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Vourvachis M, Goodarzi MR, Scaglioni MF, Tartanus J, Jones A, Cheng HT, Abdelrahman M. Utilization of the internal mammary perforators as the recipient vessels for microsurgical breast reconstruction: A systematic review and meta-analysis of the literature. Microsurgery 2024; 44:e31105. [PMID: 37675648 DOI: 10.1002/micr.31105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 07/05/2023] [Accepted: 08/17/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND The selection of reliable recipient vessels is essential for successful free tissue transfer. The use of internal mammary intercostal perforators (IMAPs), instead of the internal mammary vessels as the recipient vessels, has been described in breast reconstruction. Debates exist regarding the reliability of these perforators as recipient vessels because of their variability in location and caliber. The aim of this paper was to conduct a systematic literature review and meta-analysis to determine the reliability of the IMAPs as recipient vessels. METHODS A systematic literature review was performed on the "PubMed," "Medline," "Ovid," and "Cochrane library" databases for articles published from January 1990 to March 2021. Exclusion criteria were non-English studies, reports with case number less than 5, cadaveric or animal studies, and studies with incomplete postoperative outcomes. The reliability of using IMAPs for breast reconstruction was determined by assessing the reported rates of partial or complete flap failure and other complications (fat necrosis, skin necrosis, and requirement for revision surgery). RESULTS Three hundred and sixteen cases in 13 studies were included for further analysis with more than 85% of the IMAPs suitable for anastomosis being located in the second and third intercostal spaces. Partial or total flap failure was reported in three of 316 patients (0.95%). The rate of other complications such as fat necrosis, skin necrosis, and requirement for revision surgery were all less than 5%. CONCLUSION With deliberate preoperative planning, delicate perioperative manipulation, and meticulous microvascular anastomosis, the internal mammary perforators can be used as reliable recipient vessels in microvascular breast reconstruction.
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Affiliation(s)
- Michail Vourvachis
- Department of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Mohammad R Goodarzi
- Department of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Mario F Scaglioni
- Department of Hand and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Justyna Tartanus
- Department of General Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Alex Jones
- Department of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Hsu-Tang Cheng
- Department of Plastic and Reconstructive Surgery, Asia University Hospital, Taichung City, Taiwan
| | - Mohamed Abdelrahman
- Department of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough, UK
- Department of Surgery, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
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Friebel TR, Shanmugakrishnan RR, Zberea D, Morgan M, Hussain A, Ramakrishnan V. Internal mammary perforator vessels as recipient for microvascular breast reconstruction: Technique and outcomes in 161 flaps. J Plast Reconstr Aesthet Surg 2023; 85:454-462. [PMID: 37586312 DOI: 10.1016/j.bjps.2023.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/14/2023] [Accepted: 07/16/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The use of internal mammary perforator (IMP) vessels as recipients for free flap breast reconstruction was first described in 1999. Despite numerous advantages over the internal mammary (IM) and thoracodorsal recipient vessels, their widespread use remains mired in concern. This paper describes our method of IMP vessel preparation and outcomes with regard to safety and reliability. METHODS To support the reliability of the IMP vessel preparation, a retrospective study on prospectively collected data of all free flap breast reconstruction patients between 1 July 2016 and 31 July 2019 was performed. Data were collected on patient demographics, type of reconstruction operative details and complications. RESULTS Out of the 450 flaps performed, the IMP vessels were used in 36% of the cases. Of these cases, 18% had received neo-adjuvant chemotherapy and 15% had a history of radiotherapy to the chest wall. In total, 161 flaps were performed to reconstruct 138 breasts (115 single and 23 stacked flaps). Three patients required a return to theatre, with one needing recipient vessel revision from the IMP to the IM vessels due to calibre mismatch. No mastectomy skin flap necrosis, free flap loss or significant fat necrosis were encountered. CONCLUSION This article describes an IM vessel preparation method that results in predictable outcomes in both single and stacked flap reconstructions with a low complication rate. Due to their reliability and versatility, we consider the IMP vessels a valuable attribute to the recipient vessel arsenal of any breast reconstruction microsurgeon.
