PRS Global Open • 2023
demonstrates that the terminal peroneal perforator may lie
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Seventy-two (56%) patients received fat grafting at the
significantly higher than the recommended 5cm pivot-point
above the lateral malleolus, making these modifications
crucial in select cases. With careful technique, these modi-
fications can improve the versatility of the RSAF as a local
reconstructive option for distal lower limb defects.
A Retrospective Pre-Pectoral Implant-
Based Breast Reconstruction Study: The
Impact of Breast Implant Cohesivity on
Revision Procedures & Post-Operative
Complications.
Presenter: Neil Parikh
Co-Authors: Goutam Gadiraju,
Bryce Starr, Tanujit Dey, Justin Broyles, MD,
Matthew Prospero, Yizhuo Shen
Affiliation: Boston University, Boston, MA
PURPOSE: Implant based reconstruction (IBR) can
include prepectoral or sub-pectoral reconstruction.[1]
While up to 50% of plastic surgeons perform prepectoral
IBR, implant rippling secondary to poor superior pole cov-
erage is a common postoperative complaint from patients.
[2] Silicone implants that are used in these procedures vary
in cohesivity. In the prepectoral plane, it is suspected that
highly cohesive implants reduce rippling rates; however,
this has not yet been demonstrated.
METHODS & MATERIALS: A retrospective cohort
analysis of two-stage IBR in the pre-pectoral plane was
conducted. Patients who had undergone unilateral or bilat-
eral, skin or nipple-sparing mastectomy and two-stage IBR
from January 2020 to June 2022 were identified in our
institution’s database. Patient demographic data, procedure
characteristics (e.g., implant size and cohesivity, concur-
rent autologous fat grafting), and complications were cap-
tured. Patients who were less than 6 months after IBR were
excluded. Univariate logistic regression analysis was con-
ducted to identify relationships between implant cohesivity
and the likelihood of patients requiring revision procedures
and developing post-operative complications.
EXPERIENCE & RESULTS: 129 patients met the inclu-
sion criteria for this study. The mean follow-up time was 235
(+/- 190) days. Mean age was 48.5 (+/- 10.5) years old. All
patients received Allergan Naturelle Silicone Gel Implants.
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time of tissue expander removal and implant placement.
A total of 52 patients received the least cohesive implants,
24 patients received moderately cohesive implants, and
53 patients received the most cohesive implants. Four-
teen patients (11%) received revision fat grafting after
the original implant placement. Thirty-six patients (28%)
experienced rippling after the original implant placement.
Univariable regression modeling indicated that the patients
who received the most cohesive implants were less likely to
require additional sessions of fat grafting after the implant
placement when compared to the patients who received
the two other implant options (OR 0.07, p < 0.05). Fur-
thermore, the patients who received the moderately cohe-
sive (OR 0.30, p < 0.05) and the most cohesive (OR 0.39,
p < 0.05) implants were less likely to experience rippling
after the implant placement compared to the patients who
received the least cohesive implant. In a subgroup analy-
sis, patients with the most cohesive implants who did not
receive fat grafting at implant placement did not require
additional fat grafting at a later instance (0%). However,
11 (31%) patients who received the least cohesive implant
without fat grafting at time of IBR ultimately required addi-
tional sessions of fat grafting.
CONCLUSIONS: Rippling after prepectoral IBR is a com-
mon complication and can be mitigated with fat grafting. The
use of highly cohesive implants in prepectoral IBR correlates
with significantly fewer rippling complications and revision
fat grafting procedures. Study of the cost implications of
these findings may further support the advantages of using
highly cohesive implants in prepectoral IBR procedures.
REFERENCES:
1. Kappos EA, Schulz A, Regan MM, et alPrepectoral versus
sub-pectoral implant-based breast reconstruction after skin-
sparing mastectomy or nipple-sparing mastectomy (OPBC-
02/ PREPEC): a pragmatic, multicentre, randomised,
superiority trialBMJ Open 2021;11:e045239. doi: 10.1136/
bmjopen-2020-045239.
2. Marks, J. M., Farmer, R. L., & Afifi, A. M. (2020, August 19).
Current Trends in Prepectoral Breast Reconstruction: A
Survey of American Society of Plastic Surgeons Members.
Plastic and reconstructive surgery. Global open. Retrieved
May 25, 2022, from https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC7489685/.
