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Superficial Thinning of the DIEP Flap: A Safe Option to Achieve an Aesthetic Reconstructed Breast in the Obese Patient. Plast Reconstr Surg 2021; 148:715e-719e. [PMID: 34705771 DOI: 10.1097/prs.0000000000008481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Abdominal flap-based breast reconstruction is challenging in the overweight and obese population not only because of increased donor-site complications, but also because excessive flap thickness makes inset cumbersome, requiring thinning and remodeling that frequently result in aesthetically poor outcomes. METHODS The authors started by studying 10 deep inferior epigastric artery perforator flaps with angiographic computed tomography. Then, they prospectively performed 21 breast reconstructions using a superficial thinning technique reliant on a constant suprafascial vessel as the pedicle for the remaining deep fat and compared the rate of complications with their previous experience using traditional flap thinning techniques. RESULTS All samples studied showed a suprafascial division of the main perforator. Two constant branches were identified, one coursing over the Scarpa fascia and displaying a robust network of linking vessels with the subcutaneous and subdermal plexuses. That anatomical insight was used to develop a flap-thinning technique tested on 21 consecutive high-body mass index patients. A 7-year retrospective analysis (n = 164) showed no significant correlation between body mass index and incidence of complications except for a long-term upper pole step deformity that was associated with increasing body mass index (p = 0.001). No statistically significant difference in complications was found comparing high-body mass index patients from the retrospective group (n = 72) with the superficial thinning group, but a highly suggestive difference (p = 0.061) was found regarding the avoidance of the step deformity using the superficial thinning technique. CONCLUSION The presence of a constant suprafascial perforator branch makes superficial DIEP thinning a safe technique that facilitates inset and improves the reconstructed breast contour of obese patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Destination Design msTRAM: For Greater Reconstructive Certainty. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3704. [PMID: 34422522 PMCID: PMC8376307 DOI: 10.1097/gox.0000000000003704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/27/2021] [Indexed: 12/01/2022]
Abstract
Performing delayed reconstruction to a unilateral breast while simultaneously performing a balancing procedure on the contralateral side can be the most difficult situation to achieve symmetry. We present here a novel approach to free TRAM-based breast reconstruction using reverse planning and subunit principles with simultaneous balancing reduction mastopexy and immediate nipple reconstruction.
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Leaving the perfusion zones? Individualized flap design in 100 free DIEP and ms-TRAM flaps for autologous breast reconstruction using indocyanine green angiography. J Plast Reconstr Aesthet Surg 2021; 75:52-60. [PMID: 34511387 DOI: 10.1016/j.bjps.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 06/01/2021] [Accepted: 08/12/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND There is still no consensus regarding the ideal zoning in abdominal-based autologous breast reconstruction using free DIEP or ms-TRAM flaps. In particular, the perfusion pattern of the flap according to the number of perforators used and their location remains controversial. In this study, the perfusion of free DIEP and ms-TRAM flaps is assessed intraoperatively and analyzed with regard to different perfusion patterns. METHODS A retrospective analysis of 100 free flaps for breast reconstruction was performed. Following complete flap harvest, we used indocyanine green angiography for perfusion analysis. By applying two different contour levels, DIEP flaps with lateral or medial perforators and ms-TRAM flaps were assessed for their respective perfusion patterns. RESULTS No statistically significant differences were found in the size of the perfusion area between the different flap types when applying the contour level of 20% (p >0.05). For the contour level of 30%, however, statistically significant differences were found between DIEP flaps with medially or laterally located perforators (p = 0.038). Laterally or medially located perforators in DIEP flaps showed no significant differences in their ability to cross the midline (contour level 20%, p = 0.068; contour level 30%, p = 0.058). CONCLUSION Considering the variability of the perfusion of the abdominal wall and the high sensitivity of indocyanine green angiography for their detection, the abdominal zonings play a minor role. By using intraoperative indocyanine green angiography, a precise and patient-specific free flap surgery for autologous breast reconstruction is possible independent of perforator location.
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Palve JS, Luukkaala TH, Kääriäinen MT. Necrosis or Flap Loss After Deep Inferior Epigastric Perforator Reconstruction: Impact of Perforators and Recipient Vessels. JOURNAL OF RECONSTRUCTIVE MICROSURGERY OPEN 2021. [DOI: 10.1055/s-0041-1729638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Background The aim of this study is to analyze the impact of the number and location of perforators harvested and the recipient vessels used on deep inferior epigastric perforator (DIEP) flap survival and the occurrence of flap necrosis requiring re-operation.
Patients and Methods Four hundred and seventy-one DIEP flap reconstructions, performed between January 2008 and December 2019, were retrospectively analyzed.
Results Flap necrosis requiring re-operation was observed in 40 (9%) of flaps and total flap loss rate was 1% (n = 6). No significant differences were observed between internal mammary vessels (IMV, n = 287, 61%) and thoracodorsal vessels (TDV, n = 184, 39%) regarding postoperative re-anastomosis (p = 0.529) or flap survival (p = 0.646). Intraoperative conversion from IMV to TDV was performed on 64 (14%) patients. TDV were more commonly associated with problems in preparation of the vessels than IMV (p < 0.001). Second vein anastomosis was performed on 18 (4%) patients. In total, 81 flaps (17%) had one perforator, 165 (35%) had two, 218 (46%) had three to five, and 7 (2%) had more than five perforators. Flaps with three to five perforators were more commonly associated with flap necrosis (p < 0.001) than flaps with one or two perforators. Independent factors associated with necrosis were body mass index (BMI) > 30 (odds ratio [OR]: 2.28; 95% confidence interval: 1.06–4.91, p = 0.035) and perforator/s located on the lateral row (OR: 3.08, 95% CI 1.29–7.33, p = 0.011).
Conclusion We conclude that the occurrence of flap necrosis requiring re-operation may be higher in DIEP flaps with more than two perforators or perforator/s located on the lateral row and in obese patients. Neither the recipient vessels used nor the number of perforators harvested had any impact on the flap survival rate.
