Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation

Technique for Minimizing Donor-site Morbidity after Pedicled TRAM-Flap Breast Reconstruction: Outcomes by a Single Surgeon's Experience

Background:

Breast reconstruction with pedicled transverse rectus abdominis myocutaneous (TRAM) flap can result in significant abdominal wall donor-site morbidity. We present our technique of transversely dividing the anterior fascia and rectus abdominis combined with reinforcement above the arcuate line for closure of the anterior abdominal wall defect to prevent contour deformities performed by a single senior surgeon and compare these results with those of our prior series.

Methods:

We described our new technique of closure of the abdominal wall defect and retrospectively performed the comparison between the results of pedicled TRAM flaps using the new closure technique and those of 420 pedicled TRAM flaps from our 2003 publication in terms of abdominal bulging and hernia.

Results:

Sixty-seven pedicled TRAM flaps in 65 patients were compared with 420 pedicled TRAM flaps of the 2003 series. The new technique was associated with 5 partial TRAM flap necroses (8%). There was no total flap loss with the new technique. The median follow-up period was 13 months (range, 4–36 months). There were no instances of abdominal hernia and bulge during follow-up in the new series. Compared with the previous 2003 series, the new technique was superior in terms of occurrence of abdominal wall hernia or bulging.

Conclusions:

We are still performing pedicled TRAM flap for autologous breast reconstruction. Using the technique of transversely dividing the anterior fascia and rectus abdominis combined with reinforcement above the arcuate line can reduce the occurrence of abdominal bulging and hernia.

Abdominal perforator vs. muscle sparing flaps for breast reconstruction

Abdominally based free flaps have become the mainstay for women that desire to use their own tissue as a means of breast reconstruction after mastectomy. As the techniques have evolved, significant effort has been invested in finding the best means of minimizing morbidity to the abdominal donor site while ensuring a viable reconstructed breast that is aesthetically pleasing. This manuscript reviews and compares the muscle sparing free transverse rectus abdominis myocutaneous (MsfTRAM), the deep inferior epigastric artery perforator (DIEP), and the superficial inferior epigastric artery (SIEA) flaps, regarding flap success rate, operative times, abdominal donor site morbidity and residual functionality, hospital lengths of stay and associated costs, impact of co-morbid conditions, and resilience after adjuvant radiation treatment.

The cost effectiveness of the DIEP flap relative to the muscle-sparing TRAM flap in postmastectomy breast reconstruction

BACKGROUND

The deep inferior epigastric perforator (DIEP) flap has gained notoriety because of its proposed benefit in decreasing donor-site morbidity but has been associated with longer operative times, higher perfusion-related complications, and increased cost relative to muscle-sparing free transverse rectus abdominis myocutaneous (TRAM) flaps. The authors performed the first cost-utility analysis examining the cost effectiveness of DIEP flaps relative to muscle-sparing free TRAM flaps in women who underwent mastectomy.

METHODS

A comprehensive literature review was conducted using the MED- LINE, Embase, and Cochrane library databases to include studies directly comparing DIEP to muscle-sparing free TRAM flaps in matched patient cohorts. Eight studies were included, examining 740 DIEP flaps and 807 muscle-sparing free TRAM flaps. Costs were derived adopting both societal and third-party payer perspectives. Utilities were derived from a previous cost-utility analysis. Probabilities of clinically relevant complications were combined with cost and utility estimates to fit into a decision tree analysis.

RESULTS

The overall complication rates were 24.7 percent and 21.8 percent for DIEP and muscle-sparing free TRAM flaps, respectively. The authors' baseline analysis using Medicare reimbursement revealed a cost decrease of $69.42 and a clinical benefit of 0.0035 quality-adjusted life-year when performing DIEP flap surgery relative to muscle-sparing free TRAM flap surgery, yielding an incremental cost-utility ratio of -$19,834.29. When using societal costs, the incremental cost-utility ratio increased to $87,800.

CONCLUSION

DIEP flaps are cost effective relative to muscle-sparing free TRAM flaps when patients are carefully selected based on perforator anatomy and surgery is performed by experienced surgeons.

Achieving ideal donor site aesthetics with autologous breast reconstruction

The appearance of the donor site following breast reconstruction with abdominal flaps has become an important topic for study. Given the variety of flaps that are derived from the abdomen, decisions are often based on how much muscle and fascia will be harvested. Comparisons between muscle sparing and non-muscle sparing techniques have been performed with outcomes related to function and contour. Closure techniques will vary and include primary fascial closure, mesh reinforcement and additional fascial plication all of which can produce natural and sometimes improved abdominal contours. Proper patient selection however is important. This manuscript will describe various techniques in order to achieve ideal abdominal contour following autologous reconstruction.

Racial differences in ischemic complications of pedicled versus free abdominal flaps for breast reconstruction

PURPOSE

This study aims to determine the relationship between race and ischemic complications in women undergoing breast reconstruction with pedicled TRAM (pTRAM) and perforator flaps (DIEP).