Anatomical Study of the Sensate
Pedicled Anterolateral Thigh (ALT) Flap
for Reconstruction of Pelvi-Perineal and
Knee Region Defects
Presenter: Fernando Moreno-Garcia
 PSTM Abstract Supplement
Co-Authors: Rachel Tran,
Grayson Hostetler, MD, Bradley Miyake, MD,
Guilherme Barreiro, MD,
Rachel Jordan, MD, Henry Marsh, MD
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Affiliation: Oklahoma City, OK
PURPOSE: The pedicled anterolateral thigh (ALT) flap is
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a well-known flap that can be used in lower trunk soft tis-
sue reconstruction through standard ALT dissection.1 This
flap may also be dissected in a reverse pedicled fashion
for knee region defects.2 Literature is limited in detailed
descriptions of the surgical technique for the elevation,
rotation, and submuscular tunneling of the pedicled ALT.
Furthermore, literature is limited in a standardization that
expresses reliability. Through cadaver dissections and clin-
ical outcomes, we will standardize this technique, making
it reproducible and safe for clinical application in patients
undergoing complex pelvi-perineal and knee region
reconstructions.
METHODS AND MATERIALS: Anatomic studies of 40
ALTs were harvested in 20 cadavers. Freestyle technique
with perforator preserving incision was performed to iden-
tify perforators and isolate flap components. The lateral
femoral cutaneous nerve (LFCN) was identified in all flaps.
From May 2010 to May 2016, 42 patients, ages 28 to 60
were treated with freestyle perforator preserving technique
for the pedicled ALT. Vessels to the rectus femoris muscle
were ligated for elongation of the main pedicle as neces-
sary. Inguinal and perineal defects required submuscular
tunneling under the sartorius and rectus femoris muscles.
Contralateral defects necessitated additional suprapubic,
subcutaneous tunneling. For the reverse type, superdraining
was performed. Dissection and preservation of the LFCN
maintained flaps as sensate.
EXPERIENCE: Forty-two patients were treated with pedi-
cled ALT flaps. Eight months mean follow-up.
RESULTS: Twenty-two fasciocutaneous and 20 myocu-
taneous flaps were harvested, 60% including the LFCN.
Six functional vaginal reconstructions, 3 functional penile
reconstructions, and various hip, perineal and abdominal
defects were successfully treated. The reverse ALT required
superdraining to the greater saphenous vein in all cases.
Sensate flaps regained two-point discrimination compara-
ble to the contralateral thigh within 6 months average. The
donor area was grafted in 8 (19%) patients and no major
complications or flap losses were observed. Five minor
wound dehiscences were treated conservatively.
Reconstructive
Track:
CONCLUSIONS: The freestyle sensate perforator pre-
serving pedicled ALT flap is a flexible workhorse flap,
suitable for a wide variety of lower trunk reconstructions.
Our described method is optimal for preservation of blood
flow, as well as pedicle and nerve reach, especially when
tunneled submuscularly beneath the rectus femoris and
sartorius muscles. With the preservation of the LFCN, the
flap can gain sensation similar to the contralateral thigh in a
two-point discrimination test within a reasonable amount of
time. Moreover, preservation of the LFCN allows for coap-
tation to locoregional nerves. Superdraining the reverse
ALT is suggested to prevent flap congestion. We report our
results with the ALT flap as a safe, versatile, and reproduc-
ible means of pelvi-perineal and knee region reconstruction.
REFERENCES:
1. Ng RW, Chan JY, Mok V, Li GK. Clinical use of a pedicled
anterolateral thigh flap. J Plast Reconstr Aesthet Surg.
2008;61(2):158-164. doi:10.1016/j.bjps.2007.10.028
2. Demirseren ME, Efendioglu K, Demiralp CO, Kilicarslan K,
Akkaya H. Clinical experience with a reverse-flow anterolat-
eral thigh perforator flap for the reconstruction of soft-tissue
defects of the knee and proximal lower leg. J Plast Reconstr
Aesthet Surg. 2011;64(12):1613-1620. doi:10.1016/j.
bjps.2011.06.047
Transfemoral Osseointegration: Surgical
and Patient Reported Outcomes for
Lower Limb Reconstruction
Presenter: Ricki Chen
Co-Authors: Brielle Raine, MD,
Rachel Williams, Kateryna Zelenova, MD,
Michael Nagai, Jordan Frey, MD,
Thom Loree, MD
Affiliation: University of Buffalo,
Buffalo, NY
BACKGROUND: The use of osseointegration (OI), a
process in which there is a direct structural and functional
connection between living bone and the surface of a load-
bearing artificial implant, has long been used in dental
reconstruction. The notion of expanding this process to
extremity reconstruction has been explored within the past
three decades. OI implants have become broadly utilized in
the European sector using the Osseointegrated Prostheses
for the Rehabilitation of Amputees (OPRA) protocol sys-
tem. This system was recently adopted in the United States,
with 20 medical centers nationwide offering OI implant
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