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Affiliation(s)
- Johanna S. Palve
- Department of Plastic Surgery, Tampere University, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere, Finland
| | - Tiina H. Luukkaala
- Research, Development and Innovation Center, Tampere University Hospital and Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Minna T. Kääriäinen
- Department of Plastic Surgery, Tampere University, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere, Finland
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Rezoning Free Muscle-Sparing Transverse Rectus Abdominis Myocutaneous Flaps Based on Perforasome Groupings and a New Understanding of the Vascular Architecture of the Deep Inferior Epigastric Artery-Based Flaps. Ann Plast Surg 2020; 83:e59-e67. [PMID: 31232810 DOI: 10.1097/sap.0000000000001859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND We compare the vascular territory of free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps, deep inferior epigastric perforator (DIEP) flaps, and crossover anastomosis (CA) flaps using intraoperative ex vivo angiography. We also use ex vivo angiography to analyze the vascular architecture of the MS-TRAM flap. METHODS Our study includes 84 lower abdominal free flaps: MS-TRAM, DIEP-1 (1 perforator), DIEP-2 (2 perforators), and CA. We compare the arterial perfusion area and vascular territory pattern in each group. We also analyze the vascular architecture in MS-TRAM flaps and determine the number and location of their dominant perforators and the direction of the axial arteries connecting them. RESULTS The CA's arterial perfusion area is the largest, and the DIEP-1's, the smallest of our groups; there is no statistically significant difference between MS-TRAM and DIEP-2. In all groups, average arterial perfusion area in the vascular pedicle's ipsilateral side is larger than in its contralateral side. The MS-TRAM and DIEP-2 flaps have homologous perfusion patterns and the same arterial perfusion areas. The DIEP-1 perfusion pattern varies with perforator location. Ex vivo angiograms show the MS-TRAM flap's axial arteries heading laterally to be larger and longer than those heading medially. CONCLUSIONS Two dominant perforators are preferable in DIEP flap breast reconstruction. Lateral perforators play a more important role in flap perfusion than do medial ones. Crossover anastomosis is an effective technology for increasing arterial perfusion areas. Our rezoning shows which areas are better for surgery and which have a high risk of complications-valuable information for a surgeon designing a flap for breast reconstruction.
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Invited Discussion on: Fat Necrosis After DIEP Flap Breast Reconstruction: A Review of Perfusion-Related Causes. Aesthetic Plast Surg 2020; 44:1462-1465. [PMID: 32577804 DOI: 10.1007/s00266-020-01841-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 06/14/2020] [Indexed: 10/24/2022]
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Estimation of Contralateral Perfusion in the DIEP Flap by Scoring the Midline-Crossing Vessels in Computed Tomographic Angiography. Plast Reconstr Surg 2020; 145:697e-705e. [PMID: 32221198 DOI: 10.1097/prs.0000000000006684] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In deep inferior epigastric perforator flap surgery, the amount of perfusion achievable in the contralateral side over a midline is unclear. Predicting contralateral perfusion preoperatively using computed tomographic angiography will allow efficient breast reconstruction with decreased complications. The authors used computed tomographic angiography to determine whether contralateral perfusion is related to blood vessel status across the midline. METHODS Preoperative computed tomographic angiography scans and intraoperative perfusion in patients who underwent breast reconstruction with a deep inferior epigastric perforator flap between January of 2018 and July of 2018 were checked prospectively. A vessel scoring system was prepared according to vessel density across the flap midline on the scan (grade 0, no visible vessels; grade 1, visible vessels with disconnection or could not be judged as grade 0 or 2; grade 2, definite vessels). Intraoperative flap perfusion was confirmed with indocyanine green angiography. Postoperative fat necrosis was analyzed using ultrasonography. RESULTS Ninety-four patients were analyzed. Mean maximal contralateral perfusion length was as follows: grade 0, 7.50 ± 1.89 cm; grade 1, 7.93 ± 2.01 cm; and grade 2, 10.14 ± 2.29 cm. Grade 2 had a statistically significantly greater contralateral perfusion length than grade 0 (p < 0.001) and grade 1 (p < 0.001). Fat necrosis occurred in 27.3 percent (grade 0), 19.1 percent (grade 1), and 8 percent (grade 2), which was statistically significant (p = 0.035). CONCLUSIONS A definite vessel connection across the midline (as in grade 2) in preoperative computed tomographic angiography indicates that contralateral perfusion will be sufficiently achieved. This vessel scoring system would be helpful in predicting flap perfusion and planning the surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, IV.
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Sui X, Cao Z, Pang X, He J, Wu P, Zhou Z, Yu F, Tang JY. Reconstruction of moderate-sized soft tissue defects in foot and ankle in children: Free deep inferior epigastric artery perforator flap versus circumflex scapular artery perforator flap. J Plast Reconstr Aesthet Surg 2019; 72:1494-1502. [PMID: 31221596 DOI: 10.1016/j.bjps.2019.05.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 04/24/2019] [Accepted: 05/15/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND This retrospective study was conducted to compare the outcomes between the free deep inferior epigastric artery perforator (DIEP) flap and the circumflex scapular artery perforator (CSAP) flap in reconstruction of moderate-sized soft tissue defects in the foot and ankle of pediatric patients. PATIENTS AND METHODS From January 2004 to December 2016, 42 patients, ranging from 2 to 13 years old, underwent foot and ankle reconstruction, with a free DIEP flap in 21 cases and a free CSAP flap in the other 21cases. RESULTS All the flaps survived. No marked differences were observed in the demographics, flap size, recipient vessels, and overall early or late complication rate (p > 0.05). The CSAP group had a shorter operation time (134.3 ± 25 min vs. 202.4 ± 24.3 min, p < 0.05) and flap harvest time (29.7 ± 8.1 min vs. 52.2 ± 9.8 min, p < 0.05) than the DIEP group had. In long-term follow-up, the CSAP group showed a lower fat hyperplasia rate (14% vs. 52%, p < 0.05) and better cosmetic outcomes than the DIEP group did (p < 0.05). The functional outcomes had no marked differences (p > 0.05). CONCLUSIONS The DIEP flap and the CSAP flap are both good options for foot and ankle reconstruction of moderate-sized defects in pediatric patients. The CSAP flap has a shorter operation time and flap harvest time, a lower fat hyperplasia rate, and better long-term cosmetic outcomes than the DIEP flap does.