PATIENTS AND METHODS

A retrospective, cross-sectional study of women who underwent breast reconstruction utilizing either pTRAM or DIEP flaps from March 1, 2002 to September 1, 2012 was performed. Clinical and demographic variables, including race and ischemic complications (mastectomy flap necrosis, fat necrosis, partial abdominal flap necrosis, vascular compromise requiring reoperation), were examined. Fat necrosis was graded using a previously established scale (grade I = radiologically visible, II = palpable, III = palpable and visible, IV = symptomatic).

RESULTS

Over the 10-year study period, adequate follow-up was available for 138 women (94 Caucasian, 36 African American) who underwent pTRAM or DIEP. Fat necrosis occurred more frequently in the pTRAM group (53.5% vs. 17.4%, P < 0.001). There was no statistically significant difference in partial flap necrosis or mastectomy flap necrosis between the 2 groups. The DIEP group had a higher rate of vascular compromise requiring reoperation (13% vs. 0, P = 0.003). In the pTRAM group, there was a higher rate of fat necrosis (77% vs. 45.6%, P < 0.001) and grade IV fat necrosis in African Americans (42.8% vs. 9.5%, P = 0.005). Rates of other ischemic complications were comparable between the 2 racial groups. In the DIEP group, ischemic complications were comparable between the 2 racial groups. After stratifying by flap type and race, we saw no differences in mastectomy flap necrosis (P = 0.0182).

DISCUSSION

African Americans undergoing pTRAM flap are at higher risk for grade IV fat necrosis but not mastectomy flap necrosis or partial flap necrosis. This may be due to difficulty using physical examination to judge the vascular status of a pedicle flap that is known to undergo significant changes in vascular physiology following transfer. Intraoperative assessment of perfusion using new technologies may be useful in these higher risk patients.

Tissue expander capsule for abdominal wall in autologous breast reconstruction

Summary:

Adjuvant treatment planning can change after breast cancer resection and definitive pathological examination. Radiation therapy is often chosen as a supplementary treatment. Rectus abdominis–based muscle flaps are one of the main choices when breast reconstruction plans must be changed from implant-based to autologous methods. We herein report a case in which the patient’s own tissue expander capsule was used to repair an abdominal wall defect after muscle-sparing transverse rectus abdominis myocutaneous flap reconstruction.

Plastic surgery and the breast: a citation analysis of the literature

Background:

A large proportion of the plastic surgery literature is dedicated to the breast. It is one of the most common topics in our specialty, yet it is unclear which articles have been the most influential. The purpose of this study was to identify the top 100 most-cited articles on breast in the plastic surgery literature and examine the characteristics of each individual article.

Methods:

Using an electronic database through the Web of Science, we were able to determine the 6 journals that contributed to the 100 most-cited articles on breast in the plastic surgery literature.

Results:

Each article was examined individually looking at characteristics such as subject matter, article type, country of origin, institution, authorship, and year of publication. Plastic and Reconstructive Surgery contributed the most articles to the top 100 with 81 articles including the most-cited article which has been referenced 673 times to date. The United States produced 73% of the top 100 articles, and the most prolific institution was the University of Texas M. D. Anderson Cancer Center with 15 articles.

Conclusions:

This study has identified the most influential articles on breast in the plastic surgery literature over the past 68 years and highlighted many important scientific breakthroughs and landmarks that have occurred during this time.

Using propensity score analysis to compare major complications between DIEP and free muscle-sparing TRAM flap breast reconstructions

BACKGROUND

Previous studies comparing muscle-sparing transverse rectus abdominis myocutaneous (TRAM) versus deep inferior epigastric artery perforator (DIEP) free flaps have not considered procedure selection bias. Propensity score analysis provides a statistical approach to consider preoperative factors in flap selection, and was used to compare major complications (breast and abdominal) between these microsurgical breast reconstruction (free muscle-sparing TRAM versus DIEP).

METHODS

This study evaluated major breast and abdominal complications in 292 consecutive patients (428 free abdominal flaps). Propensity scores were calculated for patient differences affecting flap selection (DIEP versus free muscle-sparing TRAM). Multivariate logistic models using selected covariates separately analyzed breast and abdominal complications between flap methods.

RESULTS

There were 83 major complications (28 percent): breast, 20 percent; abdomen, 8 percent. Using propensity scores, the adjusted odds of abdominal complications were significantly higher in free muscle-sparing TRAM than in DIEP flaps (OR, 2.73; 95 percent CI, 1.01 to 7.07). With prior chemotherapy, body mass index significantly increased abdominal complications (OR, 1.16; 95 percent CI, 1.01 to 1.34). Using propensity scores, there was no significant association between reconstruction method and breast complications; diabetics had significantly increased breast complications (OR, 4.19; 95 percent CI, 1.14 to 15.98). Previous abdominal operations (OR, 1.77; 95 percent CI, 0.96 to 3.30) and immediate reconstruction (OR, 1.86; 95 percent CI, 0.94 to 3.71) approached significance.

