completion or primary mastectomies. Patients who underwent reconstruction followed by postmastectomy radiotherapy (PMRT) and patients followed up for less than 6 months were excluded.ResultsDIEP flaps in 27 breasts that underwent salvage mastectomy were compared with DIEP flaps in 32 breasts that underwent completion and 564 that underwent primary mastectomy. Rates of early complications, including microsurgical revision and total flap loss, and of late complications (>6 months after surgery), including fat necrosis and flap volume loss, did not differ significantly. DTI reconstruction in 20 breasts that underwent salvage mastectomy was compared with DTI reconstruction in 12 breasts that underwent completion and 351 that underwent primary mastectomy. Wound healing problems, including wound dehiscence and delayed wound healing (15% vs. 2.6%, P = 0.0022), and capsular contracture (30% vs. 5.4%, P = 0.0000), were significantly more frequent in breasts that underwent salvage than primary mastectomy.ConclusionsDIEP flap is a successful reconstruction option after salvage mastectomy. DTI reconstruction is associated with higher rates of wound healing problems and capsular contracture after salvage than after primary mastectomy.     

Recovery of sensation in immediate breast reconstruction with latissimus dorsi myocutaneous flaps after breast-conservative surgery and skin-sparing mastectomy

In breast reconstruction, sensation in the reconstructed breasts affects the patients' quality of life along with its aesthetic outcome. Fortunately, less invasive procedures such as breast-conservative surgery (BCS) and skin-sparing mastectomy (SSM) have greatly contributed to the improved aesthetic outcome in immediate breast reconstruction. However, there are few reports on the recovery of breast sensation after BCS and SSM. We retrospectively reviewed 104 consecutive patients who underwent immediate breast reconstruction with the latissimus dorsi myocutaneous flap between 2001 and 2006 at our institution. The sensations of pain, temperature, touch, and vibration were examined at the nipple and skin envelope during the follow-up period (range: 12-61 months, mean: 31 months), and a stratified analysis was performed to determine the critical factors affecting the sensation recovery after BCS and SSM. We found that large breast size significantly impaired the recovery of sensation in the nipple and skin envelope after BCS as well as SSM. Older age and high body mass index value were the factors which negatively affected the sensation in the skin envelope after SSM. While all our BCS patients underwent postoperative radiation therapy, it did not negatively affect the recovery of sensation in SSM patients. On the basis of these findings, we could further improve the sensation of the reconstructed breasts after BCS and SSM. Especially after SSM, the use of innervated flaps is recommended in the patients with large breast, increased age, or obesity when the nipple-areola complex is resected.     

Free microvascular tram flaps: report of 185 breast reconstructions.

The free TRAM flap is the most elegant technique currently available for breast reconstruction. We describe here the surgical technique, the complications, the possible effects of the prognosis of the breast cancer, and the learning curve of the surgical team. From December 1990 to the end of 1995 we reconstructed 185 breasts (10 bilateral) in 175 patients with free TRAM flaps; 27 were immediate reconstructions. We harvested the flap based on the inferior epigastric pedicle on the opposite side to the affected breast. To dissect the rectus muscle we used a muscle-sparing technique. The flap was designed and de-epithelialised while still on the abdomen, and was anastomosed to the thoracodorsal or circumflex scapular vessels with loupes only. In the immediate reconstructions we removed the breast tissue through a periareolar incision; we dissected the group I axillary lymph nodes and exposed the recipient vessels through a separate incision. The areolar complex was autotransplanted as a free skin graft. Only two flaps were lost. Eight patients were reoperated on for thrombosis of the vessels. The complication rate was nearly 50% among the first 50 patients. However, as surgical experience grew, the figure was reduced, eventually being down to 20%-25%. Of the patients who had delayed reconstructions only two died during the follow-up period of 48 months. One patient had a local recurrence above the TRAM skin. During the last eight years the free TRAM flap has been our main method of breast reconstruction. Free flaps today are reliable and the reconstruction does not seem to worsen the prognosis of breast cancer.     