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Affiliation(s)
- Xinlei Sui
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China
| | - Zheming Cao
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China
| | - Xiaoyang Pang
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China
| | - Jiqiang He
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China
| | - Panfeng Wu
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China
| | - Zhengbing Zhou
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China
| | - Fang Yu
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China
| | - Ju-Yu Tang
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, No. 87 Xiang Ya Road, Changsha, Hunan 410008, China.
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Wang L, Wu H, Yan H, Dong X, He Z, Ding J, Gao W. Effect of a nondominant perforator on multiterritory perforator flap survival in rats. Microsurgery 2019; 39:441-446. [PMID: 31112634 DOI: 10.1002/micr.30471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 04/22/2019] [Accepted: 05/10/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND During flap surgery, the dominant perforator is usually selected as the pedicle. This study investigated the effect of a nondominant perforator on multiterritory perforator flap survival. METHODS The deep circumflex iliac artery perforator flap (DCIA flap) and intercostal artery perforator flap (ICA flap) were performed (n = 12). Only the pedicle was different between the two flaps. The DCIA flap was based on the right and peripheral DCIA with three dynamic and two potential perforasomes. The ICA flap was based on the right and central ICA with five dynamic perforasomes. All adjacent perforators were ligated except the pedicle. On postoperative day 7, flap viability, angiography findings, and perfusion were compared. RESULTS Even though the diameter of DCIA (mm) was larger than that of ICA (0.49 ± 0.03 vs. 0.4 ± 0.04; p < .05), the ICA flap survival rate (%) was higher than that of DCIA flap (99.5 ± 0.7 vs. 83.8 ± 3.9; p < .001). Based on a dominant perforator, a necrotic area was observed in the potential perforasomes of the DCIA flap. The choke vessels between the anatomical and dynamic perforasomes dilated postoperatively in the two flaps, whereas the others did not. The perfusion (PU) differences between the DCIA and ICA flaps in the dynamic perforasomes were nonsignificant (average, 342.4 ± 9.1 vs. 347.3 ± 7.3; p > .05). CONCLUSION Increasing the number of dynamic perforasomes had no effect on flap survival, even based on a nondominant perforator. And the pedicle position affected flap survival.
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Affiliation(s)
- Long Wang
- Department of Hand and Plastic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University. The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Hongqiang Wu
- Department of Hand and Plastic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University. The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Hede Yan
- Department of Hand and Plastic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University. The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Xiaoming Dong
- Department of Hand and Plastic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University. The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Zhiling He
- Department of Hand Surgery, The 94th Hospital of the Chinese People's Liberation Army, Nanchang, China
| | - Jian Ding
- Department of Hand and Plastic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University. The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Weiyang Gao
- Department of Hand and Plastic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University. The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
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In-Vivo Quantitative Mapping of the Perforasomes of Deep Inferior Epigastric Artery Perforators. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1960. [PMID: 30534500 PMCID: PMC6250480 DOI: 10.1097/gox.0000000000001960] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 08/08/2018] [Indexed: 11/26/2022]
Abstract
Background There is limited understanding of anatomy of perforator angiosomes, or "perforasomes," of the deep inferior epigastric artery (DIEA). A perforasome is defined as the territory perfused by a single perforator vessel of a named artery, such as the DIEA. Given the clinical significance of this anatomical concept in microsurgical breast reconstruction, this study is a quantitative investigation of DIEA perforasome characteristics and patterns associated with perforasome size, perforator caliber, location and branching, using computed tomographic (CT) angiography. Methods Twenty abdominal arterial-phase CT angiograms were analyzed in 3 dimensions using software (Horos). DIEA perforasomes were mapped, yielding data on 40 medial-row and 40 lateral-row perforasomes. Perforator branch extents and number were measured using 3-dimensional multi-planar reconstruction, and perforator caliber on axial slices. Results Perforasomes exhibited eccentric branching distributions in horizontal and vertical axes, that is, a majority of perforators were not centrally located within their perforasomes. Lateral-row perforasomes displayed greater horizontal eccentricity than medial-row. There was a positive correlation between perforator caliber and perforasome size. Medial-row perforators had more branches and larger caliber than lateral-row. Conclusions This is the first article to quantify relationships between perforators and their territories of supply in vivo, augmenting current understanding of perforasome theory. DIEA perforasomes can be readily visualized and mapped with CT angiography, which may enable effective preoperative flap planning in DIEA perforator flap breast reconstruction. Future investigation may highlight the importance of this information in improving surgical outcomes, including flap survival and fat necrosis reduction, through careful, perforasome-based flap design.
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Marquez MDLP, Fernandez-Riera R, Cardona HV, Flores JMR. Immediate implant replacement with DIEP flap: a single-stage salvage option in failed implant-based breast reconstruction. World J Surg Oncol 2018; 16:80. [PMID: 29665804 PMCID: PMC5905049 DOI: 10.1186/s12957-018-1387-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 04/10/2018] [Indexed: 11/23/2022] Open
Abstract
Background Implant-based immediate breast reconstruction after skin-sparing mastectomy has shown a significant improvement in patients’ quality of life, making the procedure steadily more popular year after year. However, this technique has a high morbidity rate, including skin necrosis and implant exposure. Methods A retrospective review of a prospectively held database for autologous breast reconstruction in our institution of the last 5 years found eight cases with exposed implants after nipple-sparing mastectomy and immediate reconstruction. A single-stage procedure consisting on implant removal and immediate replacement with a deepithelialized DIEP flap was performed in all cases (10 DIEP flaps). Results All flaps were successful. Patients’ mean age was 45 years old. Three patients developed seroma (5, 7, and 14 days after surgery, respectively). No infections were detected in up to 24 months of follow-up. Conclusions Nipple-sparing mastectomy with immediate implant-based reconstruction is considered oncologically safe. However, it has a high rate of complications that could require implant removal. Immediate free flap reconstruction is a feasible and safe option to replace the missing volume with low risk of complications that result in a soft and natural-shaped breast.
