Free perforator crossover TRAM flap for breast reconstruction

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

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.

What Would Women Choose When Given a Choice in Breast Reconstruction?

Reconstruction after mastectomy is an important milestone for many women treated for breast cancer. However, because many surgeons only offer their preferred method of reconstruction, it is not clear which approach women would choose if offered a genuine choice.

Increasing options in autologous microsurgical breast reconstruction: four free flaps for 'stacked' bilateral breast reconstruction

For autologous breast reconstruction, there are cases where one free flap cannot provide the volume of tissue required, and the concept of 'stacked' bilateral deep inferior epigastric artery (DIEP) flaps was developed, in which hemi-abdominal flaps are raised on each deep inferior epigastric artery (DIEA), and both flaps transferred to the chest. In cases of bilateral breast reconstruction, stacked flaps may be required to achieve volume replacement, however options are not described. We demonstrate the use of stacked free flaps for bilateral breast reconstruction, using one DIEP flap stacked with one transverse upper gracilis (TUG) flap for each side. A 49-year-old woman, with BRCA1 mutation, presented for risk reduction mastectomies. Flap design was planned to achieve maximal projection and primary nipple reconstruction. This was able to be achieved by using the DIEP flap de-epithelialised and completely buried, with the flap orientated with the pedicle on its superficial surface, and the TUG flap lying superficially with its skin paddle used for nipple reconstruction and able to be monitored clinically. There were no flap or donor related complications and good aesthetic outcomes were achieved. This technique offers a further option in microsurgical breast reconstruction for patients in whom there is a paucity of abdominal tissue for reconstruction.

Stacked and bipedicled abdominal free flaps for breast reconstruction: considerations for shaping

BACKGROUND

Stacked and bipedicled abdominal flaps are useful in women who require a large breast reconstruction but have relative paucity of abdominal tissue. A new classification system is described to assist the surgeon in achieving the best possible aesthetic outcome.

METHODS

A retrospective review of 25 consecutive stacked and/or bipedicled deep inferior epigastric perforator (DIEP) flap reconstructions was assessed from 2009 to 2014. Demographic data and key variables were prospectively collected in our breast reconstruction database and an aesthetic classification devised. There are four main subtypes, (I) folded; (II) divided; (III) coned; and (IV) divided and folded. Each of these subtypes can be moulded in a symmetrically or asymmetrically fashion depending on the contralateral breast shape together with distribution and consistency of fat within the abdominal flap.

RESULTS

Of the 25 patients, three-quarter were immediate reconstruction, with an average age of 48 years and a median follow-up of 2 years 10 months. Just over half the patients (57%) had bipedicle flaps with two recipient donor vessels with the remaining 43% had stacked flaps. The most common recipient sites are the thoracodorsal vessels (62%) and intercostal perforators (26%). The average abdominal pannus weight was 610 grams (SD: 320 grams), with a hemi-abdominal weight of 305 grams. Two patients had haematomas, of which one lost their reconstruction. Another patient had a venous congestion flap which was salvaged.

CONCLUSIONS

Bipedicled or stacked abdominal flaps allow the all four zones of the abdominal tissue to be used in unilateral breast reconstruction. The approach of tailoring the abdominal flaps to match the contralateral breast reconstruction is largely an art form. The paper aims to bring some meaningful system to aid the surgeon to achieve the best possible outcome with the components presented to them.

The extraperitoneal laparoscopic TRAM flap delay procedure: an alternative approach

INTRODUCTION

Ligation of the deep inferior epigastric vessels prior to transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction (delay procedure) was introduced to augment vascularity to the island flap through improved superior epigastric flow, thus decreasing flap morbidity. There are various surgical approaches described, including open and laparoscopic approaches, for ligation of inferior epigastric arteries. We describe an extraperitoneal laparoscopic technique (EPLT) and the outcomes of the procedure.

METHODS

All patients who underwent EPLT prior to TRAM flap construction between July 2006 and December 2008 were included in the study. Data were analyzed retrospectively from a prospectively collected database.

RESULTS

The study group included 11 female patients with mean age of 55 years and mean body mass index (BMI) of 34.4 kg/m(2). There were no conversions to open procedure. Ten patients had bilateral ligation of inferior epigastric arteries, and one patient had it only on one side. There were no complications related to the procedure.

CONCLUSION

Extraperitoneal laparoscopic technique as a delay procedure for TRAM flap reconstruction is safe and feasible with no morbidity related to surgery.