Ischemic complications in pedicle, free, and muscle sparing transverse rectus abdominis myocutaneous flaps for breast reconstruction

Muscle sparing and perforator flaps techniques for breast reconstruction have focused in reducing the donor site morbidity. Theoretically this may result in a less robust blood supply to the flap. The purpose of this study was to assess flap ischemic complications with the pedicle, free, and the different muscle sparing transverse rectus abdominis myocutaneous (TRAMs) flaps for breast reconstruction and determine the factors associated with these complications. A total of 301 consecutive patients that underwent 399 breast reconstructions were retrospectively reviewed. Patient, oncologic, and reconstruction data were recorded. A flap ischemic complication scale was design including: wound healing problems, skin flap necrosis, fat necrosis, partial flap loss, and total flap loss. Analysis of donor site complications, bilateral and unilateral reconstructions were also performed. There were 147 pedicle TRAM and 154 free TRAM with the following subgroup distribution: MS-0 = 102; MS-1 = 37; and MS-2 = 15 patients. The groups were comparable in relation to age, comorbidities, cancer stage, and treatment. The overall complication rate after reconstruction had no statistical differences between the groups. The variables related to flap ischemia were statistically lower in the free TRAM. Mild and severe fat necrosis were the indicators with a statistical difference. The MS-0 group had lower ischemic complications and fat necrosis than the pedicled group, but no differences were observed for the MS-1 and MS-2 groups. The same results were seen in the unilateral reconstructions but not in the bilateral ones. No differences in donor site bulging or hernia were observed between the groups. In our study, the free TRAM flap demonstrated lower ischemic complications than the pedicle TRAM. A trend for decreased flap blood supply when more muscle is preserved and less number of perforators are used with a constant tissue volume was observed.     

Ultra-conservative skin-sparing 'keyhole' mastectomy and immediate breast and areola reconstruction

The popularity of skin-sparing mastectomy (SSM) which preserves the breast skin envelope is increasing, but the risks and benefits of this approach are only beginning to emerge. A technique involving ultra-conservative SSM and immediate breast reconstruction (IBR) has been evaluated to establish the surgical and oncological sequelae of skin conservation. Between 1994-1998, 67 consecutive patients underwent 71 SSM and expander-assisted immediate latissimus dorsi (LD) breast reconstructions (follow up, 24.1 months; range, 2-52 months). Breast resection, axillary dissection and reconstruction were performed through a 5-6 cm circular peri-areolar 'keyhole' incision. Patients were discharged 6.5 days (range, 5-15 days) after the 3.9 h (range, 3.0-5.5 h) procedure, and expansion was completed by 4.0 months (range, 0-10 months). Local recurrence occurred in 3% of breasts at risk, skin envelope necrosis occurred in 10%, and contralateral surgery was required to achieve symmetry in 14%. SSM and IBR is an oncologically safe, minimal-scar procedure which can be performed by surgeons trained in 'oncoplastic' techniques. It results in low rates of local recurrence and complication, and reduces the need for contralateral surgery.     

乳腺癌术后游离腹直肌肌皮瓣乳房再造

目的 评估乳腺癌术后游离横向腹直肌肌皮瓣（transverse rectus abdominis myocutaneousflap,TRAM）再造乳房的近期疗效.方法 2003年7至11月期间,我们在美国得克萨斯州大学圣安东尼奥科学健康中心整形重建外科共进行乳腺癌术后游离TRAM皮瓣再造乳房12例,平均年龄43.5岁,平均体重68.6kg,其中乳腺癌术后一期乳房再造2例（16.7%）、延期再造10例（83.3%）,游离皮瓣的血管蒂为对侧腹壁下动静脉,12例患者中选择胸背血管为受区血管的2例、选用胸廓内动静脉为受区血管的10例,再造手术后平均随防时间2.8个月.结果 12例游离TRAM皮瓣再造乳房手术皆顺利完成,手术成功率100%,平均手术时间8.3 h,平均住院时间9.4 d,为了对称行对侧乳房缩小术5例（41.7%）.共发生并发症3例6例次,并发症发生率25%,并发症包括皮下积液积血3例次（50%）、创口延迟愈合2例次（33.3%）,再造乳房部分脂肪坏死1例次（16.7%）,未见皮瓣坏死、腹壁疝、腹部皮肤坏死、创口感染等严重并发症的发生.患者自我评价对再造乳房总体满意者11例（91.7%）,不太满意者1例（8.3%）,无一例患者不满意.结论 乳腺癌术后游离TRAM皮瓣再造乳房安全可靠、整形效果良好,患者对重建的乳房有着较高的满意度.     