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Affiliation(s)
- Miguel De La Parra Marquez
- Division of Plastic and Reconstructive Surgery, Mexican Institute of Social Security (IMSS), No. 21 Pino Suárez y 15 de Mayo, Av. Hidalgo 2480 pte, col. Obispado. C.p.64060. Cons. 212, Monterrey Nuevo León, Mexico.
| | - Ricardo Fernandez-Riera
- Department of Plastic and Reconstructive Surgery, Hospital General Dr. Ruben Leñero, Plan de San Luis esq Salvador Díaz Mirón SN, Col. Santo Tomás. Deleg. Miguel Hidalgo. Cp. 11340. CDMX, Mexico City, Mexico
| | - Hector Vela Cardona
- Division of Plastic and Reconstructive Surgery, Mexican Institute of Social Security (IMSS), No. 21 Pino Suárez y 15 de Mayo, Av. Hidalgo 2480 pte, col. Obispado. C.p.64060. Cons. 212, Monterrey Nuevo León, Mexico
| | - Jesus María Rangel Flores
- Division of Plastic and Reconstructive Surgery, Mexican Institute of Social Security (IMSS), No. 21 Pino Suárez y 15 de Mayo, Av. Hidalgo 2480 pte, col. Obispado. C.p.64060. Cons. 212, Monterrey Nuevo León, Mexico
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Galli A, Berrino P, Rainero ML, Santi P. Transposition of Myocutaneous Flaps in Breast Reconstruction following Radical Mastectomy: Latissimus Dorsi Vs. Rectus Abdominis Flap. TUMORI JOURNAL 2018; 74:195-200. [PMID: 3368974 DOI: 10.1177/030089168807400213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We evaluated two homogeneous groups of patients (20 each) who had undergone radical mastectomy and who underwent breast reconstruction in our department by transposition of a latissimus dorsi or of a rectus abdominis myocutaneous flap. The results achieved were very similar (in terms of postoperative hospitalization, complication rate, thoracic symmetry). We therefore believe that both these techniques should be considered as first choice in breast reconstruction following radical mastectomy. However, from the aesthetic viewpoint, the use of the latissimus dorsi is best suited to tall, slim patients, whereas the rectus abdominis allows us to obtain better results in patients of sturdy build, with a voluminous residual breast.
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Affiliation(s)
- A Galli
- Department of Reconstructive Plastic Surgery, National Institute for Cancer Research, Genova
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Lee KT, Mun GH. Perfusion of the diep flaps: A systematic review with meta-analysis. Microsurgery 2016; 38:98-108. [DOI: 10.1002/micr.30024] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 12/06/2015] [Accepted: 12/22/2015] [Indexed: 11/12/2022]
Affiliation(s)
- Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center; Sungkyunkwan University School of Medicine; Gangnam-Gu, Seoul 135-710 South Korea
| | - Goo-Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center; Sungkyunkwan University School of Medicine; Gangnam-Gu, Seoul 135-710 South Korea
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Microdialysis as a Method of Investigating Factors Controlling Microcirculation Following Free Flap Transfer. Plast Reconstr Surg 2015. [DOI: 10.1097/01.prs.0000472369.95209.1e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mohan AT, Saint-Cyr M. Anatomic and physiological fundamentals for autologous breast reconstruction. Gland Surg 2015; 4:116-33. [PMID: 26005644 DOI: 10.3978/j.issn.2227-684x.2015.04.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 03/18/2015] [Indexed: 11/14/2022]
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.
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Affiliation(s)
- Anita T Mohan
- 1 Department of Plastic Surgery, Mayo Clinic, Rochester, MN, USA ; 2 Restoration of Appearance and Function Trust, RAFT, UK
| | - Michel Saint-Cyr
- 1 Department of Plastic Surgery, Mayo Clinic, Rochester, MN, USA ; 2 Restoration of Appearance and Function Trust, RAFT, UK
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Kotti B. Optimizing the pedicled rectus abdominis flap: revised designs and vascular classification for safer procedures. Aesthetic Plast Surg 2014; 38:387-94. [PMID: 24515265 DOI: 10.1007/s00266-014-0273-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 12/30/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND The rectus abdominis myocutaneous (RAM) flap is one of the most commonly used flaps in reconstructive surgery, and many designs have been published. The transverse rectus abdominis myocutaneous (TRAM), vertical rectus abdominis myocutaneous (VRAM), and oblique designs (ORAM) are the most common. The most frequent complication with these flaps is partial flap necrosis. We describe a new vascular zoning method and a revised classification of abdominal wall perfusion that is applicable when harvesting pedicled TRAM flaps to make them more secure. METHODS From February 2009 to February 2013, we performed 70 pedicled RAM flaps in 68 patients for breast reconstruction (79%) as well as pelvic and inguinal reconstruction after bowel and gynecologic tumor resection. Clinical data about cutaneous vascularization of the flaps along with before and after photos were prospectively collected and analyzed, and results were evaluated retrospectively. We collected observations on partial flap necrosis, reviewed the literature, and made design modifications to exclude doubtful vascular territories. RESULTS Of the total number of flaps, 59 were TRAMs, 7 were VRAMs, and 1 was an ORAM flap. Three combined horizontal and vertical flaps, or what we call TV RAM flaps, were performed. No flap-related complications were observed with VRAM, TV RAM, or ORAM flaps. Three instances of partial necrosis (in the same vascular territory) occurred with TRAM flaps; as a result, we changed our approach to these flaps and examined alternatives to the classical vascular zoning. CONCLUSION We discussed abdominal skin perfusion in accordance with the literature and based on our experience with harvesting pedicled RAM flaps. We proposed safer skin paddles made possible by adopting a revised vascular classification. LEVEL OF EVIDENCE V 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 .