A new approach to preexisting vertical midline abdominal scars with crossover DIEP flap breast reconstruction

Breast reconstruction using a free transverse rectus abdominis myocutaneous flap or a deep inferior epigastric perforator (DIEP) flap is a challenge in patients with a vertical midline abdominal scar due to the poor perfusion of the lower abdominal skin ellipse across the midline. In such patients, only one half of the abdominal skin ellipse can be used with certainty, and this limits the amount of tissue available for reconstructing the breast. Two cases of breast reconstruction in patients with a lower midline abdominal scar are presented using the DIEP flap, in which the poor perfusion across the midline scar was overcome by a technique of crossover anastomoses between the two deep inferior epigastric pedicles. Reliable perfusion of the entire lower abdominal skin ellipse was achieved. This crossover anastomoses technique overcomes the poor perfusion imposed by the vertical midline abdominal scar and enables DIEP flap breast reconstruction to be offered to women with midline abdominal scars.

Double-pedicle abdominal perforator free flaps for unilateral breast reconstruction: new horizons in microsurgical tissue transfer to the breast

The DIEAP (deep inferior epigastric artery perforator) flap is a suitable option for breast reconstruction resulting in excellent aesthetic outcome, and minimal donor site morbidity. Contraindications for use of the DIEAP flap may include previous abdominal liposuction and/or surgery, or lack of abdominal tissue. The purpose of this paper is to describe options of using abdominal perforator flaps, based on double-pedicle techniques, despite these contraindications. A retrospective evaluation was carried out on a series of 16 patients who required abdominal double-pedicle free perforator flaps for unilateral breast reconstruction since June 2002. The indications were multiple abdominal scars, previous abdominal liposuction and thin patients in five, three and eight cases, respectively. Preoperative mapping of the vascular network was done using Duplex and/or multi-detector CT scan imaging. Clinical evaluation of medical charts was done regarding patients' characteristics, surgical techniques, ischaemia/total operative time and complications. A clinical evaluation was done on all patients with average follow up of 15 months. Fat necrosis was investigated clinically and by mammogram examination. Different microsurgical techniques were performed to provide enough blood supply to the requested flaps: Perforator (P) to contralateral Deep Inferior Epigastric (DIE) anastomosis (P/DIEAP), in two patients; bilateral DIE vessels (DIEAP/DIEAP) in seven patients; and DIE with SIE (superficial inferior epigastric) vessels in seven patients (DIEAP/SIEA). One pedicle was always anastomosed to the internal mammary vessels. The second pedicle was anastomosed end-to-end to a side branch of the DIE or end-to-side with the DIE pedicle in 13 cases. The thoracodorsal vessels were used as recipient vessels for the second pedicle in three cases. Average operative time was 6h 30min (range 5h 30min-8h). All 16 flaps survived and fat necrosis occurred in one case. The harvesting of perforator free flaps may be contraindicated in some patients, however they are still a feasible option as long as the vessels to the skin are present. Preoperative planning combined with high expertise in microsurgical techniques are the key points in the high success rate in these difficult cases.

Double pedicle deep inferior epigastric perforator/muscle-sparing TRAM flaps for unilateral breast reconstruction

BACKGROUND

Utilizing both rectus abdominis muscles for unilateral breast reconstruction poses significant risks for hernia or bulge formation and decreased abdominal wall strength. We have used the fascial sparing double pedicle deep inferior epigastric artery perforator (DIEP)/DIEP or DIEP/muscle sparing TRAM (MS-TRAM) flap to overcome the disadvantages of the conventional bilateral TRAM or bilateral free TRAM flaps.

METHODS

Between January 1996 and March 2005, 14 double pedicle free DIEP/DIEP or DIEP/MS-TRAM flaps were performed in 14 patients for unilateral breast reconstruction. The abdominal wall was closed without mesh in all cases.

RESULTS

Evaluation of results was conducted through a retrospective chart review and questionnaire. The average hospital stay was 5.4 days. The follow-up period ranged from 9 months to 10 years. There was no flap loss. There were no hernias, although 1 obese patient had lower abdominal wall bulging. Questionnaire was returned by 11 out of 14 patients, with an average rating of 4.5 (1-5), with all but 1 who would recommend it to others. None of the 11 patients had postoperative abdominal pain or back pain, and 9/11 patients returned to daily activities and/or sports. All patients that worked preoperatively returned to work postoperatively.

