Anita Tanniru Mohan, MBBS, PhD, MBA

All Publications

• A systematic review of 3D printing in autologous breast reconstruction PLASTIC AND AESTHETIC RESEARCH Carrion, K., Akhter, M. F., Bernal, C., Cox, E., Krakauer, K., Mohan, A., Nazerali, R. S., Lee, G. K., Nguyen, D. 2024; 11

  View details for DOI 10.20517/2347-9264.2024.56

  View details for Web of Science ID 001320678200001

• BioBridge® in Lymphatic Surgery Supermicrosurgical Lymphaticovenular Anastomosis Mohan, A. T., Nguyen, D. H. 2024
• Breast reconstruction after mastectomy in patients with obesity: a narrative review. Annals of translational medicine Cevallos, P., Berry, C., Lipman, K. J., Kubiak, C. A., Mohan, A. T., Ayyala, H. S., Manrique, O. J., Nazerali, R. 2023; 11 (12): 413

  Abstract

  Breast reconstruction in patients with obesity presents numerous challenges, both in terms of surgical technique and post-operative complication management. As breast reconstruction techniques continue to evolve, the armamentarium of reconstructive options for patients with obesity has vastly expanded. Options now include immediate or delayed, implant-based, autologous, or hybrid reconstruction. Determining the optimal breast reconstruction in this complex population requires nuanced and experienced decision-making.A literature search was conducted to identify studies assessing breast reconstruction considerations in patients with obesity. The search was performed on PubMed and was limited to English language studies published between 1990 and 2023. Primary studies, case reports, chart reviews, and qualitative studies were included. Additional articles were identified for inclusion based on a review of references, as well as a web-based search, to identify additional studies that were not captured with the primary search strategy.This narrative review article summarizes the current literature available to guide surgeons in breast reconstruction in patients with obesity.The advancements in oncologic surgery and breast reconstruction techniques have expanded available surgical options, including immediate or delayed implant-based, autologous, or hybrid breast reconstruction. Each approach has its unique advantages, disadvantages, and surgical considerations. Despite the challenges, patients with obesity can achieve favorable aesthetic outcomes through careful assessment of comorbidities and expectation management.

  View details for DOI 10.21037/atm-23-1599

  View details for PubMedID 38213816

  View details for PubMedCentralID PMC10777214

• Radiation-Induced Morphea of the Breast Treated With Wide Local Excision and Abdominal Free Flap Breast Reconstruction. Eplasty Titan, A., Mohan, A. T., Tokuyama, M., Mirbegian, J., Bean, G. R., Lee, G. K. 2023; 23: e50

  Abstract

  Radiation-induced morphea (RIM) associated with breast cancer treatment is a rare and underdiagnosed skin complication of radiotherapy that can lead to severe and painful contractures, resulting in disfigurement, failure of reconstruction, and poor quality of life in patients. The condition may present on a spectrum of local or more generalized forms involving skin over the breast and anterior chest wall. This diagnosis must be differentiated from post-radiation fibrosis, infection, cancer recurrence, inflammatory breast cancer, and other inflammatory conditions as the clinical course and treatment approaches differ. Various noninvasive and topical agents have been used; however, many cases are refractory to treatment. Surgery has been less commonly described in the management of generalized RIM. This report describes a case of RIM in a patient with breast cancer who experienced simultaneous resolution of symptoms as well as successful breast reconstruction using autologous free-tissue transfer.

  View details for DOI 10.1097/01.SMJ.0000140866.97278.87

  View details for PubMedID 37664810

  View details for PubMedCentralID PMC10472431

• Human Factors Approach to Assess Physician Workload in Elective Plastic Surgery Breast Procedures. Eplasty Mohan, A. T., Linden, A. R., Lowndes, B. R., Blocker, R. C., Harless, C. A., Martinez-Jorge, J., Hallbeck, M. S., Nguyen, M. T., Law, K. E. 2023; 23: e49

  Abstract

  Human factors research involves the study of work system interactions, physician workload, cognitive effort, and performance. This pilot study incorporated a human factor approach and other surgery-based metrics to assess cognitive workload among plastic surgeons during elective plastic surgery breast procedures.In this prospective study of plastic surgery breast procedures over a 3-month period, surgeon and patient demographics and procedural details were collected. The lead surgeon assessed each procedure using a validated workload questionnaire (National Aeronautics and Space Administration Task Load Index [NASA-TLX]) that included 6 subscales (ie, mental, physical, temporal demand, performance, effort, and frustration), a question on distraction, and their expectation of procedural difficulty.Fifty-seven cases were included in this study. Surgical duration had a positive correlation with increased mental demand (P < .001), physical demand (P < .001), and degree of distractions (P < .001). Free flap reconstruction, breast reduction, and transgender mastectomy had the highest average mental, physical demands, and perceived effort. Bilateral cases had significantly higher workload than unilateral ones (P = .002). NASA-TLX scores between immediate and delayed reconstructions were comparable, but delayed cases had higher degree of distractions (P = .04). There was a strong correlation between degree of distractions and increased mental workload (R = 0.68; P < .001), increased physical demand (P = 0.61; P < .001), and increased temporal demand (R = 0.78; P < .001). More difficult procedures were associated with greater procedural duration than those rated as difficult as expected or less difficult than expected (P = .02).These preliminary data demonstrated multiple factors that may influence and govern perceived physician workload and may provide insight for targeted quality improvement to plan procedures safely and effectively.

  View details for DOI 10.1001/JAMASURG.2019.2295

  View details for PubMedID 37664816

  View details for PubMedCentralID PMC10472421

• Patient Experience and Clinical Outcomes after Same-day Outpatient Mastectomy and Immediate Breast Reconstruction Protocol during the Global Pandemic. Plastic and reconstructive surgery. Global open Mohan, A. T., MacArthur, T. A., Murphy, B., Song, A. J., Saifuddin, H., Degnim, A., Harmsen, W. S., Martinez-Jorge, J., Jakub, J. W., Vijayasekaran, A. 2023; 11 (7): e5183

  Abstract

  The coronavirus disease 2019 (COVID-19) pandemic provoked rapid changes in clinical practice to accommodate mandated restrictions within healthcare delivery. This study reviewed patient-reported experiences and clinical outcomes after implementation of a same-day discharge protocol after mastectomy with immediate alloplastic breast reconstruction compared with our historical overnight stay protocol.This is a retrospective single-institution study of consecutive patients who underwent mastectomy and immediate alloplastic reconstruction between July 2019 and November 2020. A postoperative survey was completed by patients to evaluate satisfaction with perioperative communications, recovery, and their overall experience.A total of 302 patients (100% women) underwent mastectomy and immediate alloplastic reconstruction (174 pre-COVID-19, 128 during COVID-19). During COVID-19, 71% of patients were scheduled for a same-day discharge, among which 89% were successfully discharged the same day. Compared with pre-COVID-19, there were no differences in type of surgery, operative times, pain scores, 30-day readmission, or unplanned visits (all P > 0.05) during the COVID-19 pandemic. Compared with pre-COVID-19, patients during the pandemic reported comparable satisfaction with their care experience and postoperative recovery (56% survey response rate). Patient satisfaction was also similar between those discharged the same day (n = 81) versus the next day (n = 47) during COVID-19.Same-day discharge is feasible, safe, and can provide similar patient-reported satisfaction and outcomes compared with traditional overnight stay. These data highlight the ability to deliver adaptable, high-quality breast cancer care, within the constraints of a global pandemic.

  View details for DOI 10.1097/GOX.0000000000005183

  View details for PubMedID 37492279

  View details for PubMedCentralID PMC10365192

• Outcomes of Standardized Protocols in Supercharged Pedicled Jejunal Esophageal Reconstruction. The Annals of thoracic surgery Mohan, A. T., Mahajan, N. N., Mardini, S., Blackmon, S. H. 2023; 115 (1): 210-219

  Abstract

  This study evaluated clinical and patient-reported outcomes (PROs) of long-segment supercharged pedicled jejunal (SPJ) interposition after implementation of a dedicated multidisciplinary pathway and technical refinements.This study was a 6-year review of consecutive patients who underwent complex esophageal reconstruction with SPJ interposition. Clinical data were abstracted, and PRO data were collected prospectively by using the Upper Digestive Disease mobile application (UDD App). This standardized questionnaire comprised domains for mental and physical health, pain, dysphagia, reflux, hypoglycemia dumping, and gastrointestinal dumping symptoms. Operative refinements were comprehensively established by 2018.A total of 19 patients were included in the study, 15 of whom had a history of esophageal malignant disease and neoadjuvant chemoradiation. Most patients (18; 95%) underwent delayed reconstruction after diversion. There was no 90-day mortality or flap loss. Most patients (18; 95%) achieved an enteral diet. Seven patients (37%) experienced early complications (<90 days) requiring procedural intervention. The incidence of any medical or surgical complication was similar in the earlier (2015-2017) and late (2018-2020) cohorts, but aspiration events, surgical site infections, anastomotic leak rates, and median hospital stay (reduced from 15 days [IQR, 10-21 days] to 9 days [IQR, 9-13 days]) improved in the contemporary cohort. PRO data were collected in 14 of 15 (93%) living patients. Severe symptoms in at least 1 domain were reported by most patients (11; 79%) and improved over time.Dedicated care pathways allow standardization of complex procedures, and targeted modifications may optimize recovery and patient outcomes. This cohort of patients may report severe symptoms that require ongoing monitoring and intervention.

  View details for DOI 10.1016/j.athoracsur.2022.05.048

  View details for PubMedID 35718204

• Scapular Flap Atlas in Reconstructive Microsurgery Kubiak, C., Mohan, A. T., Lee, G. 2023
• Supercharged Jejunal Interposition. Thoracic surgery clinics Mohan, A. T., Mardini, S., Blackmon, S. H. 2022; 32 (4): 529-540

  Abstract

  Complex esophageal reconstruction represents a high risk and challenging procedure. A dedicated pathway with multispecialty teams can facilitate a systematic checklist approach to perioperative management and evaluation of long-term outcomes. Refinements in the operative technique for supercharged pedicled jejunum (SPJ) for long segment interposition in esophageal reconstruction are reviewed in this article. Medical and surgical complications among this complex niche group of patients are significant and require care in specialist centers with a focused team. Patient-reported outcomes (PROs) in long-segment SPJ interposition are recognized to provide additional monitoring of surgical outcomes and may help guide interventions for subsequent symptom control.