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Tang J, Fang T, Song D, Liang J, Yu F, Wang C. Free deep inferior epigastric artery perforator flap for reconstruction of soft-tissue defects in extremities of children. Microsurgery 2013; 33:612-9. [PMID: 23843221 DOI: 10.1002/micr.22127] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 03/25/2013] [Accepted: 03/29/2013] [Indexed: 11/08/2022]
Affiliation(s)
- Juyu Tang
- Department of Hand and Microsurgery; Xiangya Hospital of Central South University; Changsha China
| | - Taolin Fang
- Department of Orthopaedic Surgery; Zhongshan Hospital, Fudan University; Shanghai China
- Department of Plastic Surgery; University of Mississippi Medical Center; Jackson, MS
| | - Dajiang Song
- Department of Hand and Microsurgery; Xiangya Hospital of Central South University; Changsha China
| | - Jieyu Liang
- Department of Hand and Microsurgery; Xiangya Hospital of Central South University; Changsha China
| | - Fang Yu
- Department of Hand and Microsurgery; Xiangya Hospital of Central South University; Changsha China
| | - Congyang Wang
- Department of Hand and Microsurgery; Xiangya Hospital of Central South University; Changsha China
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Rothenberger J, Amr A, Schiefer J, Schaller HE, Rahmanian-Schwarz A. A quantitative analysis of the venous outflow of the deep inferior epigastric flap (DIEP) based on the perforator veins and the efficiency of superficial inferior epigastric vein (SIEV) supercharging. J Plast Reconstr Aesthet Surg 2013; 66:67-72. [DOI: 10.1016/j.bjps.2012.08.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Accepted: 08/16/2012] [Indexed: 11/16/2022]
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Casal D, Fradinho N, Ramos L, Ferreira J, Varanda A, Diogo C, Baltazar J, Fernandes M, Correia C, Almeida MA. Abdominoplasty and thoraco-epigastric flaps for large anterior trunk defects after dermatofibrosarcoma protuberans wide resection: Two illustrative cases. Int J Surg Case Rep 2012; 4:134-8. [PMID: 23219975 DOI: 10.1016/j.ijscr.2012.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 10/04/2012] [Accepted: 11/03/2012] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Excision of large dermatofibrosarcoma protuberans in the anterior aspect of the trunk often results in large surgical defects that frequently dictate the need for microsurgical reconstruction. However, this option is not always available. PRESENTATION OF CASE The authors describe two patients with very large anterior trunk dermatofibrosarcoma protuberans: one in the epigastric region and the other in the hypogastric region. In the patient with the hypogastric tumor, a classical abdominoplasty flap associated with umbilical transposition was used to cover the skin defect after muscle and fascial plication, and placement of a polypropylene mesh. In the patient with the epigastric tumor, a synthetic mesh was also placed, and the skin and subcutaneous defect was reconstructed with a reverse abdominoplasty flap and two thoraco-epigastric flaps. In both cases, complete closure was possible without immediate or late complications. DISCUSSION The local options described in this paper present several potential advantages compared to microsurgical reconstruction, namely they are easier and faster to perform and teach; they provide a good skin color and texture match; they are not associated with distant donor site morbidity; follow-up is usually less cumbersome; the post-operative hospital stay tends to be shorter; they are less costly; they are less prone to complete failure. CONCLUSION The authors believe that these two patients clearly show that local flaps, although frequently neglected, continue to be valid options for reconstructing large anterior trunk defects, even in the current era of microsurgery enthusiasm.
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Erić M, Ravnik D, Žic R, Dragnić N, Krivokuća D, Lekšan I, Hribernik M. Deep inferior epigastric perforator flap: An anatomical study of the perforators and local vascular differences. Microsurgery 2011; 32:43-9. [DOI: 10.1002/micr.20944] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Revised: 06/22/2011] [Accepted: 06/30/2011] [Indexed: 11/09/2022]
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Monitoring Microcirculatory Changes in the Deep Inferior Epigastric Artery Perforator Flap With Laser Doppler Perfusion Imaging. Ann Plast Surg 2011; 67:139-42. [DOI: 10.1097/sap.0b013e3181f3e39b] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tindholdt TT, Saidian S, Tønseth KA. Microcirculatory evaluation of deep inferior epigastric artery perforator flaps with laser Doppler perfusion imaging in breast reconstruction. J Plast Surg Hand Surg 2011; 45:143-7. [DOI: 10.3109/2000656x.2011.579721] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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A Combined Anatomical and Clinical Study for Quantitative Analysis of the Microcirculation in the Classic Perfusion Zones of the Deep Inferior Epigastric Artery Perforator Flap. Plast Reconstr Surg 2011; 127:505-513. [DOI: 10.1097/prs.0b013e3181fed543] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Hamza F, Yousif J, Kotti B. La reconstruction mammaire par TRAM libre en chirurgie libérale : à propos de 20 cas consécutifs. ANN CHIR PLAST ESTH 2010; 55:524-30. [DOI: 10.1016/j.anplas.2009.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Accepted: 11/07/2009] [Indexed: 11/28/2022]
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Rozen WM, Ashton MW, Le Roux CM, Pan WR, Corlett RJ. The perforator angiosome: a new concept in the design of deep inferior epigastric artery perforator flaps for breast reconstruction. Microsurgery 2010; 30:1-7. [PMID: 19582823 DOI: 10.1002/micr.20684] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The previously described "perfusion zones" of the abdominal wall vasculature are based on filling of the deep inferior epigastric artery (DIEA) and all its branches simultaneously. With the advent of the DIEA perforator flap, only a single or several perforators are included in supply to the flap. As such, a new model for abdominal wall perfusion has become necessary. The concept of a "perforator angiosome" is thus explored. METHODS A clinical and cadaveric study of 155 abdominal walls was undertaken. This comprised the use of 10 whole, unembalmed cadaveric abdominal walls for angiographic studies, and 145 abdominal wall computed tomographic angiograms (CTAs) in patients undergoing preoperative imaging of the abdominal wall vasculature. The evaluation of the subcutaneous branching pattern and zone of perfusion of individual DIEA perforators was explored, particularly exploring differences between medial and lateral row perforators. RESULTS Fundamental differences exist between medial row and lateral row perforators, with medial row perforators larger (1.3 mm vs. 1 mm) and more likely to ramify in the subcutaneous fat toward the contralateral hemiabdomen (98% of cases vs. 2% of cases). A model for the perfusion of the abdominal wall based on a single perforator is presented. CONCLUSION The "perforator angiosome" is dependent on perforator location, and can mapped individually with the use of preoperative imaging.