CONCLUSIONS

Propensity score analysis indicated significantly higher abdominal complications in free muscle-sparing TRAM compared with DIEP flaps. This study highlights the importance of separately evaluating recipient breast and donor abdominal complications and use of propensity scores to minimize procedure selection bias.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Evidence-based medicine: breast reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Differentiate among the various techniques available to reconstructive breast surgeons. 2. Perform a comprehensive assessment of the breast reconstruction candidate. 3. Gain knowledge about the indications and contraindications for different breast reconstructive procedures. 4. Understand the complications inherent in different reconstructive breast procedures. 5. Summarize the long-term objective and subjective implications of surgery.

SUMMARY

This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

Salvage of intraoperative deep inferior epigastric perforator flap venous congestion with augmentation of venous outflow: flap morbidity and review of the literature

BACKGROUND

Breast reconstruction with deep inferior epigastric perforator (DIEP) flaps has gained considerable popularity due to reduced donor-site morbidity. Previous studies have identified the superficial venous system as the dominant outflow to DIEP flaps. DIEP flap venous congestion occurs if superficial venous outflow via the deep venous system is insufficient for effective flap drainage. Although augmentation of venous outflow through a second venous anastomosis may relieve venous congestion, effects on flap morbidity remain ill defined.

METHODS

A retrospective analysis of 1616 patients who underwent 2618 DIEP flap breast reconstructions between March 2005 and January 2012 was performed. Patients with intraoperative venous congestion underwent a second venous anastomosis. Preoperative demographic data and methods used to relieve venous congestion were recorded. Incidence of flap morbidity was calculated and compared with a group of 418 controls having 639 DIEP flap breast reconstructions with no venous congestion.

RESULTS

Venous augmentation was required to relieve venous congestion in 87 (3.3%) DIEP flaps on 81 patients. The superficial inferior epigastric vein or accompanying deep inferior epigastric venae comitantes was used to augment venous outflow. Preoperative comorbidities were similar between both groups. Patients requiring a second venous anastomosis had a longer operative time and length of hospital stay. Overall, flap morbidity, delayed wound healing, fat necrosis, and flap loss were similar to controls.

CONCLUSIONS

Arterial and venous anatomies play unique roles in flap reliability. DIEP flap venous congestion must be treated expeditiously with venous augmentation to relieve venous congestion and mitigate flap morbidity.

Ultrasound imaging evaluation of abdominal muscles after breast reconstruction with a unilateral pedicled transverse rectus abdominis myocutaneous flap

BACKGROUND

A muscle-sparing (MS) procedure using a full-width pedicled transverse rectus abdominis (RA) myocutaneous (TRAM) flap was developed to reduce abdominal morbidities after breast reconstruction. However, the effects of this procedure on the morphology of the remnant RA muscle and other abdominal muscles remain unclear.

OBJECTIVE

Ultrasound imaging was used to evaluate the morphology of the remnant RA muscle and other abdominal muscles in women with the MS pedicled TRAM flap procedure.

DESIGN

A case-control, cross-sectional design was used.

METHODS

Thirty-four women with an MS unilateral pedicled TRAM flap procedure after mastectomy (TRAM group) and 25 women who were healthy and matched for age (control group) participated. The curl-up test measured trunk flexor muscle strength. Ultrasound imaging measured the thickness of all abdominal muscles in all participants and the cross-sectional area of the RA muscle at rest and in an isometric position with the head raised in women in the TRAM group. Acoustic echogenicity and border visibility assessed the tissue composition of the remnant RA muscle.

RESULTS

Trunk flexor muscle strength was weaker in the TRAM group than in the control group. Compared with the remnant RA muscle in the contracted state, the remnant RA muscle in the relaxed state was thinner and had a smaller cross-sectional area. The remnant RA muscle in the relaxed state also was thinner, more echoic, and less visible than its contralateral counterpart. No differences in the thickness of the other abdominal muscles were found between the sides. The abdominal muscles in the TRAM group were smaller than those in the control group.

LIMITATION

Because a prospective, longitudinal design was not used, a definite cause-effect relationship could not be determined.

CONCLUSIONS

In women with an MS unilateral pedicled TRAM flap procedure, the remnant RA muscle retains its ability to change in size during contraction, albeit at reduced levels. Muscular atrophy occurs in other ipsilateral and contralateral abdominal muscles as well as the remnant RA muscle. Postoperative immobilization is the most likely cause of generalized weakness of the abdominal musculature.

The advantages of free abdominal-based flaps over implants for breast reconstruction in obese patients

BACKGROUND

The authors hypothesized that, for obese patients, delayed abdominal-based free flap (rather than implant-based and immediate) breast reconstruction would result in fewer overall complications and reconstruction losses.