  View details for DOI 10.1016/j.thorsurg.2022.07.007

  View details for PubMedID 36266038

• Microsurgical skills training course and impact on trainee confidence and workload. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Mohan, A. T., Abdelrahman, A. M., Anding, W. J., Lowndes, B. R., Blocker, R. C., Hallbeck, M. S., Bakri, K., Moran, S. L., Mardini, S. 2022; 75 (7): 2135-2142

  Abstract

  Our objective was to measure the impact of a basic microsurgery training course on trainees' confidence and workload in performing microsurgery.A prospective study of participants in an accredited 5-day microsurgery course over a 3-month period. The confidence and workload of the participants were assessed after the first and final day. The workload was assessed using the validated NASA Task Load Index composed of 6 subscales scored on a 20-point visual analog scale (VAS). Confidence was assessed over 5 dimensions on a 5-point VAS for anastomosis performance, vessels preparation, knot tying, training effectiveness, and future practice of microsurgery.A total of 31 participants completed the study with 55% reporting some previous microsurgery experience. All confidence dimensions improved significantly after completing the course, regardless of prior experience (p<0.01). Those with prior experience started and finished the course at higher confidence levels in anastomosis performance and vessel preparation than the non-experienced group (p<0.05). Overall workload showed a downward trend (improvement) at the end of the course, but no significant changes in the experienced and non-experienced groups (p>0.05). Most participants scored above the 50% "sustainability threshold" for mental demand, both before (71%) and after the course (73%), however, perceived physical demand significantly reduced, p = 0.01.The microsurgery course teaches fundamental skills and principles; therefore, it has merit in those who will utilize these skills in their future practice. Although there is increased confidence in skill acquisition, the impact on perceived workload during a short 5-day basic microsurgery course did not significantly change.

  View details for DOI 10.1016/j.bjps.2022.02.004

  View details for PubMedID 35346609

• Diversity Matters: A 21-Year Review of Trends in Resident Recruitment into Surgical Specialties. Annals of surgery open : perspectives of surgical history, education, and clinical approaches Mohan, A. T., Banuelos, J., Cespedes-Gomez, O., Kapoor, T., Moran, S. L., Heller, S. F., Dozois, E. J., Nelson, H., Stulak, J. M., Martinez-Jorge, J. 2021; 2 (4): e100

  Abstract

  Diversity within the healthcare workforce is essential to improve quality of care, although evaluation of diversity within surgical training remains limited. This study analyzed diversity in recruitment of residents into surgical subspecialties at a large academic medical institution and national trends.A 21-year cross-sectional study of medical school graduates accepted into all surgical subspecialty training programs was performed. The institutional cohort was divided into two groups (1997-2006, 2007-2017). Subspecialty acceptance rates were determined between 2011 and 2018. Data on candidate demographics including gender, race, ethnicity, citizenship, and origin of medical education at a single institution and nationally were extracted.Two thousand found hundred seventy-two residents were included in this study. From 1997 to 2018, female acceptances increased from 21.1% to 29.7% (p < 0.01), non-White increased from 27.9% to 31.8% (p = 0.01), and international medical graduates decreased from 28.8% to 25.5% (p = 0.02). There was no significant change in accepted Hispanic and Non-US candidates. Female subspecialty rates for subspecialties increased nationally and was comparable to our cohort, except in general surgery. Hispanic subspecialty acceptance rates were less than 10% and Black/African American acceptance rates remained less than 5% across subspecialties nationally and at our institution.Diversity in surgical training has modestly progressed over the last two decades, but the degree of positive change has not been universal and highlights the critical need for improvement and action. Continued institution driven and collaborative strategies are essential to promote diversity in recruitment across all surgical specialties that has implications on our future workforce and surgical leadership.

  View details for DOI 10.1097/AS9.0000000000000100

  View details for PubMedID 37637873

  View details for PubMedCentralID PMC10455279

• Intralesional Bleomycin Injection in Management of Localized Venous Problems in Children with Klippel-Trenaunay Syndrome. Plastic and reconstructive surgery Hudson, D. A., Mohan, A. T., Lelala, N. B. 2021; 147 (5): 918e-919e

  View details for DOI 10.1097/PRS.0000000000007815

  View details for PubMedID 33885399

• A Cadaveric Anatomical and Histological Study of Recipient Intercostal Nerve Selection for Sensory Reinnervation in Autologous Breast Reconstruction. Journal of reconstructive microsurgery Mohan, A. T., Suchyta, M., Vyas, K. S., Lachman, N., Mardini, S., Saint-Cyr, M. 2021; 37 (2): 136-142

  Abstract

   Autologous breast reconstruction (ABR) has grown in popularity due to improved aesthetic and long-term patient reported outcomes, but data regarding sensory reinnervation of autologous flaps remain limited. Traditionally, the lateral cutaneous branch of the fourth intercostal nerve has been used for flap neurotization, but the use of the anterior cutaneous branch of the intercostal nerves (ACB) offer a more optimal location to the microsurgical field when using internal mammary vessels for the microanastomosis. This study aimed to evaluate the optimum ACB recipient site level for sensory nerve coaptation in ABR. Twelve hemi-chests were dissected from six fresh cadaveric females. Costal cartilages were removed and the anterior cutaneous intercostal nerve (ACB) and the lateral (subcutaneous) division of the anterior cutaneous branch (LACB) of the intercostal nerve were exposed. Anatomical measurements were recorded, and nerve samples were evaluated histologically with carbonic anhydrase staining to differentiate sensory fascicles. Assessment of fascicular diameter, axonal counts, and fascicular area were compared. A total of 75 nerve specimens were assessed. The ACB was identified at all levels (100%) and the subcutaneous LACB was noted consistently in the second to fourth rib space (96% cadavers), with a median length of 43, 37.5, and 37 mm, respectively. Across all rib spaces, the fascicular and axonal counts were comparable between the LACB and ACB. Nerves in the second intercostal space had a significantly larger mean fascicular area mean (112,816 ± 157,120 µm2) compared with that in the fourth (mean 26,474 ± 38,626 µm2), p = 0.03. Axonal count of sensory fascicles was the highest in the second intercostal nerves (p < 0.05). This study provides anatomical and histological basis to determine the optimum recipient site choice for sensory coaptation in microsurgical breast reconstruction. This would aid in operative decision-making regarding the ideal recipient anterior cutaneous intercostal nerve branches for recipient site coaptation in ABR.

  View details for DOI 10.1055/s-0040-1715878

  View details for PubMedID 32862416

• Presentation of calcinosis cutis 35 years after silicone nasal implant reconstruction. BMJ case reports Antezana, L. A., Mohan, A. T., Bite, U. 2021; 14 (2)

  View details for DOI 10.1136/bcr-2020-239766

  View details for PubMedID 33526537

  View details for PubMedCentralID PMC7852974

• Fasciocutaneous Flaps and Tissue Expansion in Abdominal Wall Reconstruction Hernia Surgery Mohan, A. T., Tran, N. V., Bite, U. 2021
• Autologous Breast Reconstruction in Low Body Mass Index Patients: Strategies for Maximizing Skin Envelope and Breast Volume. Clinics in plastic surgery Mohan, A. T., Zhu, L., Vijayasekaran, A., Saint-Cyr, M. 2020; 47 (4): 611-619

  Abstract

  Pure autologous breast reconstruction in thin patients creates challenges. This review highlights techniques to optimize the scarce donor tissue available, approaches to reconstruction, and microsurgical techniques. A systematic approach to maximize breast volume and the skin envelope in patients who underwent pure autologous breast reconstruction by a single senior surgeon is presented with a clinical case series. Included in the study were 125 patients (217) with autologous breast reconstructions. Although DIEP flaps were the commonest flap used overall (79%), within in the low body mass index (<22) group, there was a greater use of Latissimus (32%), and thigh-based flaps (>50%).

  View details for DOI 10.1016/j.cps.2020.07.001

  View details for PubMedID 32892804

• Recent Advances in Microsurgery: An Update in the Past 4 Years. Clinics in plastic surgery Mohan, A. T., Saint-Cyr, M. 2020; 47 (4): 663-677

  Abstract

  Microsurgery has broad applications in reconstructive surgery. As techniques, diagnostics, and advancing technology rapidly evolve, reconstructive microsurgeons can adapt to address new challenges and push the frontiers to achieve optimal functional and aesthetic reconstruction, and minimize donor site morbidity. This article briefly outlines some of the recent advances and innovations in microsurgery within the last 5 years in perforator flaps, breast, lymphedema surgery, extremity reconstruction, targeted muscle reinnervation, head and neck reconstruction, composite tissue allotransplantation, and robotic surgery.

  View details for DOI 10.1016/j.cps.2020.07.002

  View details for PubMedID 32892808

• Preconditioning with Foam-mediated External Suction on Flap Microvasculature and Perfusion in a Rodent Model. Plastic and reconstructive surgery. Global open Mohan, A. T., Zhu, L., Michalak, G. J., Laungani, A. T., Vercnocke, A. J., Moran, S. L., Saint-Cyr, M. 2020; 8 (8): e2739

  Abstract

  Foam-mediated external suction (FMES) has previously shown to improve tissue microcirculation. We hypothesized that preconditioning fasciocutaneous perforator flaps with FMES would augment perfusion and demonstrate greater capillary recruitment.Gluteal perforator flaps were designed on sixteen 400 g rats. Continuous FMES at -125 mm Hg was applied on one side (intervention) to precondition tissue for 5 days, with the contralateral side as a paired control. In group A, we assessed changes following pretreatment, after surgery, and 7 days postprocedure, and in group B, we evaluated changes during preconditioning alone. In group A (N = 8), control and intervention flaps were assessed using laser-assisted indocyanine green fluorescence angiography. In group B, flap regions were assessed using 4-dimensional computed tomographic angiography. All flaps were analyzed for microvessel density using micro-computed tomography and histological assessment using hematoxylin and eosin and CD3 immunohistochemistry.Thirty-two flaps were included in this study (N = 16 intervention and matched controls). Four-dimensional computed tomographic angiography demonstrated 17% greater tissue perfusion in preconditioned flaps (mean, 78.7 HU; SD, 8.8) versus controls (mean, 67.3 HU; SD, 15.7; P < 0.01). Laser-assisted indocyanine green fluorescence angiography showed a 30% higher mean absolute intensity in preconditioned flaps versus controls (P < 0.01). Postsurgery mean absolute intensity in preconditioned flaps remained 21% higher than in controls (P = 0.03). Preconditioned flaps demonstrated a 2-fold increase in mean vessel volume of 9.1 mm3 (SD, 7) versus 4.5 mm3 (SD, 3) in controls (P = 0.04); there was a 33% higher mean area fraction of CD31 in preconditioned flaps, 3.9% (SD, 3) versus 2.9% (SD, 3) in controls (P = 0.03).FMES preconditioning has the potential to augment vascularity of tissue for flap harvest; however, further experimental studies are required to optimize strategies and evaluate long-term effects for clinical applications.

  View details for DOI 10.1097/GOX.0000000000002739

  View details for PubMedID 32983749

  View details for PubMedCentralID PMC7489611

• Plastic Surgery Lockdown Learning during Coronavirus Disease 2019: Are Adaptations in Education Here to Stay? Plastic and reconstructive surgery. Global open Mohan, A. T., Vyas, K. S., Asaad, M., Khajuria, A. 2020; 8 (7): e3064

  Abstract

  The novel coronavirus disease 2019 has had a major impact on human life and livelihood. The unprecedented challenges have expanded beyond just social and work life, and have grown to impact resident education. In this article, we review the structure of plastic surgery education before the pandemic, the different online learning opportunities for self-directed learning. A summary of the range of platforms and approaches of online remote access delivery of conferences and education that emerged or expanded as a result of the crisis has been reported. This article highlighted the rapid initiatives and efforts of programs and national and international societies to support continuing medical education in conjunction with the guidelines to "shelter at home" and maintain social distancing, and possible future for expanding the reach of online academic initiatives, in addition to the role of developing virtual technologies. The coronavirus disease 2019 crisis has created an opportunity to analyze and advance online learning options to overcome the associated challenges and continue as a reliable platform even following the resolution of the social distancing requirements.