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Affiliation(s)
- Warren M Rozen
- Department of Anatomy and Cell Biology, The University of Melbourne, Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Parkville, Victoria, 3050, Australia.
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Schrey A, Kinnunen I, Kalliokoski K, Minn H, Grénman R, Vahlberg T, Niemi T, Suominen E, Aitasalo K. Perfusion in free breast reconstruction flap zones assessed with positron emission tomography. Microsurgery 2010; 30:430-6. [DOI: 10.1002/micr.20770] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Perforasomes of the DIEP Flap: Vascular Anatomy of the Lateral versus Medial Row Perforators and Clinical Implications. Plast Reconstr Surg 2010; 125:772-82. [DOI: 10.1097/prs.0b013e3181cb63e0] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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30
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Breast reconstruction using tissue expander and TRAM flap with vascular enhancement procedures. J Plast Reconstr Aesthet Surg 2009; 62:1148-53. [DOI: 10.1016/j.bjps.2008.03.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Revised: 03/04/2008] [Accepted: 03/08/2008] [Indexed: 10/21/2022]
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Three- and Four-Dimensional Computed Tomography Angiographic Studies of Commonly Used Abdominal Flaps in Breast Reconstruction. Plast Reconstr Surg 2009; 124:18-27. [DOI: 10.1097/prs.0b013e3181aa0db8] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Arterial and Venous Anatomies of the Deep Inferior Epigastric Perforator and Superficial Inferior Epigastric Artery Flaps. Plast Reconstr Surg 2008; 121:1909-1919. [DOI: 10.1097/prs.0b013e31817151f8] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rozen WM, Ashton MW, Taylor GI. Reviewing the vascular supply of the anterior abdominal wall: Redefining anatomy for increasingly refined surgery. Clin Anat 2008; 21:89-98. [PMID: 18189276 DOI: 10.1002/ca.20585] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- W M Rozen
- Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, University of Melbourne, Parkville, Victoria, Australia.
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Lipa JE. Breast Reconstruction with Free Flaps from the Abdominal Donor Site—TRAM, DIEAP, and SIEA Flaps. Clin Plast Surg 2007; 34:105-21; abstract vii. [PMID: 17307075 DOI: 10.1016/j.cps.2006.11.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Multiple types of free flap can be elevated from the lower abdominal region for use in breast reconstruction. These include the free transverse rectus abdominis myocutaneous flap, the deep inferior epigastric artery perforator flap, and the superficial inferior epigastric artery flap. This sequence of flaps represents an evolution in the protection of the donor site. However, the decision as to which flap may be most appropriate for an individual patient is complex. This article serves to review pertinent surgical anatomy, preoperative planning, intraoperative decision making in flap elevation, and reported outcomes.
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Affiliation(s)
- Joan E Lipa
- Division of Plastic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Abstract
Obesity presents a risk factor for flap-related complications in autologous tissue breast reconstruction. In this study, an animal model was developed to examine this phenomenon. Abdominal flaps based on a superficial inferior epigastric pedicle were elevated in an experimental group of obese Zucker (fa/fa) rats (n = 8; mean weight, 413 g) and in their lean littermates (n = 9; mean weight, 276 g). Flap tissue was harvested from a subset of both groups for baseline characterization, including histology, and assays for ATP and oxidative phosphorylation uncoupler, UCP-2. Flaps were then evaluated for survival by planimetry at 4 and 7 days postprocedure. Flap survival 7 days postoperatively was reduced in obese (42.0% ± 8.6%) versus lean (70.3% ± 6.7%) rats ( P < 0.05). At baseline, flap tissue of obese animals had decreased ATP content relative to lean counterparts (0.12 ± 0.12 nM/μg vs 0.36 ± 0.23 nM/μg protein, P < 0.05), whereas UCP2 mRNA was higher in obese flap tissue versus lean. Reduced viability of obese flaps may be attributable to decreased baseline energy stores due to oxidative phosphorylation uncoupling by UCP-2. This study is the first to introduce a promising animal model for examining the effect of obesity on increased flap-related complications in breast reconstruction using autologous tissue.
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Affiliation(s)
- Ronald E. Reyna
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Mark E. Feldmann
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Zachary P. Evans
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina
| | - O. Seung-Jun
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Kenneth D. Chavin
- Department of Surgery, Division of Transplant Surgery, Medical University of South Carolina, Charleston, South Carolina
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Schipper J, Klenzner T, Arapakis I, Maier W, Horch R. [The transverse rectus abdominis muscle (TRAM) flap. A "second defensive line" in microvascular reconstructions of defects in the head and neck area]. HNO 2006; 54:20-4. [PMID: 15947900 DOI: 10.1007/s00106-005-1286-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The microvascular anastomosed transverse rectus abdominis muscle (TRAM) island flap has been successfully used in plastic surgery for more than 10 years. In reconstructive head and neck surgery, however, it is not yet established. METHOD We analysed the preparation and anatomical variation in TRAM flaps in an examination of eight cadavers. In a clinical case with complete reconstruction of the nose after nasal ablation and complete loss of a radial lower forearm flap that had been transplanted previously due to a recurrent tumor, the possibility of forming and modeling a TRAM flap is demonstrated. RESULTS The flap vessels of the TRAM are comparable to the radial forearm flap, and the donor site may be primarily closed. The TRAM proved to be a suitable alternative to close lesions of the head and neck area in selected cases. The myocutaneous TRAM is bulkier than the fascio-cutaneous radial forearm flap. The subcutaneous abdominal fat of the TRAM can be reduced in relation to the vascular distribution of the perforator vessels. If the subcutaneous fat of the flap is reduced, the flap can be shaped and formed well. In the described case, it was used to close the lesion after ablation of the nose and middle face. CONCLUSION The risk of an iatrogenic lesion of the peritoneal fascia or postsurgical herniation of the abdominal wall is low if several surgical prerequisites are taken into consideration. The myocutaneous TRAM will not replace the fascio-cutaneous radial forearm flap in microvascular head and neck surgery, but the large diameter of the donor vessels and the highly vascularized flap tissue makes it an alternative as a second line procedure in cases of unfavorable wound conditions.