One‐stage DIEP flap breast reconstruction: Algorithm for immediate contralateral symmetrization

The aim of this study was to investigate clinical and aesthetic results of simultaneous contralateral balancing procedures in unilateral DIEP flap reconstructions by means of a symmetrization algorithm. Between 2004 and 2013, 335 patients underwent DIEP flap breast reconstruction with 48 patients (mean age 51.8 years, range 32–69 years) undergoing contralateral procedure. Patients were divided in Group‐A including 31 cases who underwent one‐stage procedure and Group‐B including 17 cases who underwent staged procedure. A symmetrization algorithm was proposed to plan immediate breast reduction/mastopexy. The groups were homogeneous regarding patient's age, BMI, mastectomy and flap weight (P > 0.05). All flaps survived. No complications were observed to the mastectomy skin flaps and to the reduction mammaplasty/mastopexy procedures in both groups. The mean operation time was 5 h in Group‐A while 5 h and 37 min in Group‐B (P = 0.0682). Contralateral procedures included 23 breast reductions and 8 mastopexies in Group‐A, while 10 breast reductions and 7 mastopexies were performed in Group‐B. Two and 6 patients required revision of the balancing procedure in Group‐A and Group‐B, respectively. The follow‐up time was 47.3 months (range 14–120 months) in Group‐A and 91.3 months (range 41–110 months) in Group‐B. Volume, upper/lower pole shape, projection, breast mound placement, IMF, symmetry, overall appearance, and general satisfaction sub‐items obtained high‐score evaluation without significant difference between the two groups (P > 0.05). One‐stage DIEP flap reconstruction by means of the symmetrization algorithm resulted in comparable aesthetic outcomes and patient satisfaction to a staged procedure. © 2015 Wiley Periodicals, Inc. Microsurgery 36:7–19, 2016.     

Reconstruction of postburn breast deformities

Postburn breast deformity is a sequela of severe scar contraction of the burned chest. During the past 3 years, 24 female patients with such deformities required reconstruction, the surgery was performed in our department. These patients, the types of the deformities and the techniques used for reconstruction have been reviewed. For mild deformities (10 patients) reconstructions with skin grafts and local skin flaps were found to be satisfactory. For deformities which affected the mammary development (14 patients), mammary prostheses directly or under the soft tissue obtained by skin expansion or musculocutaneous flaps were used. In three of our patients, reduction mammaplasty or mastopexy was needed to symmetrize the breasts.     

Rationale for elective contralateral Mastectomy with immediate bilateral reconstruction

Background: Women with breast cancer treated by mastectomy with immediate breast reconstruction can get exceptionally good results if the reconstruction is performed with autogenous tissue using the transverse rectus abdominis myocutaneous (TRAM) flap. Bilateral reconstruction with TRAM flaps is also possible, but only if both breasts are reconstructed at the same time. To avoid the possibility of subsequently developing contralateral malignancy and having to undergo assymetrical reconstruction with a different technique, some patients have chosen the alternative of bilateral mastectomy with bilateral immediate reconstruction. This is only reasonable if the incidence of failure in bilateral breast reconstruction is very low. Methods: We prospectively studied reconstructive outcomes in 100 patients who had breast cancer and who underwent bilateral mastectomy and reconstruction (using implants as well as TRAM flaps). We also reviewed the histologic findings in 88 prophylactically removed high-risk breasts. Results: Successful outcomes were initially achieved in 95 patients; of the 5 failures, two were successfully reconstructed with alternative techniques for an overall success rate of 97%. Of the 63 patients reconstructed with bilateral TRAM flaps, all but one (98%) were successful on the first try. TRAM flap reconstructions were significantly more likely to be successful than were those based on implants (p=0.05). Previously unsuspected invasive cancer was found in 3 patients (3.4%), whereas carcinoma in situ was found in 5 patients (5.7%) and in another 18 patients (20%) cellular atypia was present. Conclusions: Bilateral breast reconstruction has a low incidence of failure, particularly if TRAM flaps are used. For selected patients, elective contralateral mastectomy with immediate bilateral reconstruction is a reasonable treatment alternative provided that the necessary expertise is available and the patients clearly understand the risks.The results of this study were presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