  View details for DOI 10.1097/GOX.0000000000003064

  View details for PubMedID 32802695

  View details for PubMedCentralID PMC7413776

• Does surgical procedure type impact postoperative pain and recovery in deep inferior epigastric artery perforator flap breast reconstruction? Archives of plastic surgery Azizi, A. A., Mohan, A. T., Tomouk, T., Brickley, E. B., Malata, C. M. 2020; 47 (4): 324-332

  Abstract

  The deep inferior epigastric artery perforator (DIEP) flap is the commonest flap used for breast reconstruction after mastectomy. It is performed as a unilateral (based on one [unipedicled] or two [bipedicled] vascular pedicles) or bilateral procedure following unilateral or bilateral mastectomies. No previous studies have comprehensively analyzed analgesia requirements and hospital stay of these three forms of surgical reconstruction.A 7-year retrospective cohort study (2008-2015) of a single-surgeon's DIEP-patients was conducted. Patient-reported pain scores, patient-controlled morphine requirements and recovery times were compared using non-parametric statistics and multivariable regression.The study included 135 participants: unilateral unipedicled (n=84), unilateral bipedicled (n=24) and bilateral unipedicled (n=27). Univariate comparison of the three DIEP types showed a significant difference in 12-hour postoperative morphine requirements (P=0.020); bipedicled unilateral patients used significantly less morphine than unipedicled (unilateral) patients at 12 (P=0.005), 24 (P=0.020), and 48 (P=0.046) hours. Multivariable regression comparing these two groups revealed that both reconstruction type and smoking status were significant predictors for 12-hour postoperative morphine usage (P=0.038 and P=0.049, respectively), but only smoking, remained significant at 24 (P=0.010) and 48 (P=0.010) hours. Bilateral reconstruction patients' mean hospital stay was 2 days longer than either unilateral reconstruction (P<0.001).Although all three forms of DIEP flap breast reconstruction had similar postoperative pain measures, a novel finding of our study was that bipedicled DIEP flap harvest might be associated with lower early postoperative morphine requirements. Bilateral and bipedicled procedures in appropriate patients might therefore be undertaken without significantly increased pain/morbidity compared to unilateral unipedicled reconstructions.

  View details for DOI 10.5999/aps.2019.01417

  View details for PubMedID 32718111

  View details for PubMedCentralID PMC7398802

• Robotic-Assisted DIEP Flap Harvest for Autologous Breast Reconstruction: A Comparative Feasibility Study on a Cadaveric Model. Journal of reconstructive microsurgery Manrique, O. J., Bustos, S. S., Mohan, A. T., Nguyen, M. D., Martinez-Jorge, J., Forte, A. J., Terzic, A. 2020; 36 (5): 362-368

  Abstract

   The deep inferior epigastric perforator (DIEP) flap is the most common perforator flap for microsurgical breast reconstruction. Contrary to the conventional open approach, robotic-assisted DIEP flap harvest intends to preserve ARS integrity, thereby reducing the morbidity. We assessed the feasibility and compared performance outcomes of a robotic, cadaveric training model for DIEP flap harvest using two approaches: transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP). A robotics system (da Vinci Xi) was applied in conjunction with a cadaveric training model. Ports were placed in the abdominal wall to triangulate each DIEP flap. Surgical time and technical characteristics were recorded. Values were analyzed and compared. Eight female cadavers (16 hemi-DIEP flaps) were dissected: 50% TAPP and 50% TEP approaches. Mean harvest time was 56 minutes (range: 48-74 minutes) and 65 minutes (range: 60-83 minutes) for TAPP versus TEP groups, respectively (p < 0.05). Mean pedicle dissection time was 36 minutes (range: 25-40 minutes) and 39 minutes (range: 30-42 minutes) for TAPP versus TEP groups, respectively (p > 0.05). Intra-abdominal contents were manipulated twice on average in the TAPP group versus 0 times in the TEP group (p < 0.05). One TAPP case had an injury to the bowel, and one TEP case was converted to conventional open due to pneumoperitoneum. Robotic-assisted DIEP flap harvest represents a technological enhancement for advanced regenerative plastic surgery. Our model demonstrated both TAPP and TEP are feasible, with TEP less invasive, preserving the posterior rectus sheath, and decreasing complication risks. However, there is a steeper and longer learning curve for TEP.

  View details for DOI 10.1055/s-0040-1701666

  View details for PubMedID 32106313

• Improving Reality Virtually: Advent of the Virtual "Digi-ceutical"? Mayo Clinic proceedings Mohan, A. T., Kapa, S. 2020; 95 (6): 1097-1098

  View details for DOI 10.1016/j.mayocp.2020.04.020

  View details for PubMedID 32498767

• Complications after thigh sarcoma resection. Journal of surgical oncology Elswick, S. M., Curiel, D. A., Wu, P., Akhavan, A., Molinar, V. E., Mohan, A. T., Sim, F. H., Martinez-Jorge, J., Saint-Cyr, M. 2020; 121 (6): 945-951

  Abstract

  Standard treatment for extremity sarcoma is limb-sparing surgery often with radiation, but complications occur frequently. We sought to determine factors predictive of wound complications after thigh sarcoma resection and reconstruction while analyzing trends over time.We reviewed all thigh defects requiring plastic surgeon reconstruction following sarcoma resection at our institution from 1997 to 2014. Patient demographics, comorbidities, operative characteristics, multi-modality therapies, and complications were analyzed. Wound complications were: infection, dehiscence, seroma, hematoma, or partial/total flap loss.There were 159 thigh reconstructions followed for 30 months on average. Eighty-seven percent of patients underwent radiation and 42% had chemotherapy. Almost half (49.1%) had a complication. The most common wound complication was surgical site infection (23.3%) followed by dehiscence (19.5%), and seroma (10.7%). Less common were partial (2.5%) or total flap loss (0.6%). Reoperation was required in 21 patients (13.2%). Tobacco use, older patient age, cardiac disease, and higher body mass index were independently associated with wound complications. Complications trended towards decreasing over time, but this was not statistically significant.Tobacco use, cardiac disease, and higher body mass index, but not the timing of reconstruction, appear to increase the risk of wound complications after thigh soft tissue sarcomas resection and plastic surgery reconstruction.

  View details for DOI 10.1002/jso.25830

  View details for PubMedID 32020627

• Extremity free fillet flap for reconstruction of massive oncologic resection-Surgical technique and outcomes. Journal of surgical oncology Kreutz-Rodrigues, L., Mohan, A. T., Moran, S. L., Carlsen, B. T., Mardini, S., Houdek, M. T., Rose, P. S., Bakri, K. 2020; 121 (3): 465-473

  Abstract

  The purpose of this study is to present our experience using free fillet flaps to reconstruct massive oncologic defects of the upper and lower extremity.A retrospective chart review was performed to include patients who underwent oncologic resection followed by reconstruction using free fillet flaps from July 2001 to October 2018. Patient demographics, clinical and surgical characteristics, and postoperative complications were reviewed.In total, 12 patients were identified and included in this study. Mean age was 48.9 years old. Five patients had extended forequarter amputations and seven patients had external hemipelvectomies, all for locally advanced tumors. Mean tumor size was 15 ± SD 6.4 cm, and negative tumor margins were achieved in all the patients. Mean flap size was 1028 ± SD 869 cm2 . The mean follow-up was 13 months. There were no partial or total flap losses in the postoperative period. Two patients had flap-related postoperative complications, including flap bleeding and wound dehiscence. Median survival was 18 months.The free fillet flap is a safe, reliable, and valuable approach for reconstructing oncological defects. It offers the advantage of avoiding donor site morbidity, while providing extensive soft-tissue coverage as a one-step solution for massive oncologic defects.

  View details for DOI 10.1002/jso.25795

  View details for PubMedID 31853992

• Transverse Upper Gracilis Flaps Spear’s Surgery of the Breast Mohan, A. T., Falola, R., Saint-Cyr, M. 2020
• Profunda Artery Perforator Flaps Spear’s Surgery of the Breast Mohan, A. T., Falola, R., Saint-Cyr, M. 2020
• A reconstructive algorithm after thigh soft tissue sarcoma resection including predictors of free flap reconstruction✰. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Elswick, S. M., Wu, P., Arkhavan, A. A., Molinar, V. E., Mohan, A. T., Sim, F. H., Martinez-Jorge, J., Saint-Cyr, M. 2019; 72 (8): 1304-1315

  Abstract

  Reconstruction of defects of the thigh after oncologic resection plays a vital role in limb salvage. Our goal was to evaluate our institution's experience on thigh sarcomas to develop evidence-based recommendations to guide the reconstructive surgeon, including factors that would predict the need for free flap reconstruction.We reviewed all thigh defects requiring plastic surgeon reconstruction following sarcoma resection at our institution from 1997 to 2014. Patient demographics, comorbidities, multimodality therapies, and operative characteristics were analyzed.There were 159 thigh reconstructions. Reconstruction was achieved by primary closure (15%), skin graft (13%), local fasciocutaneous flap (8%), local muscle flap (31%), regional muscle flap (28%), or free flap (4%). For the proximal third of the thigh, the most common flaps were pedicled thigh muscle and rectus abdominis flaps; for the middle third of the thigh, it was pedicled thigh muscle flaps; and for the distal third, it was pedicled gastrocnemius muscle flaps. Factors shown to be predictive of requiring a free flap included wide defects (p = 0.03) and location in the middle third of the thigh (p = 0.001).There are multiple options for reconstructing defects from thigh STS. When primary closure and skin grafts are not an option, most defects can be closed with pedicled local or regional muscle or fasciocutaneous flaps. Free flap reconstruction is rarely required but can be necessary when defects are wide or located in the middle third of the thigh.

  View details for DOI 10.1016/j.bjps.2019.04.016

  View details for PubMedID 31229407

• Reappraisal of Perforasomes of the Superficial Femoral, Descending Genicular, and Saphenous Arteries and Clinical Applications to Locoregional Reconstruction. Plastic and reconstructive surgery Mohan, A. T., Zhu, L., Morsy, M., Sur, Y. J., Michalak, G. J., Lachman, N., Mardini, S., Saint-Cyr, M. 2019; 143 (3): 613e-627e

  Abstract

  The superficial femoral artery and medial thigh region has been an underused donor site for perforator flaps. This study evaluated perforasomes of the superficial femoral artery and its principal branches to review the clinical applications for locoregional reconstruction.Twenty-six fresh cadaveric lower extremities were dissected. Perforator size and anatomical course from the superficial femoral artery, descending genicular artery, and saphenous artery branch were documented. Perforators were selectively injected with iodinated contrast to assess vascular territories using computed tomography. A retrospective chart review was conducted on consecutive patients (2014 to 2015).One hundred thirty perforators were mapped in the medial thigh region. Eleven extended medial thigh perforator flaps and 15 hemicircumferential flaps were harvested. The mean distance from the joint line was 16.7 ± 7.3 cm. Perforators arose from the superficial femoral artery (62 percent), saphenous artery branch (23 percent), and descending genicular artery (15 percent). Superficial femoral artery perforators were located around the mid and proximal thigh region (p < 0.001). The median perforasome surface area was 244 cm, representing 36 percent in hemithigh flaps with preferential filling in the anteromedial region. Proximal perforasomes were the smallest. Perforasome areas based on vessel origin were comparable; however, saphenous artery perforators had a broader perforasome compared with descending genicular (p = 0.01) and superficial femoral artery perforators (p = 0.04). Six clinical case examples were presented for knee, thigh, and lower leg reconstruction.The superficial femoral artery or its branches can provide nontraditional reconstructive perforator flap options in regional reconstruction. They can be simple to harvest using a free-style approach, do not require preoperative imaging, offer a one-stage reconstructive method with low morbidity, and obviate the need for microsurgery or muscle flaps.