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Affiliation(s)
- J Schipper
- Universitätsklinik für Hals-, Nasen- und Ohrenheilkunde und Poliklinik, Universitätsklinikum Freiburg.
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Abstract
BACKGROUND The Hartrampf perfusion zones of the lower abdominal flap are generally accepted. They were empirically based on the clinical impression of the perfusion in the first 16 unipedicled transverse rectus abdominis musculocutaneous flaps and have been uncritically adopted for the free transverse rectus abdominis musculocutaneous and the free deep inferior epigastric perforator (DIEP) flap. Scientific data proving the validity of these perfusion zones do not exist. The objective of this study was to evaluate and quantitatively assess the perfusion zones of the DIEP flap. METHODS In a clinical, prospective study of 15 patients undergoing DIEP flap breast reconstruction, tissue perfusion was intraoperatively assessed using the method of laser-induced fluorescence of indocyanine green. RESULTS Perfusion of zones I, II, and III was seen 25, 41, and 32 seconds, respectively, after injection, and the perfusion index constituted 76, 25, and 47 percent (median) of normal tissue. Perfusion of zone IV was completely absent in five patients (33 percent); in the remaining patients, it was dramatically decreased (5 percent) and occurred with a delay of 67 seconds. CONCLUSIONS On the basis of the results of this study, the Hartrampf concept of a centrally perfused skin ellipse with declining perfusion of its peripheral ends is wrong and should be revised. Instead, one should think of the lower abdominal flap as two halves separated by the midline. The ipsilateral half has an axial pattern of perfusion; the contralateral half shows a random-pattern, individually variable blood supply. Therefore, the classic Hartrampf zones should be rearranged, switching zones II and III.
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Affiliation(s)
- Charlotte Holm
- Department of Plastic, Reconstructive, and Hand Surgery, Klinikum Bogenhausen, Technical University Munich, Munich, Germany.
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Amir A, Silfen R, Hauben DJ. "Apron" flap and re-creation of the inframammary fold following TRAM flap breast reconstruction. Plast Reconstr Surg 2000; 105:1024-30. [PMID: 10724265 DOI: 10.1097/00006534-200003000-00029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To the best of our knowledge, the recreation of an inframammary fold after TRAM flap breast reconstruction has not yet been described. This article offers a technique for the creation of an inframammary fold as a secondary procedure. The technique has been performed thus far in two patients with good aesthetic outcomes and no postoperative complications. It may also be suitable for adding bulk to the TRAM flap, especially in bilateral breast reconstruction, and for other minor chest deformities.
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Affiliation(s)
- A Amir
- Department of Plastic and Reconstructive Surgery, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel.
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Cederna PS, Chang P, Pittet-Cuenod BM, Razaboni RM, Cram AE. The effect of the delay phenomenon on the vascularity of rabbit rectus abdominis muscles. Plast Reconstr Surg 1997; 99:194-205. [PMID: 8982203 DOI: 10.1097/00006534-199701000-00028] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The transverse rectus abdominis muscle (TRAM) flap has become the "gold standard" for autogenous breast tissue reconstruction. Complications are reported in 10 to 40 percent of patients undergoing this procedure, and many are related to soft-tissue necrosis secondary to ischemia. Various methods have been proposed to improve TRAM flap survival, including surgical delay of the flap. The beneficial effects of the delay phenomenon have been well established in laboratory studies and clinical evaluations. Many investigators agree that the delay phenomenon will enhance arterial inflow and venous outflow from the TRAM flap. No study has quantified the changes seen in the rectus abdominis muscle following a delay procedure. In this prospective, controlled, and blinded experiment, we evaluate the effect of a unilateral superficial inferior epigastric and deep inferior epigastric artery and vein ligation on the vascularity of the rectus abdominis muscles in rabbits. Thirty-eight rabbits underwent a left superficial inferior epigastric and deep inferior epigastric pedicle ligation as a delay procedure. The rectus abdominis muscle vasculature was then evaluated by lead oxide microangiography at 0, 5, 10, 15, 21, and 27 days following the delay procedure. Magnification (x 2) was used to count the number of vessels at the periphery of the deep inferior epigastric artery angiosomes in the microangiograms. An increase in the number of vessels from day 0 to day 27 was seen on both the ligated and nonligated sides in all the following: the number of large (> 0.5 mm) "choke" vessels and total number of vessels (all sizes) crossing the abdominal wall midline and the total number of vessels (all sizes) at the medial, superior, and lateral aspects of the right and left deep inferior epigastric artery angiosomes. A statistically significant increase in these vessels was not seen until day 21. The effect of the delay phenomenon was significantly greater on the ligated side compared with the nonligated side. The areas of the rectus abdominis muscles that were relatively more ischemic following left deep inferior epigastric pedicle ligation (medial aspect of the left deep inferior epigastric artery angiosome) showed greater increases in vascularity with the delay procedure than did areas of lesser ischemia (lateral aspect of the right deep inferior epigastric artery angiosome).
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Affiliation(s)
- P S Cederna
- Department of Surgery, University of Iowa College of Medicine, Iowa City, USA
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Ninković M, Anderl H, Hefel L, Schwabegger A, Wechselberger G. Internal mammary vessels: a reliable recipient system for free flaps in breast reconstruction. BRITISH JOURNAL OF PLASTIC SURGERY 1995; 48:533-9. [PMID: 8548152 DOI: 10.1016/0007-1226(95)90040-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In breast reconstruction with a free flap following mastectomy, the recipient vessels most widely used are in the axillary system, which limits flap movement and flexibility in breast shaping. In addition, scarring and fibrosis can make dissection of the vessels difficult. We have performed 22 breast reconstructions using a free transverse rectus abdominis myocutaneous (TRAM) flap anastomosed to the internal mammary (thoracic) vessels. There has been no flap failure. The surgical techniques and the advantages and limitations of the internal mammary system are presented and the internal mammary vessels compared with the axillary vessels as a recipient vascular system.