METHODS

The authors retrospectively analyzed consecutive implant- and abdominal-based free flap breast reconstructions performed in obese patients between 2005 and 2010 by utilizing the World Health Organization obesity classifications: class I, 30.0 to 34.9 kg/m2; class II, 35.0 to 39.9 kg/m2; and class III, ≥40 kg/m2. Primary outcome measures included flap failures and overall complications. Logistic regression analysis identified associations among patient, defect, and reconstructive characteristics and surgical outcomes.

RESULTS

The analysis included 990 breast reconstructions (548 flaps versus 442 implants) in 700 patients. Mean follow-up was 17 months. Age, smoking, medical illness, and body mass index greater than 37 predicted overall complications on regression analysis. Implants demonstrated a higher failure rate (15.8 percent) than flaps (1.5 percent). Although failure rates were similar for immediate and delayed flap reconstructions overall (1.3 versus 1.9 percent) and among obesity classifications, there was a trend toward more implant failures in immediate rather than delayed reconstructions (16.8 versus 5.3 percent). Differences between immediate implant versus flap reconstruction failure rates were highest among more obese patients [class II (24.7 versus 1.3 percent) and class III (25.4 versus 0 percent) compared with class I (11.7 versus 1.4 percent)].

CONCLUSIONS

Obese patients (particularly class II and III) experience higher failure rates with implant-based breast reconstruction, particularly immediate reconstruction. Free flap techniques or delayed implant reconstruction may be warranted in this population.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Comparing the donor-site morbidity using DIEP, SIEA or MS-TRAM flaps for breast reconstructive surgery: a meta-analysis

BACKGROUND

Countless studies have compared the use of autologous tissue for breast reconstruction; however, rates of donor-site morbidity differ greatly. This study examined the donor-site morbidity of superficial inferior epigastric artery (SIEA), deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps when used for unilateral breast reconstruction.

METHODS

Searches in PubMed and Medline as well as three manual search strategies for English-language articles published from 1 January 1995 to 1 January 2011 resulted in 2154 publications. Four levels of screening identified five studies suitable for the meta-analysis. StatsDirect software was used to perform the Mantel-Haenszel fixed-effect model.

RESULTS

Only one study reported rates of donor-site morbidity for SIEA flaps. It was therefore impossible to perform any analysis regarding SIEA flaps. Five studies reported rates for both DIEP and MS-TRAM flaps and were used to estimate pooled relative risk (RR) and confidence intervals (CIs) of bulging. There was a 20% reduced risk of bulging when DIEP flaps were used compared to MS-TRAM flaps (RR 0.80, 95% CI 0.48-1.35). Subgroup analysis demonstrated that the risk of bulging in DIEP flap patients was one-third of MS-TRAM flap patients (RR 0.29; 95% CI 0.06-1.36), when rates were reported by clinical examinations. However, when rates were reported by surveys there was no difference in bulge formation between DIEP and MS-TRAM flap patients (RR 1.04; 95% CI 0.59-1.79). The adjusted RR of hernia in DIEP flap patients was approximately one-half of MS-TRAM flap patients (RR 0.43; 95% CI 0.07-2.63).

CONCLUSION

This analysis demonstrated a clear trend towards a favourable outcome when DIEP flaps were used compared to MS-TRAM flaps.

Perfusion-related complications are similar for DIEP and muscle-sparing free TRAM flaps harvested on medial or lateral deep inferior epigastric Artery branch perforators for breast reconstruction

BACKGROUND

Anatomical studies suggest that the deep inferior epigastric artery (DIEA) medial branch perfuses more tissue across the midline than the lateral branch. The authors hypothesized that unilateral deep inferior epigastric perforator (DIEP) and muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flaps based on medial branch perforators would have fewer perfusion-related complications.

METHODS

The authors evaluated consecutive DIEP or muscle-sparing TRAM free flaps definitively harvested from a single DIEA branch. Flaps were grouped by tissue volume (hemiflaps, cross-midline flaps, or total flaps). Primary outcome measures were fat necrosis and partial flap necrosis. Logistic regression was used to evaluate the association between patient and reconstruction characteristics and outcomes.

RESULTS

There were 228 patients, with 120 medial (52.6 percent) and 108 lateral (47.4 percent) branch flaps. Mean follow-up was 33.2 months. Cross-midline flaps (79.8 percent) were the most common design. Medial and lateral branch flaps had similar rates of fat necrosis (8.3 percent and 13.0 percent, respectively; p = 0.26) and partial flap necrosis (3.3 percent and 2.8 percent, respectively; p = 1.0). There was no difference in the incidence of fat necrosis between DIEP and muscle-sparing free TRAM flaps (10.2 percent and 11.3 percent, respectively; p = 0.81) or in partial necrosis (3.2 percent and 2.8 percent, respectively; p = 1.0). Medial and lateral branch flap perfusion-related complications were also similar among the flap volume classifications.