  View details for DOI 10.1097/PRS.0000000000005395

  View details for PubMedID 30817665

• Cell-Based Therapies in Vascularized Composite Allotransplantation Vyas, K. S., Mohan, A. T., Morrison, S. D., Tran, D. C., Mardini, S. THIEME MEDICAL PUBL INC. 2018: 642–50

  Abstract

   Dendritic cells (DCs) are bone marrow-derived, professional antigen-presenting cells with tolerogenic function. The ability of DCs to regulate alloantigen-specific T cell responses and to promote tolerance has aligned them ideally for a role in vascularized composite allotransplantation (VCA). In this study, we summarize the current evidence for DC therapies for tolerance induction to alleviate the requirement for chronic immunosuppression. A comprehensive and structured review of manuscripts published on VCA was performed using the MEDLINE and PubMed databases. All eligible studies published from the year 2000 to 2017 were included in the final results. Nineteen original preclinical and clinical studies that employed cell therapy for VCA were included in this review. In vivo DC therapy was found to direct the alloimmune response toward either transplant rejection or tolerance in VCA models. While injection of mature DCs rapidly increases T-cell activity in humans and promotes transplant rejection, the injection of immature DCs acts as an immunosuppressant and inhibits T-cell activity. In addition to immature DCs, mesenchymal stem cells were also found to have a positive effect on allotransplantation of solid organs and bone marrow via cytokine expression which decreases the alloreactive effector lymphocytes and increases CD4+/CD25+/FoxP3 Tregs. Despite the promising findings, the efficacy of cell-based therapies varies greatly across studies, partly due to different methods of cell isolation and purification techniques, source, route and timing of administration, and combination immunosuppressive therapy. Additional research is needed to evaluate the efficacy and safety of DC and other cell-based therapeutic measures in human allotransplant recipients. Future direction will focus on the development of novel methods to reduce immunosuppression and develop more individualized management, as well as the clinical application of basic research in the mechanisms of immunologic tolerance.

  View details for PubMedID 29945289

• Surgeons’ Perspectives on User-Designed Prototypes of Microsurgery Armrests Proceedings of the Human Factors and Ergonomics Society Abdelrahman, A. M., Lowndes, B. R., Mohan, A. T., Noland, S. S., Finnie, D. M., Lemaine, V., Hallbeck, M. S. 2018
• Does surgical procedure type impact postoperative pain and recovery in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction? Azizi, A. A., Mohan, A. T., Tomouk, T., Brickley, E. B., Malata , C. M. Eur Surg Res . 2018
• Refinements in Microcirculation of the Deep and Superficial Venous Territories and Contribution of the Dermal Plexus in DIEP Flap Reconstruction: An Anatomical Study Mohan, A. T., Michalak, G., Lachman, N., Mardini, S., Moran , S. L., Saint-Cyr, M. PRS Glob Open. 2018
• Novel Assessment of Intraoperative Venous Outflow with Laser Assisted Indocyanine Green Angiography in Bilateral DIEP Breast Reconstruction Mohan , A. T., Sabbagh, D., Moran , S. L., Mardini, S., Saint-Cyr, M. PRS Glob Open. 2018
• Donor site morbidity in DIEP free flap breast reconstructions: A comparison of unilateral, bilateral, and bipedicled surgical procedure types. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Tomouk, T., Mohan, A. T., Azizi, A., Conci, E., Brickley, E. B., Malata, C. M. 2017; 70 (11): 1505-1513

  Abstract

  The use of abdominal tissue in post-mastectomy autologous breast reconstruction is a popular choice among reconstructive surgeons. This is the first study to evaluate donor complications comparing unilateral, bilateral, and bipedicled DIEP breast reconstructions.A retrospective chart review was conducted of all women undergoing rib-preserving DIEP free flap breast reconstruction at a University Hospital between 2008 and 2015 by the senior surgeon (CMM).A total of 130 patients were included in this study and were divided into three groups: unipedicled unilateral (n = 93), unipedicled bilateral (n = 19), and bipedicled unilateral (n = 18). Relative to the unipedicled unilateral group, the age and BMI-adjusted odds of complication were almost two-fold higher in the bilateral group [Odds ratio (95% CI): 1.97 (0.63, 6.19)] and approximately halved in the bipedicled group [Odds ratio (95% CI): 0.59 (0.22, 1.61)]; however, these associations were not statistically significant. Overall, 75% of complications were managed conservatively. The majority of Clavien-Dindo grade 3 complications were observed in participants from the unipedicled unilateral group (84%), whereas no patients in the bipedicled group developed morbidity that required recourse to surgery or readmission to hospital.Although further research with greater statistical power will be valuable, the results of this investigation provide evidence that donor site morbidity of bipedicled DIEP free flap breast reconstructions does not increase when compared with those of unipedicled unilateral and unipedicled bilateral surgical procedure types.

  View details for DOI 10.1016/j.bjps.2017.05.044

  View details for PubMedID 28684286

• Reply: The Concepts of Propeller, Perforator, Keystone, and Other Local Flaps and Their Role in the Evolution of Reconstruction. Plastic and reconstructive surgery Saint-Cyr, M., Mohan, A. T., Sur, Y. J., Zhu, L., Morsy, M., Wu, P. S., Moran, S. L., Mardini, S. 2017; 139 (5): 1220e-1221e

  View details for DOI 10.1097/PRS.0000000000003324

  View details for PubMedID 28445387

• Anastomosis of the Superficial Inferior Epigastric Vein to the Internal Mammary Vein to Augment Deep Inferior Artery Perforator Flaps. Clinics in plastic surgery Vijayasekaran, A., Mohan, A. T., Zhu, L., Sharaf, B., Saint-Cyr, M. 2017; 44 (2): 361-369

  Abstract

  Use of the retrograde limb of the internal mammary vein has been described previously as a lifeboat for venous congestion but not prophylactically. Maximizing the length of the deep inferior artery perforator (DIEP) flap pedicle, identifying and dissecting the superficial inferior epigastric vein proximally in every patient, and taking advantage of the retrograde internal mammary vein are all technical details that facilitate the additional venous anastomosis and flap inset. Performing a second venous anastomosis routinely using the superficial inferior epigastric vein to the retrograde internal mammary vein helps with flap inset.

  View details for DOI 10.1016/j.cps.2016.12.006

  View details for PubMedID 28340668

• Application of Posterior Thigh Three-Dimensional Profunda Artery Perforator Perforasomes in Refining Next-Generation Flap Designs: Transverse, Vertical, and S-Shaped Profunda Artery Perforator Flaps. Plastic and reconstructive surgery Mohan, A. T., Zhu, L., Sur, Y. J., Morsy, M., Michalak, G. J., Lachman, N., Rammos, C. K., Saint-Cyr, M. 2017; 139 (4): 834e-845e

  Abstract

  This study aimed to delineate and compare the hot spots and three-dimensional vascular territories of dominant profunda artery perforators in the posterior thigh region, and modifications in flap design are discussed.Twenty-nine posterior thigh flaps were raised in fresh cadaveric specimens, and profunda artery perforators were documented. Dominant perforators were injected with iodinated contrast to assess perforasomes using computed tomographic angiography. Analysis with three-dimensional rendering and volume calculations of perfusion patterns was performed.In total, 316 perforators were mapped and 33 perforators were injected for analysis. The hot spot for dominant perforators was the proximal medial quadrant, 5 to 10 cm from the inferior gluteal crease, with two smaller hot spots in the upper lateral and distal posterior midline. Although 69 percent were musculocutaneous, distal perforators were predominantly septocutaneous in the posterior midline, 5 to 8 cm from the popliteal crease. Proximal perforators were classified into first (most proximal) and second perforators, and their median perforasome was 233 and 286.4 cm, respectively (p = 0.86). There were no significant differences between proximal and distal perforators in perforasome surface areas, percentage areas perfused, and perforasome volumes. Large linking vessel networks were attributed to a broader perforasome and greater overlap between adjacent or distal perforators.Dominant linking vessels and recurrent flow through the subdermal plexus contribute to the robust vascular supply of profunda artery perforator flaps. Posterior thigh region perforator hot spots and their perfusion characteristics can inform the potential limits, orientation, and modifications of flap or skin paddle designs.

  View details for DOI 10.1097/PRS.0000000000003224

  View details for PubMedID 28350651

• Study of the Impact of the Location of a Perforator in the Perfusion of a Perforator Flap: The Concept of "Angle of Perfusion". Journal of reconstructive microsurgery Laungani, A. T., Christner, J., Primus, J. A., Lachman, N., Ballman, K. V., Mohan, A., Saint-Cyr, M. 2017; 33 (1): 49-58

  Abstract

  Background Perforator flaps remain challenging in their design, especially as free flaps. We used a cadaveric model to help refine the design of perforator flaps by studying their vascular features. We define the angle of perfusion of a perforator as a tool to achieve safer flap designs. Methods A total of 83 flaps were designed from 20 fresh cadaveric anterolateral thigh flaps. The most dominant perforator larger than 0.5 mm was used as the reference point on the midline of the flap, and the tip of the flap was set at 5 cm (n = 10), 2 cm (n = 5), or 10 cm (n = 5) from this perforator. The perforator was injected with contrast agent, and the flap was scanned with computed tomography (CT) angiography. The vascular territory of the injected perforator was drawn twice by two different investigators. Perfused volumes were then obtained through a computerized algorithm on the CT workstation. Flaps were then flushed with heparinized saline and cut at decreasing angles (120, 90, 60, and 45 degrees) and rescanned with contrast for each perfusion angle. The perfused volumes were calculated for each angle. Results Volume and percentage of perfusion were significantly decreased with decreasing angles of perfusion, regardless of perforator location (2 cm, p = 0.002; 5 cm, p = 0.02; 10 cm, p < 0.001). Conclusions Acute angles of perfusion were associated with fewer incorporated linking vessels and lower flap perfusion. This phenomenon was less apparent in centrally located perforators. Perfusion angle and perforator location influence flap vascularity in a cadaveric model.

  View details for DOI 10.1055/s-0036-1588017

  View details for PubMedID 27636539

• Reconstructive Microsurgery: The Future Is Today. Annals of plastic surgery Amin, K., Mohan, A. T. 2017; 78 (1): 5-6

  Abstract

  This reconstructive microsurgery course will run yearly and was borne and popularized from its infant meeting the year before, primarily focused on perforator flaps. It is a 2-day course updating residents/registrars to attending physicians/consultants about the most topical advancements in microvascular reconstructive surgery. The course is held at the New York University Langone Hospital in the United States.The timetable is primarily lecture based with the advantage of live-surgical procedures by world-renowned faculty. The timetable includes, but not limited to, facial/hand vascularized composite allotransplantation, upper/lower limb, breast, head and neck, transgender, and lymphedema surgery. Lectures were highly informative and there was ample time for case discussion with the appreciation that managing complex situations often requires input from other colleagues. The faculty focused on the lessons they have learned and potential pitfalls to avoid. The faculty was comprised of leading experts in reconstructive microsurgery from Europe, Korea, and throughout the United States.The primary emphasis of the course was to appreciate the global recognition in advances in microsurgery.

