Chlorhexidine should be used preferentially for preoperative antisepsis in clean-contaminated surgery.

IntroductionThe deep inferior epigastric artery perforator free flap is the gold standard for autologous breast reconstruction. However, using a single vascular pedicle may not yield sufficient tissue in patients with midline scars or insufficient lower abdominal pannus. Double-pedicled free flaps overcome this problem using different vascular arrangements to harvest the entire lower abdominal flap. The literature is, however, sparse regarding technique selection. We therefore reviewed our experience in order to formulate an algorithm and comprehensive classification for this purpose.MethodsAll patients undergoing unilateral double-pedicled abdominal perforator free flap breast reconstruction (AFFBR) by a single surgeon (CMM) over 40 months were reviewed from a prospectively collected database.ResultsOf the 112 consecutive breast free flaps performed, 25 (22%) utilised two vascular pedicles. The mean patient age was 45 years (range = 27–54). All flaps, but one (which used the thoracodorsal system), were anastomosed to the internal mammary vessels using the rib-preservation technique. The surgical duration was 656 min (range = 468–690 min). The median flap weight was 618 g (range = 432–1275 g) and the mastectomy weight was 445 g (range = 220–896 g). All flaps were successful and only three patients requested minor liposuction to reduce and reshape their reconstructed breasts.ConclusionBipedicled free abdominal perforator flaps, employed in a fifth of all our AFFBRs, are a reliable and safe option for unilateral breast reconstruction. They, however, necessitate clear indications to justify the additional technical complexity and surgical duration. Our algorithm and comprehensive classification facilitate technique selection for the anastomotic permutations and successful execution of these operations.Levels of evidenceTherapeutic level IV.

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Flap reconstruction after complex orbital exenteration is associated with low morbidity. Cervicofacial rotation-advancement flaps offer reliable, single-stage, aesthetically pleasing reconstructions. They should be avoided in the previously irradiated. Free tissue transfer is indicated for volume replacement, after previous radiotherapy, after tumor recurrence and previous use of locoregional flaps. Reconstruction of complex orbital exenteration defects for malignancies should be undertaken in centers with experience in the management of these procedures.