CONCLUSIONS

The authors suggest that surgeons base their decisions regarding DIEA branch harvest on the clinical assessment of perforator perfusion quality rather than relying on the theoretical benefit of medial branch perforator harvest.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Update on Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps

Breast reconstruction using autologous tissue is commonly accomplished using the transverse rectus abdominis myocutaneous (TRAM) flap. The establishment of microvascular surgery led to the development of the free TRAM flap because of its increased vascularity and decreased rectus abdominis sacrifice. The muscle-sparing free TRAM, DIEP, and SIEA flap techniques followed in an effort to decrease abdominal donor site morbidity by decreasing injury to the rectus abdominis muscle and fascia. Data have accumulated over the past decade that show that muscle- and fascia-sparing techniques, such as the use of DIEP flaps, result in measurably better postoperative abdominal strength. However, muscle-sparing techniques do not appear to decrease the risk of abdominal bulging or hernia, and there are no significant differences in patient-reported abdominal weakness or functional impairments. The SIEA flap is presented as a reemerging method that can virtually eliminate abdominal donor site morbidity. Sensory nerve coaptation to improve reconstructed breast sensation is also reviewed.

A comparison of the superficial inferior epigastric artery flap and deep inferior epigastric perforator flap in postmastectomy reconstruction: A cost-effectiveness analysis

PURPOSE

To perform a cost-effectiveness analysis comparing the superficial inferior epigastric artery (SIEA) and deep inferior epigastric perforator (DIEP) flaps in postmastectomy reconstruction.

METHODS

A decision analytic model with seven clinically important health outcomes (health states) was used, incorporating the Ontario Ministry of Health's perspective. Direct medical costs were estimated from a university-based hospital. The utilities of each health state converted into quality-adjusted life years (QALYs) were obtained from previously published data. Health state probabilities were computed from a systematic literature review. Analyses yielded SIEA and DIEP expected costs and QALYs allowing calculation of the incremental cost-utility ratio (ICUR). One-way sensitivity analyses were conducted under five plausible scenarios, assessing result robustness.

RESULTS

Five SIEA and 27 DIEP studies were identified. The baseline SIEA expected cost was slightly higher than that for the DIEP ($16,107 versus $16,095), with slightly higher QALYs (33.14 years versus 32.98 years), giving an ICUR of $77/QALY. Taking into account conversions from SIEA to DIEP, the ICUR increased to $4,480/QALY. Sensitivity analysis gave ICURs ranging from $2,614/QALY to 'dominant', all consistent with the adoption of the SIEA over the DIEP.

CONCLUSION

The best available evidence suggests the SIEA is a cost-effective procedure. However, given the high SIEA to DIEP conversion rates and small marginal differences in cost and effectiveness, the ICUR may be sensitive to minor changes in costs or QALYs. The 'truth' can only be obtained from a randomized, controlled trial comparing both techniques side by side, simultaneously capturing the costs of the competing interventions.

Double-mesh technique for correction of abdominal hernia following mammary reconstruction carried out with bipedicled TRAM flap and the primary closing of the donor area by using a single polypropylene mesh

BACKGROUND

Mammary reconstruction by using the transverse myocutaneous flap of the abdominal straight muscle (TRAM) is still an option well accepted in many parts of the world. However, bipedicled TRAM flaps are associated with greater morbidity of the abdominal donor area. The aim of this study was to describe an efficient technique for correcting the delayed defects of the abdominal wall following mammary reconstruction carried out with bipedicled TRAM flaps by using two polypropylene prostheses overlapped in different anatomical planes.

METHODS

At Hospital Estadual Sumaré at Universidade Estadual de Campinas, 18 women who underwent unilateral mammary reconstruction with bipedicled TRAM flaps and immediate fixation of two rectangular flaps of polypropylene mesh on the donor area were assessed. Later on, three patients (16.7%) presented with deformity of the anterolateral abdominal wall in the donor area. Each of these herniations was corrected by fixing two polypropylene meshes in different anatomical planes: the first mesh, which was bigger and preperitoneal, was fixed from the costal borders until the pubis; the second mesh was fixed from the external oblique muscle to the contralateral external oblique muscle, remaking the median line.

RESULTS

All patients were followed up for at least 18 months, without any signs of relapse, abdominal asymmetry, or chronic pain and with satisfactory functional results.

CONCLUSION

The correction of delayed deformities of the abdominal wall after mammary reconstruction with bipedicled TRAM flaps using double mesh was carried out in an effective and secure way, providing an interesting surgical option for mastologists and plastic and general surgeons.