Skin-sparing mastectomy flap complications after breast reconstruction: review of incidence,management, and outcome

This study assesses the incidence and outcome of skin-sparing mastectomy (SSM) flap complications after breast reconstruction. The authors performed a retrospective review of 37 consecutive patients undergoing SSM and immediate breast reconstruction, focusing on preoperative demographics, management of complications, and early outcome. Univariate analysis comparing patients with and without complications was performed using Student's t-test and chi-square analysis. From July 2000 to December 2001, 37 patients (mean age 48.1, range 24-71 y) underwent SSM and breast reconstruction (unilateral 20, bilateral 17) via TRAM flaps (n = 18), latissimus flaps (n = 13), and expander/implants (n = 6). SSM flap complications occurred in nine patients (24.3%) and included mild (n = 2), moderate (n = 5), and severe (n = 2) skin loss, resulting in four cases of dehiscence, five reoperations, and no delay in postoperative adjuvant therapy (required in six patients). Previous irradiation (n = 5, p = 0.045) and diabetes (n = 3, p = 0.001) were associated with SSM flap complications, but age, smoking, previous breast cancer, and type of reconstruction were not. Patients with SSM flap loss had a higher body mass index (BMI) than those without complications (30.0 vs. 24.3; p = 0.025). Skin flap complications after SSM and breast reconstruction are not uncommon but did not delay the initiation of adjuvant chemotherapy or radiotherapy, despite the need for reoperation. Patients with elevated BMI, diabetes, and previous irradiation may be at increased risk for SSM flap complications.     

Second- and third-degree burns as a complication in breast reconstruction

Over the last five years 10 patients in our practice have developed second- or third-degree burns following breast reconstruction. This has occurred in the reconstructed breasts of patients who have had tissue expansion, latissimus dorsi flaps, and transverse rectus abdominis musculocutaneous (TRAM) flaps. Second- or third-degree burns have also occurred on the abdomen following TRAM flap procedures. The lack of normal sensation in the surgical areas has been the common etiological factor. Aggressive wound care has led to primary and secondary healing in all patients without the need for skin grafts. Patient education preoperatively and postoperatively is necessary to prevent this potential complication.     

Results of immediate breast reconstruction after skin-sparing mastectomy

Skin sparing mastectomy (SSM) removes the breast, nipple-areolar complex, previous biopsy incisions, and skin overlying superficial tumors. Preservation of the native skin envelope facilitates immediate breast reconstruction. The procedure has been adopted for the treatment of breast cancer. All cases of SSM and immediate breast reconstruction performed by the senior author (G.W.C.) from January 1, 1993, through December 12, 1997, were reviewed. Patient demographics, cancer staging, treatment, types of surgery performed, and postoperative outcomes were examined. Aesthetic outcomes were measured using four 3-point subscales. A total of 100 patients underwent 118 SSMs during the study period. The American Joint Committee on Cancer staging was as follows: stage 0, 27 patients; stage I, 25 patients; stage II, 39 patients; stage III, 7 patients; stage IV, 3 patients; recurrent, 2 patients; and cystosarcoma phylloides, 1 patient. The mean follow-up was 42.7 months. Local recurrence occurred in 2 patients (2.7%). Reconstructive methods included the transverse rectus abdominis musculocutaneous flap (N = 82; pedicled, 73; free, 9), the latissimus flap (N = 18), and tissue expansion (N = 20). Two patients underwent contralateral delayed reconstruction. The aesthetic results achievable with the three methods were similar. The failure rate was higher for expander reconstruction (10%) than those observed for transverse rectus abdominis musculocutaneous (4.9%) and latissimus (5.6%) flaps. SSM can be used in the treatment of invasive breast cancer without compromising local control. The aesthetic results of the three methods were similar, but tissue expander reconstruction had a higher failure rate.     