  View details for DOI 10.1097/SAP.0000000000000824

  View details for PubMedID 27015330

• Techniques and Perforator Selection in Single, Dominant DIEP Flap Breast Reconstruction: Algorithmic Approach to Maximize Efficiency and Safety. Plastic and reconstructive surgery Mohan, A. T., Zhu, L., Wang, Z., Vijayasekaran, A., Saint-Cyr, M. 2016; 138 (5): 790e-803e

  Abstract

  Perforator selection is critical to deep inferior epigastric perforator (DIEP) flap harvest. Commitment to a single perforator has the potential benefit of a simpler dissection, but may increase fat necrosis or perfusion-related complications compared with multiple perforator harvest.A 3-year retrospective study was carried out of all patients who underwent DIEP flap breast reconstruction performed by the senior author (M.S.-C). Data were collected on patient demographics and surgical outcomes.One hundred eighty-three flaps were performed (105 patients) over 3 years. One hundred fifty-six bilateral (78 patients) and 24 unilateral flaps were included in the final study. Mean age was 47.8 ± 8.4 years and mean body mass index was 29.1 ± 5.3 kg/m. Seventy-five percent of flaps were based on single dominant perforators. Single perforators were used in 33.3 percent of flaps weighing over 1000 g, 80 and 74 percent of flaps weighing 500 to 1000 g and less than 500 g, respectively (p = 0.01). There were no differences in overall complications between single- versus multiple-perforator DIEP flaps. Neither body mass index nor flap weight posed additional risk to overall complications. Conversion to a muscle-sparing flap was 9.4 percent.The authors present an algorithm for perforator selection, stepwise approach to flap harvest, and considerations for intraoperative decision-making in DIEP flap reconstruction. Single-dominant perforator flaps can be safely performed, but inclusion of the largest perforator is critical to flap perfusion. Additional perforators must be weighed against the associated tradeoff with donor-site morbidity. The threshold for conversion to a muscle-sparing flap is reduced with increased clinical experience.Therapeutic, III.

  View details for DOI 10.1097/PRS.0000000000002716

  View details for PubMedID 27782983

• The Concepts of Propeller, Perforator, Keystone, and Other Local Flaps and Their Role in the Evolution of Reconstruction. Plastic and reconstructive surgery Mohan, A. T., Sur, Y. J., Zhu, L., Morsy, M., Wu, P. S., Moran, S. L., Mardini, S., Saint-Cyr, M. 2016; 138 (4): 710e-729e

  Abstract

  After studying this article, the participant should be able to: 1. Understand the history and physiology of perforator flaps. 2. Understand the concept of "free-style" perforator flaps and principles in design and harvest. 3. Understand the uses of perforator flaps in reconstruction and applications in new settings. 4. Understand new principles in single and multiple perforator flap harvest and adjunct techniques that can be used in perforator flaps. 5. Highlight pertinent anatomy and techniques for selected perforator flaps described.Extended knowledge of vascular anatomy has propagated the development of perforator flaps, which preserve muscle function and reduce morbidity. This has been achieved through the exemplary works of Manchot, Salmon, Milton, Taylor, and many others. With over 350 clinically relevant perforators in the body, this has created new flap options and a sense of creative freedom for reconstruction tailored toward a specific defect, without constraints of specific landmarks and using a "free-style" approach. Dominant perforators may be found in zones of high perforator density or "hot spots," which can help to conceptualize local flap options and aid flap design. This article aims to outline the history, physiology, and principles of flap design and harvest, and highlight traditional and evolving concepts and modifications of contemporary and traditional flaps that are changing reconstructive practice. This is a broad overview focusing on clinical applications, highlighting key concepts in a selection of new or evolving flaps being used in clinical practice and providing source references to acquire detailed flap descriptions.

  View details for DOI 10.1097/PRS.0000000000002610

  View details for PubMedID 27673542

• Response to "Comments on 'Maximizing the Volume of Latissimus Dorsi Flap in Autologous Breast Reconstruction with Simultaneous Multisite Fat Grafting'". Aesthetic surgery journal Zhu, L., Mohan, A. T., Vijayasekaran, A., Hou, C., Sur, Y. J., Morsy, M., Saint-Cyr, M. 2016; 36 (7): NP239-41

  View details for DOI 10.1093/asj/sjw071

  View details for PubMedID 27118003

• Evolving Concepts of Keystone Perforator Island Flaps (KPIF): Principles of Perforator Anatomy, Design Modifications, and Extended Clinical Applications. Plastic and reconstructive surgery Mohan, A. T., Rammos, C. K., Akhavan, A. A., Martinez, J., Wu, P. S., Moran, S. L., Sim, F. H., Behan, F., Mardini, S., Saint-Cyr, M. 2016; 137 (6): 1909-1920

  Abstract

  Keystone flaps have demonstrated growing clinical applications in reconstructive surgery in the past decade. This article highlights flap modifications and their versatility for clinical applications and management of complex defects.A retrospective chart review was conducted of consecutive patients undergoing keystone flap reconstruction at the authors' institution from January of 2012 to December of 2014. Patient demographics, indications, and operative and postoperative details were abstracted.Forty-two keystone flaps were performed in 36 patients. Indications included malignant melanoma (n = 14), soft-tissue sarcoma (n = 12), benign pathologic conditions (e.g., exposed hardware, enterocutaneous fistula, tissue necrosis) (n = 6), and nonmelanoma skin cancer (n = 4). Twenty-eight percent received neoadjuvant irradiation, and 70 percent of these were for sarcoma. Locoregional adjunct flaps were performed in eight patients. The deep fascia was nearly completely in a circumferential manner in 18 of 36 patients (50 percent), in 92 percent of the sarcoma reconstructions, and located mainly in the lower extremity. Average defect size was 215 cm (range, 4 to 1000 cm). Average defect size was 474 cm and 35.8 cm after sarcoma and malignant melanoma resection, respectively. Average flap size was 344 cm (range, 5 to 1350 cm). Ninety percent of cases had flap sizes exceeding the traditional 1:1 ratio. There was no flap loss or partial necrosis. Mean time to mobilization was 1.8 days, and mean hospital length of stay was 6.8 days.Keystone flaps offer an excellent versatile tool for reconstructive surgeons. Fundamental principles behind the vascular basis of the keystone flap and its modifications permit their greater utility in complex wounds in the settings of large oncologic resections, irradiation, and trauma.Therapeutic, IV.

  View details for DOI 10.1097/PRS.0000000000002228

  View details for PubMedID 26895582

• Comparison of subcutaneous versus submuscular expander placement in the first stage of immediate breast reconstruction. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Zhu, L., Mohan, A. T., Abdelsattar, J. M., Wang, Z., Vijayasekaran, A., Hwang, S. M., Tran, N. V., Saint-Cyr, M. 2016; 69 (4): e77-86

  Abstract

  Tissue expander-based two-stage reconstruction remains the most commonly used technique in immediate breast reconstruction. This study compares the subcutaneous expander placement to the traditional submuscular placement and describes our early experience with the expander insertion plane-choosing algorithm.A retrospective study of patients who underwent two-stage immediate breast reconstruction from May 2012 to October 2014 was conducted. All expander insertion planes were chosen using the same algorithm. Expansion, pain, and complications were compared between two groups.The study included 88 patients (158 expanders; 50 subcutaneous and 108 submuscular). The subcutaneous group had a higher intraoperative expansion ratio (p < 0.001), high first postoperative expansion ratio (p < 0.001), shorter duration of expansion (p = 0.02), less number of expansion visits (p = 0.002), and less average pain during admission (p = 0.004). Significant differences in the intraoperative and first postoperative expansion ratios in patients with postmastectomy radiation therapy were also found between the two groups (p = 0.005 and 0.01, respectively). Complications during expansion and after second-stage autologous flap reconstruction were comparable between two groups.The subcutaneous expander placement was associated with greater intraoperative and first postoperative expansion, shorter expansion duration, less expansion visits, and less pain. With the expander insertion plane-choosing algorithm, subcutaneous expander placement could be performed with comparable complications rates with the submuscular placement during expansion and after second-stage autologous flap reconstruction. Further studies can be performed due to the lack of long-term complications following second-stage implant reconstruction in the subcutaneous approach.

  View details for DOI 10.1016/j.bjps.2016.01.006

  View details for PubMedID 26922050

• Procedure type, post-operative pain, recovery and clinical outcomes in DIEP flap breast reconstruction Azizi, A. A., Mohan, A. T., Tomouk, T., Conci, E., Brickley, E. B., Malata, C. M. WILEY-BLACKWELL. 2016: 50-51

  View details for Web of Science ID 000374301300153

• DIEP free flap breast reconstruction: review of impact of surgical procedure on donor site morbidity Tomouk, T., Mohan, A. T., Azizi, A., Conci, E., Brickley, E. B., Malata, C. M. WILEY-BLACKWELL. 2016: 50

  View details for Web of Science ID 000374301300151

• Advances in imaging technologies for planning breast reconstruction. Gland surgery Mohan, A. T., Saint-Cyr, M. 2016; 5 (2): 242-54

  Abstract

  The role and choice of preoperative imaging for planning in breast reconstruction is still a disputed topic in the reconstructive community, with varying opinion on the necessity, the ideal imaging modality, costs and impact on patient outcomes. Since the advent of perforator flaps their use in microsurgical breast reconstruction has grown. Perforator based flaps afford lower donor morbidity by sparing the underlying muscle provide durable results, superior cosmesis to create a natural looking new breast, and are preferred in the context of radiation therapy. However these surgeries are complex; more technically challenging that implant based reconstruction, and leaves little room for error. The role of imaging in breast reconstruction can assist the surgeon in exploring or confirming flap choices based on donor site characteristics and presence of suitable perforators. Vascular anatomical studies in the lab have provided the surgeon a foundation of knowledge on location and vascular territories of individual perforators to improve our understanding for flap design and safe flap harvest. The creation of a presurgical map in patients can highlight any abnormal or individual anatomical variance to optimize flap design, intraoperative decision-making and execution of flap harvest with greater predictability and efficiency. This article highlights the role and techniques for preoperative planning using the newer technologies that have been adopted in reconstructive clinical practice: computed tomographic angiography (CTA), magnetic resonance angiography (MRA), laser-assisted indocyanine green fluorescence angiography (LA-ICGFA) and dynamic infrared thermography (DIRT). The primary focus of this paper is on the application of CTA and MRA imaging modalities.