Comparisons of the postoperative rectus abdominis muscle thickness and the biomechanical properties of donor sites among different subtypes of muscle-sparing transverse rectus abdominis myocutaneous flaps (MS0, MS1, MS2, MS3): a rat model

BACKGROUND

The primary presumed advantages of the deep inferior epigastric perforator flap over the other muscle-sparing (MS) transverse rectus abdominis myocutaneous flaps are the improved functional rectus abdominis muscle outcomes and decreased abdominal contour morbidities. The purpose of this study was to verify this viewpoint objectively and quantitatively using an animal model.

METHODS

Six rats were used in the pilot study and 40 rats were equally divided into a control group and 4 experimental groups (MS0, MS1, MS2, and MS3) according to the amount of rectus abdominis muscles harvested. At 3 and 6 weeks, 4 rats in each group were killed, then, the percentage of residual rectus abdominis muscle thickness compared with the control side and the ultimate load at failure of the abdominal wall were recorded and compared.

RESULTS

All of the flaps survived completely without complications. Regarding the percentage of residual rectus abdominis muscle thickness compared with the control side, the results suggested MS3 > MS2 ≈ MS1 > MS0; concerning the ultimate load at failure of the abdominal wall, the results showed MS3 ≈ MS2 > MS1 > MS0. (≈: P > 0.05; >: P < 0.05).

CONCLUSIONS

According to the findings of this study, we advocate the use of the deep inferior epigastric perforator flap when possible, and the MS2-transverse rectus abdominis myocutaneous flap can serve as a backup when the perforator anatomy does not meet the flap safety criteria for preservation of rectus abdominis muscle function.

The variability of the Superficial Inferior Epigastric Artery (SIEA) and its angiosome: A clinical anatomical study

INTRODUCTION

The superficial inferior epigastric artery (SIEA) is a useful pedicle in supply to the lower abdominal integument, with its use sparing damage to rectus abdominis muscle or sheath. However, it is limited in usefulness due to its anatomical variability. While previous anatomical studies have been limited in number and study design, the use of preoperative imaging has enabled the analysis of this vasculature in large numbers and greater anatomical detail.

METHODS

A clinical anatomical study of 500 hemi-abdominal walls in 250 consecutive patients undergoing preoperative computed tomographic angiography (CTA) prior to autologous breast reconstruction was undertaken. The presence, size, location, and branching pattern of the SIEA were assessed in each case.

RESULTS

The SIEA was identified in 468 cases, an incidence of 94%. Its mean diameter was 0.6 mm, and in 24% of cases was of a diameter >1.5 mm. SIEA location was highly variable, with mean position 2-cm lateral to the linea semilunaris (range 0-8 cm lateral), and relationship to the superficial inferior epigastric vein (SIEV) was also highly variable, with the distance between them ranging from 0.3 to 8.5 cm apart. SIEA branches directly crossed the abdominal midline in 5% of cases. Larger SIEA diameters correlated with a decrease in diameter of ipsilateral DIEA perforators.

CONCLUSION

The SIEA is present more frequently than previously demonstrated, but is typically too small for use in free tissue transfer. The variable degree of SIEA branching suggests that its territory of supply is also variable, and that preoperative imaging may be useful in planning SIEA flaps.

The Deep Inferior Epigastric Perforator Flap for Breast Reconstruction: Is this the Ideal Flap for Asian Women?

Introduction: This study aims to evaluate the outcome and safety of the deep inferior epigastric perforator (DIEP) flap for breast reconstruction in a group of Southeast Asian women treated in our unit and to identify risk factors for breast reconstruction using the DIEP flap in this population. Materials and Methods: This is a prospective study on 50 consecutive DIEP flap breast reconstructions by a single surgeon in an academic institution between July 1999 and July 2006. Data on patient demographics, diagnosis, procedure type, adjuvant and neoadjuvant treatments, risk factors and complications were prospectively collected and registered in a clinical database. Outcome variables include total flap loss, partial flap loss, fat necrosis and minor complications related to the donor site or flap. Known risk factors are analysed to determine if they affect outcome in terms of complication rate in this group of patients. Results: Total flap loss, partial flap loss and fat necrosis complication rates were 6%, 4% and 10%, respectively. Flap complication rates were comparable to those quoted by previous studies done worldwide. Obesity (BMI >27) is a statistically significant factor associated with development of DIEP flap complications in our population. Conclusion: Breast reconstruction with DIEP flap is a safe and reliable method when used in Southeast Asian women, offering optimal results with less donor-site morbidity. Obesity increases the incidence of flap complication in this group of patients. Keywords: Abdominal-based free flap, Complication, Microsurgery, Post-mastectomy reconstruction

Unilateral failures in bilateral microvascular breast reconstruction

BACKGROUND

As rates of bilateral prophylactic mastectomy and contralateral prophylactic mastectomy have increased over the past decade, bilateral microvascular breast reconstruction has played an increasing role in breast cancer care. Data on unilateral flap failure in bilateral microvascular breast reconstructions have been lacking, and strategies to address the challenges encountered in this situation are needed.