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Affiliation(s)
- M Ninković
- University Clinic for Plastic and Reconstructive Surgery, Innsbruck, Austria
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Galli A, Raposio E, Santi P. Reconstruction of full-thickness defects of the thoracic wall by myocutaneous flap transfer: latissimus dorsi compared with transverse rectus abdominis. SCANDINAVIAN JOURNAL OF PLASTIC AND RECONSTRUCTIVE SURGERY AND HAND SURGERY 1995; 29:39-43. [PMID: 7597388 DOI: 10.3109/02844319509048421] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Ten patients with primary or recurrent cancer of the chest wall underwent full-thickness resection and immediate reconstruction of the defect by placement of an alloplastic implant and transposition of a latissimus dorsi (n = 5) or transverse rectus abdominis (n = 5) myocutaneous flap. When up to three ribs were removed, these were replaced by a reabsorbable mesh sutured to the residual rib stumps. Larger skeletal defects were stabilized by placement of a permanent mesh or polytetrafluoroethylene (PTFE) sheet. In only one case the PTFE reconstruction was reinforced by metallic implants, but that caused dehiscence of the overlying flap suture, leading to major complications and eventually death. Both the latissimus dorsi and the rectus abdominis myocutaneous flaps were ideally suited to soft tissue reconstruction. There were no appreciable complications concerning viability of the flaps, and the operating time needed for the transposition of the two flaps was similar. The rectus abdominis flap showed a distinct advantage when an absorbable mesh was to be covered, as its superior thickness minimized the risk of creating a 'flail' reconstructed chest wall. This advantage was in part counter-balanced by the more limited arc of rotation compared with the latissimus dorsi flap.
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Affiliation(s)
- A Galli
- Department of Plastic and Reconstructive Surgery, University of Genoa, Genova, Italy
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Marshall DR, Ross DA. A Fleur de Lys modification of the TRAM flap for breast reconstruction. BRITISH JOURNAL OF PLASTIC SURGERY 1994; 47:521-6. [PMID: 7697279 DOI: 10.1016/0007-1226(94)90135-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A major problem of the standard TRAM flap is uncertain vascularity. Many modifications have been made to overcome this problem, but they usually lead to an increase in both the duration and complexity of the operative procedure. The modification described here uses a single muscle pedicle flap, but adds a vertical component comprising the well vascularised tissue above the umbilicus in continuity with the usual horizontal skin flap. This has the advantage of greater volume of available tissue, much improved blood supply, shorter operative time, greater exposure for dissection, a technically more simple procedure, and quicker recovery. The vertical and horizontal skin flaps are approximated as a cone to provide excellent breast projection. All this can be achieved at the cost of a vertical abdominal scar, which is well accepted when explained to patients.
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Affiliation(s)
- D R Marshall
- Division of Plastic Surgery, Monash Medical Centre, Melbourne, Australia
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el-Tamer M, Chaglassian T, Martini N. Resection and debridement of chest-wall tumors and general aspects of reconstruction. Surg Clin North Am 1989; 69:947-64. [PMID: 2675353 DOI: 10.1016/s0039-6109(16)44931-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The main criterion for adequate local control of a chest-wall malignancy remains wide excision. With the available techniques of skeletal and soft-tissue reconstruction, even large lesions can be resected with safe margins. The primary purpose is to achieve a curative resection, although a significant number of symptomatic patients can benefit from palliative resection provided by such procedures. A key element in the success in treating chest-wall tumors is a multidisciplinary approach by all participating physicians, namely the thoracic surgeon, the plastic and reconstructive surgeon, the radiotherapist, and the medical oncologist.
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Affiliation(s)
- M el-Tamer
- Memorial Sloan-Kettering Cancer Center, New York, New York
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Bricout N, Banzet P. Rectus abdominis myocutaneous flap of the lower type in breast reconstruction. SCANDINAVIAN JOURNAL OF PLASTIC AND RECONSTRUCTIVE SURGERY 1986; 20:93-6. [PMID: 2946075 DOI: 10.3109/02844318609006300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A lower rectus abdominis myocutaneous flap has been used in thirteen cases; in twelve patients for breast reconstruction with delay after mammectomy, and in one patient to close a defect due to an extensive mammectomy for cancer recurrence. In our opinion, the main advantages of the lower rectus abdominis myocutaneous flap are the very natural shape and the firmness of the reconstructed breast. The color and thickness of the abdominal skin is also quite similar to that of the chest. The low design of the cutaneous island, as in an abdominoplasty, gives an excellent cosmetic result. There is also enough skin and fat to make a breast implant unnecessary. In corpulent women the ends of the flap have to be resected to avoid partial necrosis. In slim women, the entire cutaneous island can be used. In all cases, repair of the musculo-aponeurotic wall has been performed without any prosthetic material. No foreign material has been used in this reconstruction. No eventration was observed in our patients.
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Lebeau J, Fasano D, Antoine P, Raphaël B, Champetier J, Zarebski M. Anatomical basis of rectus abdominis myo-cutaneous flaps. ANATOMIA CLINICA 1985; 7:219-25. [PMID: 2938609 DOI: 10.1007/bf01784638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The recent development of myo-cutaneous flaps and their use in plastic and reconstructive surgery prompted the authors to have a particular interest in musculo-cutaneous flaps of the rectus abdominis. From their personal studies and from a review of the literature, they consider the anatomical bases for these flaps and the different methods proposed for their construction. Finally they indicate their vast area of application which is essentially related to the wide range over which they can act.
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Dinner MI, Coleman C. Breast reconstruction. Use of autogenous tissue. AORN J 1985; 42:490-6. [PMID: 2932998 DOI: 10.1016/s0001-2092(07)64861-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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50
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Abstract
Postmastectomy reconstruction is an integral part of the rehabilitation of a patient with breast cancer. Four questions are to be answered: Who is a candidate? When should this be performed? What are the goals of a breast reconstruction? How should these be obtained?
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