Breast cancer surgery has evolved. The goals not only successfully treat cancer, but also minimize deformity. Oncoplastic lumpectomy reconstruction delivers excellent treatment and improves aesthetics with equal survival to mastectomy. Some patients choose mastectomy or require mastectomy after lumpectomy and radiation for a recurrence. 1,6 Patients who test positive for genetic mutations proceed with bilateral mastectomy to confer a survival benefit. 2 For these women, autologous breast reconstruction is gaining popularity. 3 Plastic and reconstructive surgeons and oncologic surgeons need to continue optimizing mastectomy outcome. Factors such as previous radiation, multiple incisions, and protein deficiencies, in combination with an inherent "devascularizing" operation, impair mastectomy healing. In our daily practice, and through tumor board discussion, close communication among breast surgeons, breast radiologists, and plastic surgeons facilitates a plan for autologous reconstruction that optimizes

term repair, can be diffi cult as many comorbidities persist.General surgeons and plastic and reconstructive surgeons should communicate the anatomic and physiologic obstacles they foresee after history and examination of the patient to maximize repair success and decrease recurrence. This effective communication between the operating surgeons and review of CT-scans can help formulate successful fl ight plans for surgery.The more time spent in the pre-operative preparation and in the fl ight planning stage, the more optimized the patient is for success even in the face of previous radiation, comorbidities, or encountered post-operative obstacles.

Background: Pathologic fractures of the mandible following radiation and embolization can be a challenging problem for patients. Occasionally, patients have already completed the oncologic component of their treatment and are trying to move on with their lives. A pathologic fracture is not only painful, but also a frustrating hindrance as it limits food intake and overall nutrition. In addition, pathologic fractures are challenging to repair. Purpose: To demonstrate a step-by-step approach for pathologic mandibular fracture repair with an ipsilateral free fi bula fl ap following oncologic resection of a tonsillar tumor that underwent pre-operative embolization and post-operative radiation therapy. Methods/Results: A 65 year old male presented with a tonsillar head and neck tumor. The patient had pre-operative embolization for an intra-oral bleed, successful resection with clear margins, and then post-operative radiation therapy. During a subsequent dental procedure, the patient developed a pathologic mandibular fracture with subsequent pain and malocclusion including a posterior open bite. The pathologic mandible fracture was repaired with and ipsilateral free fi bula fl ap. A chart review was completed to create a pictorial essay to describe our technique. Conclusion: Successful repair of pathologic mandibular fractures can be rewarding for the operative surgeon and satisfying for the patient. Optimizing chances of success are improved with pre-operative CT scans and orthodontic models as well as intra-operative models. A step by step intraoperative approach is helpful for maximizing success and optimizing occlusion.

Background: Abdominal wall reconstruction of ventral hernias can be challenging. Patients have undergone successful treatment of cancer or other intra-abdominal processes and have worked hard to get back to a “normal” life. Successful repair of abdominal wall hernias can be difficult as many comorbidities persist. Previous radiation, ongoing smoking, or overall protein malnutrition may affect wound healing and overall outcome. Surgical teams need to communicate to maximize repair success and decrease recurrence. Purpose: To create a systematic approach from our current method of abdominal wall reconstruction that facilitates communication between general surgeons and plastic and reconstructive surgeons for optimizing hernia repair outcomes. Methods: A retrospective chart review was done on patients who underwent abdominal wall reconstruction of ventral hernias and recurrent hernias with component separation and placement of strattice acellular dermal matrix or synthetic mesh over a 10 year period. Pre-op imaging consisted of an abdominal/pelvic CT-scan. A surgical flight plan was created to determine a plane of Strattice insertion and abdominal wall exposure. Pre/post-operative CT-scans were compared as well as before and after photographs. Patient satisfaction was assessed subjectively in follow-up appointments. Results: The most commonly encountered clinical scenarios were placed into a pictorial essay and a step by step approach to abdominal wall reconstruction was then created. Strattice or synthetic mesh were placed using a “load-sharing” principle and restoration of a dynamic abdominal wall was associated with high patient satisfaction, a more functional repair, and a lower incidence of recurrence. Conclusions: Successful repair of primary and recurrent abdominal wall hernias requires communication between general surgeons and plastic & reconstructive surgeons. Incision placement is important for adequate exposure and the ability to place transfascial sutures. T-junction skin breakdown and seroma formation can be minimized by maintaining blood supply and minimizing dead space. High protein nutritional stores are important for expeditious healing.

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