  View details for DOI 10.3978/j.issn.2227-684X.2016.01.03

  View details for PubMedID 27047790

  View details for PubMedCentralID PMC4791355

• The first perforating branch of the deep femoral artery: A reliable recipient vessel for vascularized fibular grafts: An anatomical study. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Sur, Y. J., Morsy, M., Mohan, A. T., Zhu, L., Lachman, N., Saint-Cyr, M. 2016; 69 (3): 351-8

  Abstract

  Although the perforating branches of the deep femoral artery have been introduced as recipient vessels for vascularized fibular grafts in the treatment of osteonecrosis of the femoral head, comprehensive knowledge of the related anatomy is deficient. The aims of this study were to provide detailed anatomical data for the perforating branches of the deep femoral artery and validate their usefulness as recipient vessels for vascularized fibular grafts.Anatomical dissection was performed on 11 fresh human cadaveric lower extremities. The number, locations, and diameters of the perforating branches were documented. The topographic relationships with the vastus ridge and the tendinous insertion of the gluteus maximus were clarified. The diameters of the perforating branches were compared with those of the ascending branch of the lateral circumflex femoral and the peroneal arteries.The mean number of perforating branches was 3.5. The mean distances from the vastus ridge to the first, second, and third perforating branches were 8.1, 13.7, and 20.4 cm, respectively. The first perforating branch was always located medial to the tendinous insertion of the gluteus maximus, whereas the second perforating branch was always located distal to the gluteus maximus. The mean diameters of the first, second, third, and fourth perforating branches were 3.1, 2.3, 1.6, and 1.2 mm, respectively. The mean diameters of the ascending branch of the lateral circumflex femoral and the peroneal arteries were 2.0 and 3.6 mm, respectively.The first perforating branch of the deep femoral artery is an appropriate alternative recipient vessel for vascularized fibular grafts in the treatment of osteonecrosis of the femoral head. It has a very consistent anatomy with a suitable location and diameter for anastomosis of the peroneal artery.

  View details for DOI 10.1016/j.bjps.2015.10.024

  View details for PubMedID 26626196

• Comparative Study of Liposomal Bupivacaine Versus Paravertebral Block for Pain Control Following Mastectomy with Immediate Tissue Expander Reconstruction. Annals of surgical oncology Abdelsattar, J. M., Boughey, J. C., Fahy, A. S., Jakub, J. W., Farley, D. R., Hieken, T. J., Degnim, A. C., Goede, W., Mohan, A. T., Harmsen, W. S., Niesen, A. D., Tran, N. V., Bakri, K., Jacobson, S. R., Lemaine, V., Saint-Cyr, M. 2016; 23 (2): 465-70

  Abstract

  Several approaches to minimize postoperative pain, nausea, and enhance recovery are available for patients undergoing mastectomy with immediate tissue expander (TE) reconstruction. We compared the effectiveness of intraoperative local infiltration of liposomal bupivacaine (LB) to preoperative paravertebral block (PVB).We retrospectively reviewed patients who underwent mastectomy with immediate TE reconstruction between May 2012 and October 2014 and compared patients with preoperative ultrasound-guided PVB to those with intraoperative LB infiltration.Fifty-three patients (54.6 %) received LB and 44 received PVB. LB was associated with less opioid use in the recovery room (p < 0.001), fewer patients requiring antiemetics (p = 0.03), and lower day of surgery pain scores (p = 0.008). LB also was associated with longer time to first opioid use (p = 0.04). On multivariable analysis controlling for expander placement location, year of surgery, and axillary lymph node dissection (ALND), the only variable that remained statistically significant was lower opioid use in the recovery room for patients with LB (p = 0.03) and day of surgery pain scores approached significance (p = 0.05). There was no difference in the proportion of patients discharged within 36 h of surgery between the groups. Focusing on first cases of the day (where PVBs are performed in the OR) showed average time to skin incision was 15 min shorter in the LB group (p = 0.004).Local infiltration of LB in patients undergoing mastectomy with immediate TE reconstruction decreases narcotic requirements in the recovery room, shortens preoperative anesthesiology time, and provides similar, if not better, perioperative pain control compared with PVB.

  View details for DOI 10.1245/s10434-015-4833-4

  View details for PubMedID 26307232

• Maximizing the Volume of Latissimus Dorsi Flap in Autologous Breast Reconstruction with Simultaneous Multisite Fat Grafting. Aesthetic surgery journal Zhu, L., Mohan, A. T., Vijayasekaran, A., Hou, C., Sur, Y. J., Morsy, M., Saint-Cyr, M. 2016; 36 (2): 169-78

  Abstract

  The pedicled latissimus dorsi (LD) flap serves an important function in breast reconstruction, but its utility is limited by its inability to provide sufficient breast volume.The purpose of this preliminary report was to review the techniques and outcomes of utilizing fat-grafted, volume-enhanced LD flap transfer with fat grafting recipient sites in autologous breast reconstruction.A retrospective study was performed of 10 patients (14 breasts) who underwent autologous breast reconstruction utilizing the LD flap transfer technique and simultaneous fat grafting between August 2012 and September 2014. Multilayer, multisite fat grafting was performed to the LD muscle, LD skin paddle, mastectomy skin flaps, and the pectoralis major and serratus muscles simultaneously with the LD flap transfer.Three patients underwent an immediate breast reconstruction, four underwent a delayed breast reconstruction, and four underwent a tertiary breast reconstruction following previously failed breast reconstructions (one patient underwent each of the first two procedures, one on each breast). The average age of the patients was 55 years (range, 39-76 years), the average body mass index of the patients was 29.3 (range, 19.6-39.9), and the average fat grafting volume for the patients was 176 mL (range, 50-300 mL). There was 100% flap survival and complete wound healing. No seroma or fat grafting-related complications were clinically detected. Three patients required additional fat grafting.The fat-grafted, volume-enhanced LD flap procedure with fat grafting recipient sites offers a simple and safe technique for autologous breast reconstruction, with low morbidity and fast recovery. It can be a useful alternative to utilizing abdomen-based flaps in autologous breast reconstruction or could be performed to salvage both implant-based and free-flap breast reconstructions. LEVEL OF EVIDENCE 4: Therapeutic.

  View details for DOI 10.1093/asj/sjv173

  View details for PubMedID 26546990

• Three-dimensional computed tomographic angiographic study of the inter-perforator flow of the lower leg Plast Reconstr Surg Sur, Y. S., Morsy, M., Mohan, A. T., Zhu, L., Michalak, G. J., Lachman, N., Laungani, A. T., Alphen, N. V., Saint-Cyr, M. 2016
• Adioofascial Flap Versus ADM: An intraoperative selection algorithm for Implant Coverage in Immediate Breast Reconstruction Mohan, A. T., Hwang, S. M., Zhu, L., Gaba, P., Brickley, E., Abdelsattar, J. M., Reusche, R., Tran, N. V., Saint-Cyr, M. Plast Reconstr Surg Glob Open. 2016
• An Anatomical and Histological Intercostal Nerve Study to Determine Optimal Recipient Site for Sensory Reinnervation in Autologous Breast Reconstruction Mohan, A. T., Suchyta, M., Akdag, O., Zhu, L., Lachman, N., Mardini, S., Saint-Cyr, M. Plast Reconstr Surg Glob Open. 2016
• Vascular Anatomy of Facial Units for Vascularized Composite Tissue Transplantation Design in a Large Animal Model: An in-Vivo and Radiological Study Mohan, A. T., Suchyta, M., Sharaf, B., Bakri, K., Alsubaie, S., Michalak, G., Mardini, S. Plast Reconstr Surg Glob Open. 2016
• Radiological and Histological Assessment in Perforator Flap Microvasculature Following Pretreatment with Topical Negative Pressure Therapy: An Experimental Rat Model Mohan, A. T., Hwang, S. M., Zhu, L., Michalak, G., Laungani, A. T., Vernocke, A., Anderson, J. L., Grande, J., Bishop, A., Moran, S. L., Saint-Cyr, M. Plast Reconstr Surg Glob Open. 2016
• Surgeon’s Perspectives on User-Designed Prototypes of Microsurgery Armrests Abdelrahman, A. M., Lowndes, B. R., Mohan, A. T., Noland, S. S., Finnie, D. M., Lemaine, V., Hallbeck, M. S. Proceedings of the Human Factors and Ergonomics Society Annual Meeting. 2016
• Propeller flaps and Keystone Flaps in the Lower Extremity Master Techniques in Orthopaedic Surgery: Soft Tissue Surgery Mohan, A. T., Morsy, M., Saint-Cyr, M. 2016
• Anatomic and Physiological Fundamentals For Autologous Breast. Reconstruction Reconstructive Surgery In Breast Cancer Mohan, A. T., Saint-Cyr, M. 2016
• Creative Use of Contralateral Combined Myocutaneous Free Flap for Empyema Cavity. The Annals of thoracic surgery Tan, H. B., Mohan, A. T., Coonar, A. S., Malata, C. M. 2016; 101 (1): e1-3

  Abstract

  Treatment of chronic postpneumonectomy empyema is a reconstructive problem that is always complicated by previous thoracic surgical procedures. Free flaps may be used because they effectively obliterate remaining pleural cavity dead space. Combined muscle free flaps with common vascular pedicles are viable alternatives when single muscle flaps do not possess adequate bulk. This case describes a contralateral combined latissimus dorsi-serratus anterior myocutaneous free flap with anastomoses to thoracodorsal vessels used for correction of chronic empyema. We also describe successful correction of a posterolateral chest wall defect using the adjacent axillary system as a recipient vessel. An accompanying skin paddle also enabled reliable cutaneous coverage of the external defect.

  View details for DOI 10.1016/j.athoracsur.2015.06.106

  View details for PubMedID 26694302

• Is the SMAS Flap Facelift Safe? A Comparison of Complications Between the Sub-SMAS Approach Versus the Subcutaneous Approach With or Without SMAS Plication in Aesthetic Rhytidectomy at an Academic Institution. Aesthetic plastic surgery Rammos, C. K., Mohan, A. T., Maricevich, M. A., Maricevich, R. L., Adair, M. J., Jacobson, S. R. 2015; 39 (6): 870-6

  Abstract

  For treating the aging face, a facelift is the surgical standard. A variety of techniques have been described. The purpose of the current study is to evaluate the safety of the sub-SMAS facelift compared to the subcutaneous facelift with or without SMAS plication.A retrospective chart review was conducted on all patients who underwent facelift surgery between 2003 and 2011. Patients included in the study were seeking elective improvement of facial appearance. All charts were reviewed to identify the presence of hematoma, seroma, deep venous thrombosis, skin loss, unfavorable scar, wound infection, or motor and sensory deficit following the operation. The primary outcome was overall complication rate.A total of 229 facelifts were included; 143 patients underwent a subcutaneous facelift with or without SMAS plication and 86 underwent a sub-SMAS facelift. For the subcutaneous facelifts, 88% of the patients were female with a mean age of 62 years. For the sub-SMAS dissections, 88% of the patients were female with a mean age of 59 years. The overall complication rate was 29.4% (n = 42) for patients who underwent a subcutaneous facelift compared to 24.4% (n = 21) for patients with a sub-SMAS facelift (p = 0.4123). Analysis of each individual complication failed to yield any statistically significant difference between the two groups.In the present study, sub-SMAS facelift complication rates were not statistically different compared to those of subcutaneous facelift with or without SMAS plication. These data suggest that sub-SMAS dissection can be performed with similar safety compared to the traditional subcutaneous facelift, with the potential additional advantage of the SMAS flap elevation.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