Reconstruction of soft tissue after complicated calcaneal fractures.

A total of 35 flap reconstructions were done to cover exposed calcaneal bones in 31 patients. All patients had calcaneal fractures, 19 of which were primarily open. Soft tissue reconstruction for the closed fractures was indicated by a postoperative wound complication. A microvascular flap was used for reconstruction in 21 operations (gracilis, n = 11; anterolateral thigh, n = 5; rectus abdominis, n = 3; and latissimus dorsi, n = 2). A suralis neurocutaneous flap was used in eight, local muscle flaps in three, and local skin flaps in three cases. The mean follow-up time was 14 months (range 3 months-4 years). One suralis flap failed and was replaced by a latissimus dorsi flap. Necrosis of the edges that required revision affected three flaps. Deep infection developed in two patients and delayed wound healing in another four. During the follow-up the soft tissues healed in all patients and there were no signs of calcaneal osteitis. Flaps were considered too bulky in five patients. Soft tissues heal most rapidly with microvascular flaps. In the long term, gracilis muscle covered with free skin grafts gives a good contour to the foot. The suralis flap is reliable and gives a good final aesthetic outcome. Local muscles can be transposed for reconstruction in small defects.     

De-epithelialized dermal barrier for a safe immediate prosthetic breast reconstruction post circumvertical skin sparing/reducing mastectomy (SSM/SRM)

Background

Skin-sparing mastectomy (SSM) and skin-reducing mastectomy (SRM) with immediate breast reconstruction (IBR) is oncologically safe and has become increasingly popular as an effective treatment for patients with early stage breast cancer requiring mastectomy. Cosmetic appearance following IBR depends largely on the location of the skin incision, the quantity of breast skin left as well as the pocket for prosthetic placement, whether submuscular, subcutaneous, or both. SRM with Le Jour pattern skin excision has already been described in conjunction with autogenous tissue reconstruction. This technique is not recommended for implant-based IBR because any compromise of skin viability can result in exposure of the implant or expander.

Methods

We propose SRM with a circumvertical skin excision pattern and IBR comprising a de-epithelialized dermal barrier to reinforce the vertical suture line. We performed this technique on 10 breast cancer patients.

Results

Eight patients underwent SSM with IBR using textured anatomical cohesive gel implants. One patient had Becker tear drop implants for both breasts (right SSM with IBR, and delayed left breast reconstruction); and the last patient had completion mastectomies with IBR using Becker tear drop implants. None of the patients developed complications.

Conclusion

This technique is reliable and safe for implant-based IBR, ensuring minimal scarring and pleasing aesthetic results. Level of Evidence: Level IV, therapeutic study.     

Immediate nipple reconstruction with thoracodorsal artery perforator flap in breast reconstruction by latissimus dorsi myocutaneous flap in patients with Poland's syndrome

Loss of long‐term projection is the major disadvantage of nipple reconstruction using local flaps. We report a technique of immediate perforator flap nipple reconstruction in breast reconstruction by latissimus dorsi (LD) myocutaneous flap in patients with Poland's syndrome. From March 2007 to July 2012, 12 female patients (age range, 15–21 years) underwent breast reconstructions and immediate nipple reconstructions. A thoracodorsal artery perforator (TAP) flap was simultaneously raised on the LD muscle flap and folded by itself to form the nipple. Both the LD flap and TAP flaps survived postoperatively. The nipple projection was measured by a caliper, and the average loss was 29% by the 1‐year follow‐up. Eleven patients considered the aesthetic appearance of reconstructed breast and nipple to be very good or good. The immediate nipple reconstruction with TAP flap could be safely performed and results in considerable satisfaction in breast reconstruction by LD myocutaneous flap in patients with Poland's syndrome. © 2015 Wiley Periodicals, Inc. Microsurgery 36:49–53, 2016.