METHODS

A retrospective review of all simultaneous bilateral microvascular breast reconstructions performed by the senior author (M.Y.N.) from July of 1999 to July of 2008 was conducted. Flap failures were identified and reviewed for operative parameters, causes of flap loss, and techniques used for secondary reconstruction.

RESULTS

The authors identified 171 consecutive patients who underwent bilateral microvascular breast reconstruction between July of 1999 and July of 2008. In these patients, 342 flaps were attempted, including 108 free transverse rectus abdominis musculocutaneous flaps, 228 deep inferior epigastric artery perforator flaps, and six superior gluteal artery perforator flaps. Twelve flaps failed or were aborted intraoperatively, yielding an overall failure rate of 3.5 percent. The authors' unilateral microsurgical breast reconstruction failure rate over this period was 2.1 percent (eight of 386). No bilateral failures occurred. Causes of flap failure included venous insufficiency (six of 12), lack of adequate perforator anatomy (three of 12), and perforator injury during dissection (two of 12). Secondary reconstruction with tissue expanders and implants was performed in 11 of 12 patients who underwent an average of 2.25 additional procedures to complete reconstruction.

CONCLUSIONS

Flap failure is more common in bilateral reconstructions than in unilateral reconstructions, largely secondary to the obligation to use both sides of the abdominal donor tissue. When flap failure does occur, techniques to optimize prosthetic reconstruction can ultimately result in successful bilateral reconstructions despite free flap failure.

Technical tips for safe perforator vessel dissection applicable to all perforator flaps

The introduction of perforator flaps by Koshima and Soeda in 1989 was met with much animosity in the surgical community. The flaps challenged conventional teaching and were often branded as being unsafe. Surgeries using perforator flaps are now routinely practiced all over the world, with increasing emphasis on minimizing donor site morbidity, and perforator flaps are becoming the current gold standard. The simple principles and techniques of perforator dissection can be applied to all perforator flaps, provided the surgeon has an intimate knowledge of the regional anatomy. Thus, virtually any piece of skin can be harvested as long as it incorporates a feeding vessel. This article highlights the essential techniques in planning and raising perforator flaps and the common pitfalls to be avoided.

A new classification system for muscle and nerve preservation in DIEP flap breast reconstruction

The main advantage of deep inferior epigastric perforator (DIEP) flap breast reconstruction is muscle preservation. Perforating vessels, however, display anatomic variability and intraoperative decisions must balance flap perfusion with muscle or nerve sacrifice. Studies that aggregate DIEP flap reconstruction may not accurately reflect the degree of rectus preservation. At Beth Israel Deaconess Medical Center from 2004-2009, 446 DIEP flaps were performed for breast reconstruction. Flaps were divided into three categories: DIEP-1, no muscle or nerve sacrifice (126 flaps); DIEP-2, segmental nerve sacrifice and minimal muscle sacrifice (244 flaps); DIEP-3, perforator harvest from both the medial and lateral row, segmental nerve sacrifice and central muscle sacrifice (76 flaps). Although the rate of abdominal bulge was similar among groups, fat necrosis was significantly higher in DIEP-1 when compared with DIEP-3 flaps (19.8% vs. 9.2%, P = 0.049). We describe a DIEP flap classification system and operative techniques to minimize muscle and nerve sacrifice.

Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques

BACKGROUND

Despite a growing literature on patient satisfaction in breast reconstruction, few studies have compared perforator flaps with the more commonly practiced methods. The authors compared four reconstructive techniques and identified factors influencing patient satisfaction.

METHODS

All patients undergoing postmastectomy breast reconstruction between 1999 and 2006 at a single academic institution were included in our study. A total of 583 patients with tissue expander/implant, latissimus, pedicle transverse rectus abdominis muscle (TRAM), and deep inferior epigastric perforator (DIEP) flap reconstructions received a validated questionnaire on satisfaction, health-related quality of life, and sociodemographic data.

RESULTS

Patient response was 75 percent, with 439 completed questionnaires including 87 tissue expander/implant, 116 latissimus, and 119 pedicle TRAM and 117 DIEP flap patients. DIEP patients had the highest level of general satisfaction at 80 percent, and pedicle TRAM patients had the highest level of aesthetic satisfaction at 77 percent (p < 0.001 and p < 0.001, respectively). Health-related quality of life and length of time since surgery were identified as significant covariates influencing patient satisfaction. After logistic regression analysis, autologous reconstruction had significantly higher general and aesthetic satisfaction than implant-based reconstruction (p = 0.017 and p < 0.001). Among the autologous reconstructions, abdominal-based flaps had significantly higher general and aesthetic satisfaction than latissimus flaps (p = 0.011 and p = 0.016). When comparing the abdominal-based reconstructions, general and aesthetic satisfaction were no longer statistically significant between pedicle TRAM and DIEP flaps (p = 0.659 and p = 0.198).