  View details for DOI 10.1007/s00266-015-0558-9

  View details for PubMedID 26311561

• A simple approach to harvest of the pedicled descending branch muscle-sparing latissimus dorsi flap. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Zhu, L., Mohan, A. T., Saint-Cyr, M. 2015; 68 (11): e179-81

  View details for DOI 10.1016/j.bjps.2015.07.009

  View details for PubMedID 26239374

• Modified aesthetic abdominoplasty approach in perforator free-flap breast reconstruction: Impact of drain free donor site on patient outcomes. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Mohan, A. T., Rammos, C. K., Gaba, P., Schupbach, J., Goede, W. J., Ballman, K., Batdorf, N., Cheng, A., Saint-Cyr, M. 2015; 68 (6): 800-9

  Abstract

  The use of progressive tension sutures alone has been shown to be comparable to using abdominal drains in aesthetic abdominoplasty. This study reviews outcomes with the use of barbed progressive tension suture technique without drains in DIEP donor site closure compared to standard closure with drains.A two year retrospective review was conducted of DIEP flap reconstructions in the enhanced recovery program at Mayo Clinic, Rochester (USA). Donor site closure was divided into barbed progressive tension sutures (B-PTS) without drains, and standard abdominal closure with drains(S-AD). Demographics, perioperative data and donor site complications were documented.93 patients were included in the study, 42 in the B-PTS no drain group and 51 in the S-AD with drains. 81% of all procedures were bilateral and 39% were immediate. Patients were discharged faster to the ward postoperatively and total hospital admission was reduced in the B-PTS group, 3.7 (SD = 1.4) days versus 4.7 (SD = 2.1) days in the standard group (P = 0 < 0.001 and 0.004 respectively). Less morphine was required postoperative day (POD) 1, 2 and 3 (P = 0.04, 0.03, 0.02 respectively), and time to mobilize was quicker but not statistically significant (P = 0.09) in the B-PTS group. Overall there were 18 patients in the S-AD group who had complications versus 9 in the B-PTS group (P = 0.14). The incidence of complications occurring within 30 days were lower in the B-PTS group (P = 0.05). The overall seroma rate was 5.4% and rates in the B-PTS group was 2.4% versus 7.8% in the S-AD group, P = 0.37.Use of barbed progressive tension sutures for abdominal closure after DIEP flap harvest can obviate the need for abdominal drains, reduce postoperative pain and encourage early discharge from the hospital without an increased risk in complications.III.

  View details for DOI 10.1016/j.bjps.2015.03.008

  View details for PubMedID 25843908

• Intralesional bleomycin injection in management of low flow vascular malformations in children. Journal of plastic surgery and hand surgery Mohan, A. T., Adams, S., Adams, K., Hudson, D. A. 2015; 49 (2): 116-20

  Abstract

  Low flow vascular malformations are challenging to manage, particularly with their propensity to grow, and can lead to severe disfigurement and dysfunction. Traditional surgical excision is fraught with tedious dissection and complications, particularly in the head and neck region. Trends toward less invasive techniques, such as intralesional sclerotherapy, are proving to be successful independent treatments or adjuncts in management in low flow vascular malformations. This study was a retrospective case note review, over an 8-year period, reporting the outcomes of 32 children (mean = 5.8 years, range = 5 months-11.5 years) with radiologically confirmed low flow vascular malformations, treated with serial intralesional bleomycin injection (IBI) therapy. Patient demographics, lesion characteristics, imaging findings, treatment course, radiological and clinical response to treatment were recorded. An overall 91% (n = 29) response rate was achieved, with 28% obtaining complete resolution for low flow vascular malformations. Lesions were sub-categorized into venous malformation, including mixed venous-capillary (n = 27) or lymphatic malformation (LM) (n = 5). Twenty-seven of 32 children experienced no complications. Local complications included superficial skin infection (n = 2), skin necrosis (n = 1), hyperpigmentation, and minor contour deformity. There was no recurrence and no systemic side-effects to bleomycin. Mean follow-up was 38 months (range = 6-95 months). In conclusion, serial intralesional bleomycin injections can be effective and also safe in a paediatric population for the successful management of symptomatic or disfiguring low flow vascular malformations.

  View details for DOI 10.3109/2000656X.2014.951051

  View details for PubMedID 25204206

• Impact of drain free donor site closure on patient outcomes in DIEP breast reconstruction Mohan, A. T., Rammos, C., Gaba, P., Schupbach, J., Goede, W., Batdorf, N., Saint-Cyr, M. WILEY-BLACKWELL. 2015: 23

  View details for Web of Science ID 000354029300069

• Anatomic and physiological fundamentals for autologous breast reconstruction. Gland surgery Mohan, A. T., Saint-Cyr, M. 2015; 4 (2): 116-33

  Abstract

  The success of autologous tissue transfer is reliant on adequate blood supply and as we endeavour to tailor our reconstructive options through our flap choices and design. Autologous breast reconstruction has made substantial progress over the years and the evolution of refinements over the last 30 years has allowed flaps to be based on specific perforators. The ultimate goal of breast reconstruction following mastectomy is to match optimal tissue replacement with minimal donor-site expenditure. In parallel surgeons will seek ways to ensure safe flap design and harvest while maintaining predictability and reliable tissue perfusion. Better understanding of the vascular anatomy and physiology of the cutaneous circulation of soft tissues, and that of patterns of blood flow from individual perforator has provided insight to advance perforator flap harvest and modifications in flap design. The aim of this article is to review the principles of blood supply and flap design exemplified through common flaps used in autologous breast reconstructive surgery, to better understand approaches for safe flap harvest and transfer of well perfused tissue.

  View details for DOI 10.3978/j.issn.2227-684X.2015.04.01

  View details for PubMedID 26005644

  View details for PubMedCentralID PMC4409677

• Assessing the augmented breast: a blinded study comparing round and anatomical form-stable implants. Aesthetic surgery journal Al-Ajam, Y., Marsh, D. J., Mohan, A. T., Hamilton, S. 2015; 35 (3): 273-8

  Abstract

  Controversy persists as to whether round or anatomical form-stable breast implants provide the most aesthetically pleasing results, and there is a paucity of evidence comparing cosmetic outcomes of these two implants. A blinded study comparing aesthetic outcomes was conducted in an attempt to address this issue.The authors compare aesthetic outcomes between round and anatomical form-stable breast implants.Pre- and postoperative photographs of 60 consecutive patients undergoing breast augmentation (33 round, 27 anatomical) by a single surgeon were reviewed by 22 plastic surgeons. Photographs were graded on a modified Likert scale (1, poor; 4, excellent) for overall aesthetic result, upper pole contour, and natural appearance. The panel was asked to determine implant shape.Anatomical implants scored higher for upper pole contour: anatomical 2.80 (±0.44 - standard deviation) vs round 2.60 (±0.38). With regard to natural appearance and overall aesthetic results, anatomical implants scored higher: 2.89 (±0.42) vs 2.56 (±0.36) and 2.86 (±0.41) vs 2.72 (±0.37), respectively. None of these differences achieved statistical significance, and 62.7% of round and 49% of anatomical implants were correctly identified. There was no significant difference in the body mass index (BMI) between the 2 groups (P = .21).No significant difference (P > .05) in the general and specific cosmetic points between round and anatomical implants was demonstrated; many on the panel were unable to identify implant shape correctly. Both techniques seem to yield good cosmetic results. Clearly the decision on which implant to use must be made on an individual patient basis because many factors influence overall aesthetic outcome. Anatomical implants should not be assumed to produce a more natural result.4 Therapeutic.

  View details for DOI 10.1093/asj/sju053

  View details for PubMedID 25805281

• Appraisal Of Perforasomes And Venosomes Of Perforators In Bilateral DIEP Breast Reconstruction Using Updated SpyQ Analysis Mohan, A. T., Zhu, L., Mardini, S., Moran, S., Saint-Cyr, M. Plast Reconstr Surg. 2015
• The impact of negative pressure therapy to enhance vascularity and wound healing in perforator flap preconditioning: an experimental rat model Mohan, A. T., Hwang, S., Laungani, A. T., Zhu, L., Bishop, A., Saint-Cyr, M. British Journal of Surgery. 2015
• Strategies in oncological reconstruction: modification to the keystone perforator flap concept in sarcoma reconstruction Mohan, A. T., Akhavan, A., Martinez-Jorge, J., Wu, P., Moran, S., Saint-Cyr, M. British Journal of Surgery. 2015
• Profunda Artery Perforator Flap Perforasome Territories: Implications of Vascular Anatomy for Optimal Flap Design in Reconstructive Microsurgery Mohan, A. T., Zhu, L., Rammos, C. K., Michalak, G., Lachman, N., Moran, S., Saint-Cyr, M. Plast Reconstr Surg. 2015
• Maximizing the Volume of Extended Latissimus Dorsi Flap for Autologous Breast Reconstruction with Immediate Fat Grafting and Thoracoabdominal Advancement Flap Vijayasekaran, A., Zhu, L., Mohan, A. T., Saint-Cyr, M. Ann Plast Surg. 2015
• Principles of surgical treatment of chronic lymphedema Handbook of Venous Disorders Al-Ajam, Y., Mohan, A. T., Saint-Cyr, M. 2015
• The Transverse Upper Gracilis Flap for Breast Reconstruction Following Liposuction of the Thigh Liposuction Mohan, A. T., Wong, C., Saint-Cyr, M. 2015
• Post-radiation tracheoesophageal fistula following salvage laryngectomy: microsurgical repair using a "bi-laminar" lateral arm flap EUROPEAN JOURNAL OF PLASTIC SURGERY Mohan, A. T., Malata, C. M. 2014; 37 (12): 683-686

  View details for DOI 10.1007/s00238-014-1004-y

  View details for Web of Science ID 000217752300009

• Hand flaps. Hand clinics Chim, H., Ng, Z. Y., Carlsen, B. T., Mohan, A. T., Saint-Cyr, M. 2014; 30 (4): 487-99, vi-vii

  Abstract

  The role of the hand as the primary form of interaction with the surrounding physical environment is often underappreciated, and injuries to it can become especially debilitating. The hand has evolved into a complex, intricate structural conglomeration of bones, joints, tendons, ligaments, and neurovascular structures, with an overlying soft tissue envelope that is varied and adapted to particular functions. Wounds to the hand requiring flap coverage warrant careful planning. Increasing knowledge of anatomy has led to the description of many flaps. This article presents a review of the commonly used flaps in reconstruction of the hand and the various considerations involved.

  View details for DOI 10.1016/j.hcl.2014.07.007

  View details for PubMedID 25440077

• Soft tissue coverage of the upper extremity: an overview. Hand clinics Chim, H., Ng, Z. Y., Carlsen, B. T., Mohan, A. T., Saint-Cyr, M. 2014; 30 (4): 459-73, vi

  Abstract

  Prehension is a complex function of the hand that gives it mechanical precision combined with a standard sensory pattern. The priority in soft tissue reconstruction for the upper extremity is to restore function. Significant injury to the upper extremity may result after trauma because of various etiologies. The timing and choice of soft tissue coverage for upper extremity defects warrant special consideration to avoid prolonged immobilization, which can result in joint stiffness, tendon adhesions, scar contractures, and ultimately, loss of function. This article reviews the various reconstructive options and considerations involved in providing coverage for upper extremity soft tissue defects.

