Porcine model for deep superior epigastric artery perforator flap harvesting: Anatomy and technique

BACKGROUND Microsurgical training on rats before starting with clinical practice is a well-established routine. Animal model training is less widespread for perforator flaps, although these flaps represent a technical challenge. Unlike other flaps, they require specific technical skills that need to be adequately trained on a living model 1 : a cadaver is not enough because no bleeding, vessel damage, or vasospasm can be simulated. 2 The purpose of this study was to assess the suitability of the porcine abdomen as a training model for the deep inferior epigastric artery perforator (DIEAP) flap, commonly used in human breast reconstruction. METHODS A female swine (Sus scrofa domesticus, ssp; weight 25kg) was used. The procedure was performed with the pig under general anesthesia and in the supine position. A deep superior epigastric artery perforator (DSEAP) flap was harvested on the left side of the abdomen, including the 3 cranial nipples and stopping in the midline to spare the contralateral flap for another dissection (as in bilateral breast reconstructions in humans; Fig. 1). All steps of a DIEAP harvest were simulated: superficial vein harvest, suprafascial perforator dissection, intramuscular perforator harvest with preservation of the nerves, and flap isolation. Observation of capillary refill was used to confirm flap viability at the end of the dissection. The procedure was recorded by means of a GoPro camera and simultaneously with a head mounted (4 7 magnification) Loupecam system. Photographs were taken using 2 cameras during surgery at relevant time points. RESULTS At the end of the dissection, the flap was viable. The subcutaneous adipose tissue of the pig is less represented than in human and pigs have an additional muscular layer, the panniculus carnosus, which is the analogue of the human Scarpa's fascia. The rectus fascia is thinner. The perforators are lined in 2 rows: 1 lateral and 1 medial, as in the DIEAP, and the intercostal nerves cross the vessels, as happens in humans. The porcine rectus abdominis muscle is thinner than the human one, but vessels' branching faithfully reproduces the human model. 1 We identified 5 perforating vessels of more than 1mm in diameter (2 lateral and 3 medial). We isolated a lateral perforator first and a medial one last: the latter was eventually used to nourish the flap (Fig. 2). CONCLUSIONS The DSEAP flap allows one to closely reproduce all the steps of DIEAP flap harvesting and also to carry out the intramuscular dissection of 2 perforators for each side (up to 4 for each animal), confirming the adequacy of this pig model for microsurgical training. The deep superior epigastric artery is dominant in pigs. 3 Despite this anatomical difference, the DSEAP allows one to reproduce the main steps of DIEAP flap harvesting, providing an excellent training model. Moreover, the presence of double perforating rows allows simulating the dissection twice on each side

The impact of COVID-19 pandemic on breast surgery in Italy: a multi-centric retrospective observational study

COVID-19 pandemic had an impact on surgical activities. The aim of this multi-centric, retrospective study was to evaluate the impact of the COVID-19 pandemic on breast surgery. The patients who operated during the pre-pandemic year 2019 were compared to those operated in 2020. Fourteen Breast Care Units provided data on breast surgical procedures performed in 2020 and 2019: total number of breast-conserving surgery (BCS), number of 1st level oncoplastic breast surgery (OBS), number of 2nd level OBS; total number of mastectomies, mastectomies without reconstruction, mastectomies with a tissue expander, mastectomies with direct to implant (DTI) reconstruction, mastectomies with immediate flap reconstruction; total number of delayed reconstructions, number of expanders to implant reconstructions, number of delayed flap reconstructions. Overall 20.684 patients were included: 10.850 (52.5%) operated during 2019, and 9.834 (47.5%) during 2020. The overall number of breast oncologic surgical procedures in all centers in 2020 was 8.509, compared to 9.383 in 2019 (- 9%). BCS decreased by 744 cases (- 13%), the overall number of mastectomies decreased by 130 cases (- 3.5%); mastectomy-BCS ratio was 39-61% in 2019, and 42-58% in 2020. Regarding immediate reconstructive procedures mastectomies with DTI reconstruction increased by 166 cases (+ 15%) and mastectomies with immediate expander reconstruction decreased by 297 cases (- 20%). Breast-delayed reconstructive procedures in all centers in 2020 were 142 less than in 2019 (- 10%). The outburst of the COVID-19 pandemic in 2020 determined an implemented number of mastectomies compared to BCS, an implemented number of immediate breast reconstructions, mainly DTI, and a reduction of expander reconstruction

A hybrid stress-assumed transition element for solid to beam and plate to beam connections

This paper presents a new transition element for modelling solid-to-beam and plate-to-beam connections. The approach is based upon the hybrid stress method and the resulting transition element is hypostatic, i.e. the number of independent stress parameters is less than the number of independent displacements. As a consequence, there are further displacement modes called spurious kinematic modes which are eliminated by means of a suitable “penalty” method. The numerical performance of the proposed element is assessed by a number of relevant tests

An unsymmetric stress formulation for Reissner-Mindlin plates: a simple and locking free four node element

In the present paper a simple mixed-hybrid element for the linear analysis of Reissner-Mindlin plates is discussed. The element is derived from a modified Reissner functional and standard bilinear (isoparametric) interpolation for displacement and rotations is assumed whereas local stresses (rather than stress resultants and moments) are explicitly modelled. It is assumed that in plane shear stresses are not a priori symmetric. This choice allows to decouple the equilibrium equations, and involves introducing an in-plane infinitesimal rotation field, corresponding to drilling degrees of freedom. Out-of-plane shear stresses are then obtained such that equilibrium equations are exactly satisfied. The proposed element does not exhibit locking effects at all: i.e. the shear deformation energy is zero in the thin plate limit. Details of the formulation are provided, and the performances of the element are assessed with reference to well-established benchmark problems

A four-node hybrid assumed-strain finite element for laminated composite plates

Fibre-reinforced plates and shells are finding an increasing interest in engineering applications. Consequently, efficient and robust computational tools are required for the analysis of such structural models. As a matter of fact, a large amount of laminate finite elements have been developed and incorporated in most commercial codes for structural analysis. In this paper a new laminate hybrid assumed-strain plate element is derived within the framework of the First-order Shear Deformation Theory (i.e. assuming that particles of the plate originally lying along a straight line which is normal to the undeformed middle surface remain aligned along a straight line during the deformation process) and assuming perfect bonding between laminae. The in-plane components of the (infinitesimal) strain tensor are interpolated and by making use of the constitutive law, the corresponding in-plane stress distribution is deduced for each layer. Out-of-plane shear stresses are then computed by integrating the equilibrium equations in each lamina, account taken of their continuity requirements. Out-of-plane shear strains are finally obtained via the inverse constitutive law. The resulting global strain field depends on a fixed number of parameters, regardless of the total number of layers; 12 degrees of freedom are for instance assumed for the developed rectangular element. The proposed model does not suffer locking phenomena even in the thin plate limit and provides an accurate description of inter-laminar stresses. Results are compared with both analytical and other finite element solutions