CONCLUSIONS

Autologous, abdominal-based reconstructions had the highest satisfaction rates across all four groups. After logistic regression analysis, differences in patient satisfaction between pedicle TRAM and DIEP flap reconstruction were no longer observed. Discussing satisfaction outcomes with patients will help them make educated decisions about breast reconstruction.

Aesthetic refinements and reoperative procedures following 370 consecutive DIEP and SIEA flap breast reconstructions: important considerations for patient consent

BACKGROUND

Breast reconstruction often requires multiple operations. In addition to potential complications requiring reoperation, additional procedures are frequently essential in order to complete the reconstructive process, with aesthetic outcome and breast symmetry shown to be the most important factors in patient satisfaction. Despite the importance of these reoperations in decision-making and the consent process, a thorough review of the need for such operations has not been definitively explored.

METHODS

A review of 370 consecutive autologous breast reconstructions (326 patients) was undertaken, comprising 365 deep inferior epigastric artery perforator (DIEP) flaps and 5 superficial inferior epigastric artery (SIEA) flaps. The need for additional procedures for either complications or aesthetic refinement following initial breast reconstruction was assessed.

RESULTS

Overall, there was an average of 1.06 additional interventions for every patient carried out after primary reconstructive surgery. Of 326 patients, 46 underwent early postoperative operations for surgical complications (0.17 additional operations per patient as a consequence of complications). Procedures for aesthetic refinement included those performed on the reconstructed breast, contralateral breast, or abdominal donor site. Procedures for aesthetic refinement included nipple reconstruction, nipple-areola complex tattooing, dog-ear correction, liposuction, lipofilling, scar revision, mastopexy, and reduction mammaplasty.

CONCLUSION

While DIEP flap surgery for breast reconstruction provides favorable results, patients frequently require additional procedures to improve aesthetic outcomes. The need for reoperation is an important part of the consent process prior to reconstructive surgery, and patients should recognize the likelihood of at least one additional procedure following initial reconstruction.

Outcomes and patient satisfaction following breast reconstruction with bilateral pedicled TRAM flaps in 105 consecutive patients

BACKGROUND

Breast reconstruction using pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps has come under increasing scrutiny secondary to presumed abdominal wall morbidity. This study analyzes morbidity and patient satisfaction in a consecutive series of breast reconstructions performed using bilateral pedicled TRAM flaps.

METHODS

Between 1991 and 2007, 105 women underwent bilateral pedicled TRAM flap breast reconstruction performed by the senior author (J.J.P.). Charts were reviewed for postoperative complications and demographic data. Minimum 11-month follow-up survey data were obtained through the Michigan Breast Satisfaction Questionnaire, the Qualitative Assessment of Back Pain Questionnaire, and the Short Form-36 questionnaire.

RESULTS

The mean follow-up interval was 6 years. Abdominal wall complications included three abdominal hernias (2.9 percent), three abdominal wall bulges (2.9 percent), and four partial donor-site skin dehiscences (3.8 percent). Fat necrosis was the most common flap complication, present in 24 flaps (11.4 percent). The survey response rate was 61.9 percent. Short Form-36 data demonstrated no significant difference from a mean age-matched female population in general well-being, although patients with a body mass index greater than or equal to 30 reported significantly lower emotional well-being (p = 0.01), social functioning (p = 0.03), and overall energy scores (p = 0.03) in comparison with patients with a body mass index less than 30. Thirteen of the 65 patients who completed the survey (20 percent) complained of postoperative back pain, although most of these patients reported their symptoms to be mild in nature.

CONCLUSIONS

Low complication rates were demonstrated and patients were generally satisfied in this series of 105 consecutive bilateral pedicled TRAM flaps. This suggests that the bilateral pedicled TRAM flap remains a viable option for breast reconstruction.

The "limited rectus sheath incisions" technique for DIEP flaps using preoperative CT angiography

The abdominal wall donor site has become popularized for autologous breast reconstruction, with low donor site morbidity one of its key attributes. Further improvements in donor site outcomes have been facilitated through muscle sparing techniques, such as the use of the deep inferior epigastric artery (DIEA) perforator (DIEP) flap, and the use of modifications to closing the rectus sheath following muscular dissection, such as the use of endoscopic techniques and the use of mesh. We describe a new and unique method for potentially minimizing donor site damage during DIEP flap harvest: the "limited rectus sheath incisions" technique. This approach is only possible in select cases, the choice of which can be aided with the use of preoperative computed tomography angiography (CTA). In select patients, there may be an extended segment of DIEA that does not give any musculocutaneous perforators, and thus does not require open exposure. In such cases, limited incision to the rectus sheath may be made: one to access the periumbilical perforators and a separate incision to access the pedicle near its origin on the external iliac artery. This incision may then be made in a muscle-splitting fashion, in the line of external oblique fibers. This approach may reduce damage to the anterior rectus sheath, and may contribute to improving donor site morbidity. (c) 2009 Wiley-Liss, Inc. Microsurgery, 2009.