CONCLUSIONS

Double pedicle free flaps for unilateral breast reconstruction are a safe option when autologous breast reconstruction is desired, but the volume of tissue required to build a breast exceeds the amount that could be transferred on a single pedicle flap. The double pedicle DIEP (DIEP/DIEP) and/or MS-TRAM (DIEP-MS-TRAM) flap offers good symmetric results for unilateral breast reconstruction and can minimize abdominal wall morbidity.

Cutaneous Viability in a Rat Pedicled TRAM Flap Model

BACKGROUND

The transverse rectus abdominis musculocutaneous (TRAM) flap is widely used in breast reconstruction. However, morbidity with its pedicled form has resulted in a high incidence of complications. The authors conducted a study of the pedicled TRAM flap procedure in 35 female Wistar rats based on the left deep inferior epigastric vessel, which was nondominant.

METHODS

In all the rats, the flap was divided into four areas: area 1, the skin on the left rectus abdominis muscle pedicle; area 2, the skin contralateral to the midline, opposite of the left rectus abdominis muscle pedicle; and areas 3 and 4, the skin lateral to areas 1 and 2, respectively. The occurrence, percentage, and distribution of necrosis on the TRAM flap surface were determined.

RESULTS

Necrosis was observed at four statistically distinct and significant levels, distributed in the four different areas as follows: area 1, 9 percent; area 2, 37 percent; area 3, 74 percent; and area 4, 100 percent (p < 0.001). The median proportion of necrosed flap surface was 15 percent (range, 2 to 42 percent).

CONCLUSIONS

The determination of necrosis allowed us to identify three distinct levels of necrosis: area 4 with the highest scores, area 3 with intermediate scores, and areas 1 and 2 with the lowest scores (p < 0.001). Areas 1 and 2 of the TRAM flap surface had less incidence of necrosis, contrary to the lateral areas 3 and 4, in which cutaneous necrosis was found to be more significant.

Strategies and Options for Free TRAM Flap Breast Reconstruction in Patients with Midline Abdominal Scars

BACKGROUND

Patients who have a midline abdominal scar from previous abdominal surgery often present a challenge when use of a transverse rectus abdominis myocutaneous (TRAM) flap is desired for breast reconstruction. In this study, the authors reviewed their experience with the TRAM flap for breast reconstruction in patients with midline abdominal scars to evaluate the various strategies used to optimize reconstructive outcomes.

METHODS

Between January of 1994 and December of 2001, 43 patients with a midline abdominal scar underwent unilateral autologous tissue breast reconstruction with a TRAM flap at The University of Texas, M. D. Anderson Cancer Center.

RESULTS

The mean age of the midline abdominal scar was 13 years (range, 4 to 45 years). In 26 patients, only free hemi-TRAM flaps were used for breast reconstruction. Free TRAM flaps were used in nine patients in whom zone II across the midline scar had an adequate blood supply and was able to be incorporated into the flap for breast reconstruction. In five patients, blood supplies from both sides of the TRAM flap were used to augment perfusion to the tissue across the midline scar. In three patients with infraumbilical midline scars, a free TRAM flap was designed higher in the abdomen so that the superior half of the flap was scar-free.

CONCLUSIONS

Various strategies are available for autologous tissue breast reconstruction using a free TRAM flap in patients with a previous midline abdominal surgical scar. In some cases, the TRAM flap tissue across the midline scar can be used reliably for breast reconstruction.

Analyzing the Vascular Architecture of the Free TRAM Flap Using Intraoperative Ex Vivo Angiography

BACKGROUND

Using ex vivo intraoperative angiography to analyze 14 flaps from 12 breast reconstruction patients, the authors investigated the vascular architecture of free transverse rectus abdominis musculocutaneous (TRAM) flaps nourished by the deep inferior epigastric artery.

METHODS

Contrast medium was injected through the deep inferior epigastric artery and flaps were radiographed to observe their vascular patterns.

RESULTS

TRAM flaps showed one or two segmental arteries stained on their ipsilateral side (zones 1 and 3) and serving as the flap's axial artery. These segmental arteries directly connect to the large perforators (axial perforators) and emerge not only from the paraumbilical perforators but also from the caudal branches of the deep inferior epigastric artery. Arterial density is always lower in the contralateral area (zones 2 and 4) than in the ipsilateral area (zones 1 and 3).

CONCLUSIONS

Because the cephalic half of zone 2 and all of zone 4 remain unstained, these areas are prone to skin or fat necrosis, especially in high-risk patients. Ex vivo angiography, by providing specific information about the individual flap and by reflecting its flow physiology, enables one to observe and to chart the vascular architecture of free TRAM flaps nourished by the deep inferior epigastric artery.