  View details for DOI 10.1016/j.hcl.2014.08.002

  View details for PubMedID 25440074

• Combination of the superior and inferior pedicle "continuities" for anastomosis of an SIEA flap to a contralateral DIEP flap in double-pedicled abdominal free flaps: A further modification of the Hamdi classification. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Mohan, A. T., Patel, N. G., Malata, C. M. 2014; 67 (10): e237-9

  View details for DOI 10.1016/j.bjps.2014.06.008

  View details for PubMedID 25047701

• Extended Transverse Upper Gracilis Flap in Breast Reconstruction Grabb’s Encyclopedia of Flaps Reusche, R., Mohan, M. T., Saint-Cyr, M. 2014
• Lessons learned from revision cosmetic breast Implant surgery: motivation, trends and a practical approach Mohan, A. T., Tomouk, T., Fopp, L., Malata, C. M. J Plast Reconstr Aesth Surg. 2014
• Double-pedicled Abdominal Free Flaps Utilising the Superior Continuity of the DIEP Vascular Pedicle in Unilateral Breast Reconstruction: Case reports and Discussion/ Review of Novel Additions to Hamdi’s type II DIEA/SIEA bipedicled flaps Breast Reconstruction Erel, E., Mohan, A. T., Malata, C. M. 2014
• The Pedicled Descending Branch Muscle- Sparing Latissimus Dorsi Flap for Breast Reconstruction Grabb’s Encyclopedia of Flaps Johnson, C., Mohan, A. T., Zhu, L., Saint-Cyr, M. 2014
• Current uses of smartphones and apps in orthopaedic surgery. British journal of hospital medicine (London, England : 2005) Popat, R., Mohan, A. T., Branford, O. A. 2013; 74 (12): 672-6

  View details for DOI 10.12968/hmed.2013.74.12.672

  View details for PubMedID 24326713

• Trends in tertiary breast reconstruction: literature review and single centre experience. Breast (Edinburgh, Scotland) Mohan, A. T., Al-Ajam, Y., Mosahebi, A. 2013; 22 (2): 173-178

  Abstract

  Autologous flap reconstruction can improve aesthetic results after failed implant reconstruction and be considered following previous failed autologous flap reconstruction. This study presents a review of the indications, motivation and outcomes of tertiary breast reconstruction.A comprehensive literature review was conducted using Pubmed, Embase, Web of Science and Google Scholar. Articles were identified using key search terms and through citations. A single centre, retrospective, review of all patients who underwent autologous flap reconstruction following previous breast reconstruction between 2004 and 2010. Details on patient demographics, surgical outcomes and patient satisfaction were collected.Out of 580 autologous flap breast reconstructions, 31 patients had 36 tertiary breast reconstructions with an autologous free or pedicled flap. Indications for surgery included: capsule contracture with discomfort (n = 24), asymmetry (n = 8), extrusion of implant (n = 4), exposed implant (n = 1). and previous failed autologous flap reconstruction (n = 7). The mean age our cohort was 50.1 years, BMI of 26.1, 52.3% had radiotherapy (n = 19) and 51.6% had chemotherapy. We performed free DIEP(n = 22), LD with or without an implant (n = 11) and free TRAM flap (n = 3). 5 were bilateral procedures. Flap complications included total flap loss (n = 2), partial skin necrosis (n = 1) and fat necrosis (n = 1). Mean follow up time was 20 months. Overall satisfaction, excluding the two flap failures was good.Only small case series were published on tertiary breast reconstruction. More recent literature had larger patient samples. A total of 7 studies were identified, with a total of 532 flaps, following unsatisfactory or failed implant reconstruction. The Deep Inferior Epigastric Artery Perforator (DIEP) flap was the most favourable first choice for autologous tertiary reconstruction. Breast cancer was the commonest indication for primary surgery. Motivations for tertiary surgery included cosmesis (including asymmetry and shape), symptomatic capsule contracture and desire for a natural feel. A handful of studies explored the outcomes of autologous flaps following a previously failed flap.Autologous breast reconstruction for tertiary reconstruction can be performed successfully to improve cosmesis and physical discomfort following failed or unsatisfactory results from implant reconstruction or previous failed flap reconstruction. The goal is to excise scarred tissue, recreate the breast mound and the normal anatomical shape. It provides new skin and well vascularised tissue to facilitate healing, producing a more natural feel and aesthetic breast.

  View details for DOI 10.1016/j.breast.2012.06.004

  View details for PubMedID 22795362

• Mono-articular synovial chondromatosis of the metacarpophalangeal joint EUROPEAN JOURNAL OF PLASTIC SURGERY Mohan, A. T., Carton, J., O'Toole, G. A. 2013; 36 (3): 203-205

  View details for DOI 10.1007/s00238-011-0669-8

  View details for Web of Science ID 000217676800011

• Identification of the biopsy track in musculoskeletal tumour surgery: a novel technique using India ink. The bone & joint journal Jalgaonkar, A., Dawson-Bowling, S. J., Mohan, A. T., Spiegelberg, B., Saifuddin, A., Pollock, R., Skinner, J. A., Briggs, T. W., Aston, W. 2013; 95-B (2): 250-3

  Abstract

  Local recurrence along the biopsy track is a known complication of percutaneous needle biopsy of malignant musculoskeletal tumours. In order to completely excise the track with the tumour its identification is essential, but this becomes increasingly difficult over time. In an initial prospective study, 22 of 45 patients (48.8%) identified over a three-month period, treated by resection of a musculoskeletal tumour, had an unidentifiable biopsy site at operation, with identification statistically more difficult after 50 days. We therefore introduced the practice of marking the biopsy site with India ink. In all 55 patients undergoing this procedure, the biopsy track was identified pre-operatively (100%); this difference was statistically significant. We recommend this technique as a safe, easy and accurate means of ensuring adequate excision of the biopsy track.

  View details for DOI 10.1302/0301-620X.95B2.30123

  View details for PubMedID 23365037

• Can immediate post-operative radiographs predict clinical outcome at 5 years following total hip and knee arthroplasty? Dhinsa, B., Gallagher, K., Dawson-Bowling, S., Mohan, A. T., Miles, J., Carrington, R., Skinner, J., Briggs, T. W. Bone Joint J. 2013
• Deep soft tissue leiomyoma mimicking fibromatosis in a 5-year-old male. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons Jalgaonkar, A., Mohan, A., Dawson-Bowling, S., Skinner, J., Briggs, T. W. 2012; 51 (1): 110-3

  Abstract

  Leiomyomas of the deep soft tissue in the extremities of children are very rare. These benign soft tissue tumors occur more frequently in adults between the fourth and sixth decades of age. Women are more commonly affected than men, with the uterus the most common location. We present a rare case of deep soft tissue leiomyoma in the foot of a 5-year-old male. The tumor was misdiagnosed as a desmoid-type fibromatosis from the findings of both magnetic resonance imaging and needle biopsy. The unusual age of presentation, atypical location, and failure of magnetic resonance imaging and ultrasound-guided needle biopsy in diagnosing the lesion make the case interesting. The case also highlights the importance of treating such patients at specialist tertiary centers with a multidisciplinary setting.

  View details for DOI 10.1053/j.jfas.2011.10.013

  View details for PubMedID 22078158

• iGuide to plastic surgery: iPhone apps, the plastic surgeon, and the health care environment. Aesthetic surgery journal Mohan, A. T., Branford, O. A. 2012; 32 (5): 653-8

  Abstract

  The growth in the adoption of smartphones among clinicians has been phenomenal. The demand for medical applications, or "apps," downloaded by smartphone users has led to the development of practical and educational apps for clinicians, medical students, and patients. In addition to being a valuable resource for the clinician, mobile technologies are revolutionizing the nature and delivery of health care services. This article summarizes the current trends in the smartphone market and explores the medical apps that are currently available.

  View details for DOI 10.1177/1090820X12448815

  View details for PubMedID 22628896

• Securing fingertip dressings: the new 'cinch pink' technique. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Mughal, M., Mohan, A. T., Branford, O. A., Dewar, D. 2012; 65 (6): e167-8

  View details for DOI 10.1016/j.bjps.2011.12.017

  View details for PubMedID 22240246

• Preoperative biopsy tract identification using india ink skin tattooing in tumour surgery Jalgaonkar, A., Mohan, A. T., Pollock, R., Skinner, J., Cannon, S., Briggs, T. W., Aston, W. J Bone Joint Surg Br. 2012
• Mass endoprosthetic replacement for Forearm tumours: Our Experience at Stanmore Jalgaonkar, A., Mohan, A. T., Park, D., Dawson-Bowling, S., Aston, W., Cannon, S., Skinner, J., Briggs, T. W. Bone Joint Journal Orthopaedic Proceedings. 2012
• A prospective Study of Intra-lesional Bleomycin Injection for the Management of Low Flow Vascular Malformations Mohan, A. T., Adams, S., Hudson, D. Plast Reconstr Surg J. 2012
• Intraosseous xanthoma of the hand without an underlying lipid disorder. The Journal of hand surgery, European volume Mohan, A., Jalgaonkar, A., Briggs, T. W. 2011; 36 (6): 520-2

  View details for DOI 10.1177/1753193411409316

  View details for PubMedID 21593068

• Intra-neural Ewing's sarcoma of the upper limb mimicking a peripheral nerve tumour. A report of 2 cases. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Mohan, A. T., Park, D. H., Jalgaonkar, A., Alorjani, M., Aston, W., Briggs, T. 2011; 64 (6): e153-6

  Abstract

  Ewing's sarcoma is a malignant round cell tumour of bone commonly affecting children and young adults. Intra-neural Ewings is very rare form of extraosseous Ewing's sarcoma (EES), posing diagnostic and therapeutic challenges. We report two cases of intra-neural EES presenting with elbow pain and swelling, mimicking an upper limb peripheral nerve sheath tumour. Following a CT guided biopsy to confirm diagnosis, the patients were treated with a combination of surgical resection, chemotherapy and radiotherapy. These cases highlight the potential diagnostic challenges as their presentation can be misleading due to the non-specificity of symptoms. These are highly aggressive tumours with the propensity to metastasize. We review importance of collective radiological and immunohistochemical analysis followed by early, aggressive multimodal treatment within a multidisciplinary setting. This provides the best prognosis in the context of upper limb peripheral nerve tumours.

  View details for DOI 10.1016/j.bjps.2011.01.010

  View details for PubMedID 21330228

• A Large Skull Base tumour with Acute Urinary Retention Mohan, A. T., Balfour, A., Simo, R. The Journal of Laryngology & Otology. 2011
• A modified 'template' transperineal prostate biopsy technique - can side-effects be reduced and high cancer detection rates maintained? Kastner, C., Nuttall, M. C., Au, E., Mohan, A., Brewin, J., Popert, R. BLACKWELL PUBLISHING. 2008: 20

  View details for Web of Science ID 000255956700054

• Does upper tract urine culture help to prevent sepsis post-percutaneous nephro-lithotomy? Mohan, A. T., Dasgupta, R. Journal of Endourology. 2008
• Uses and Benefits of SMS in Healthcare Delivery Atun, R. A., Sittampalam, S. R., Mohan, A. Centre of Health Management, Tanaka Business School. Imperial College London, UK. 2006