).To date, the senior author (Robert J. Allen) has performed more than 3,500 microsurgical flap surgeries; more than 2,850 have been microsurgical breast reconstructions. The deep inferior epigastric perforator (DIEP) flap, superficial inferior epigastric artery (SIEA), gluteal artery perforator (GAP) flaps, transverse upper gracilis (TUG) flap, and most recently the profunda artery perforator (PAP) flap have been utilized to varying degrees in this practice. Over 20 years of experience in autologous microvascular breast reconstruction have been influenced by changes in breast cancer treatment, vascular imaging, patient empowerment, and globalization of health care. Here, we examine the trends in flap choice that have emerged during the 20 years since performing the inaugural DIEP flap in a microvascular breast reconstruction practice. 1 Materials and MethodsData were extracted from a personal logbook of all microsurgical free flaps from August 1992 to August 2012, and divided into 12 monthly segments to facilitate a 20-year comparison. Information recorded included date of surgery, location, referral source, and indication for surgery and mastectomy pattern in primary AbstractIt is over 20 years since the inaugural deep inferior epigastric perforator (DIEP) flap breast reconstruction. We review the type of flap utilized and indications in 2,850 microvascular breast reconstruction over the subsequent 20 years in the senior author's practice (Robert J. Allen). Data were extracted from a personal logbook of all microsurgical free flap breast reconstructions performed between August 1992 and August 2012. Indication for surgery; mastectomy pattern in primary reconstruction; flap type, whether unilateral or bilateral; recipient vessels; and adjunctive procedures were recorded. The DIEP was the most commonly performed flap (66%), followed by the superior gluteal artery perforator flap (12%), superficial inferior epigastric artery perforator flap (9%), inferior gluteal artery perforator flap (6%), profunda artery perforator flap (3%), and transverse upper gracilis flap (3%). Primary reconstruction accounted for 1,430 flaps (50%), secondary 992 (35%), and tertiary 425 (15%). As simultaneous bilateral reconstructions, 59% flaps were performed. With each flap, there typically ensues a period of enthusiasm which translated into surge in flap numbers. However, each flap has its own nuances and characteristics that influence patient and physician choice. Of note, each newly introduced flap, either buttock or thigh, results in a sharp decline in its predecessor. In this practice, the DIEP flap has remained the first choice in autologous breast reconstruction.

Autologous microvascular breast reconstruction is widely accepted as a key component of breast cancer treatment. There are two basic donor sites; the anterior abdominal wall and the thigh/buttock region. Each of these regions provides for a number of flaps that are successfully utilised in breast reconstruction. Refinement of surgical technique and the drive towards minimising donor site morbidity whilst maximising flap vascularity in breast reconstruction has seen an evolution towards perforator based flap reconstructions, however myocutaneous flaps are still commonly practiced. We review herein the current methods of autologous microvascular breast reconstruction.

Dedicated education sessions on skin lesions can improve the diagnostic accuracy of GP trainees, and we suggest that they are incorporated into the GP training curriculum.

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We present our experience using the vastus lateralis myocutaneous flap for the repair of defects around the groin and pelvis. It is a relatively new technique, with many advantages over other flaps used in this area, though it has limitations. The history, anatomy and surgical technique of raising the flap are described and clinical cases are discussed. The importance of patient selection is highlighted.