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Affiliation(s)
- Thessa R Friebel
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom.
| | - R Raja Shanmugakrishnan
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom
| | - Diana Zberea
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom
| | - Mary Morgan
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom
| | - Amer Hussain
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom
| | - Venkat Ramakrishnan
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom
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Fernandez-Diaz OF, Christopoulos G, Griffiths M. A Systematic Review and Meta-analysis of Clinical Outcomes in Autologous Breast Reconstruction Using Internal Mammary Artery Perforators as Recipient Vessels. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4969. [PMID: 37207242 PMCID: PMC10191480 DOI: 10.1097/gox.0000000000004969] [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: 10/13/2022] [Accepted: 03/13/2023] [Indexed: 05/21/2023]
Abstract
Recipient vessel selection is vital for successful autologous free-flap breast reconstruction. Internal mammary artery perforators have gained interest as a recipient vessel option. However, previous studies on their microsurgical safety and efficacy are limited and inconsistent. Thus, we conducted a systematic review and meta-analysis to assess the safety and effectiveness of using internal mammary artery perforators as recipient vessels in breast reconstruction. Methods The protocol has been previously published in PROSPERO (CRD42020190020). The PubMed, Scopus, Web of Science, and PROSPERO databases were searched. Two independent reviewers evaluated the articles for inclusion in the study. Study quality was assessed using the Newcastle-Ottawa Scale and the MINORS instrument (Methodological Index for Non-Randomized Studies). Results Of the 361 articles screened, 13 studies were included (313 patients with 318 flaps; 223 unilateral, 31 bilateral, mean average age 51.2 and mean BMI 27.8 ± 1.9). The mean overall success rate was 99.8%, the pooled surgical success rate was 100% [95% confidence interval (CI): 97%-100%], and the overall rate of complications was 11% (95% CI: 7%-18%). The most common complication was vascular-related to microanastomoses, with an incidence of 5% (95% CI: 2%-10%). The fat necrosis rate was 3% (95% CI: 2%-6%). Conclusions This study verified that internal mammary artery perforator vessels are reliable in breast reconstruction, with a high success rate and a relatively low complication rate. Moreover, in selected microsurgical breast reconstruction patients, internal mammary artery perforators may be the primary recipient vessel choice over the internal mammary artery or thoracodorsal vessels.
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Affiliation(s)
- Oscar F. Fernandez-Diaz
- From the St. Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, UK
- Group for Academic Plastic Surgery, Blizard Institute, Queen Mary University of London, London, UK
| | - Georgios Christopoulos
- Group for Academic Plastic Surgery, Blizard Institute, Queen Mary University of London, London, UK
- Department of Plastic Surgery, Queen Victoria Hospital, East Grinstead, West Sussex, UK
| | - Matthew Griffiths
- From the St. Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, UK
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Shin D, Sung KW, Fan KL, Park TH, Song SY, Roh TS, Lew DH, Lee DW. Expanding the use of internal mammary artery perforators as a recipient vessel in free tissue transfer: An anatomical analysis by computed tomography angiography in breast cancer patients. Microsurgery 2019; 39:509-514. [PMID: 30830973 DOI: 10.1002/micr.30446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 01/25/2019] [Accepted: 02/22/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND The internal mammary artery (IMA) perforator has assumed recent prominence as recipient vessels in free autologous breast reconstruction. However, anatomical understanding is unclear, due to limited cadaver and clinical studies. We evaluated the usability of these vessels by evaluating perforator size, dominance, laterality, interspace location, and relationship with breast volume. METHODS A retrospective review assessed 197 female patients with breast cancer who had undergone computed tomography angiography (CTA) of the chest wall. The average age and body mass index (BMI) of patients was 49.0 ± 6.5 years and 24.2 ± 5 .8 kg/m2 , respectively. The average volume of breasts was 437 ± 190 mL. Our analysis focused on the anatomy of IMA perforator and its relationship to volume and BMI. RESULTS A total of 377 hemi-chest evaluations were performed. Most patients (95.5%) had sizeable perforating artery identified on CTA. Among all sizeable perforators identified, the mean diameter of the most dominant arterial perforator was 1.8 ± 0 .8 mm. The right hemi-chest had significantly larger perforators than the left (1.9 ± 0 .9 mm vs. 1.7 ± 0 .7 mm, p = 0.002). The first intercostal space (ICS) had a slightly greater of perforators than second ICS (34.6% vs. 29.8%, p = 0.172). However, second ICS had a greater number of most dominant perforators compared to first ICS (38.9% vs. 34.7%, p = 0.357). Perforators from first ICS emerge medial to the sternal edge and breast footprint. When dividing groups with 0-1 versus 2-3 reliable perforators, breast volume was significantly higher in the later (422.0 mL vs. 461.2 mL, p = 0.019). CONCLUSION These results are expected to encourage microsurgeons to use the IMA perforator by providing a clear anatomical roadmap.
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Affiliation(s)
- Dongwoo Shin
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Ki Wook Sung
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Tae Hwan Park
- Department of Plastic and Reconstructive Surgery, Bundang CHA Medical Center, Seongnam, Gyeonggi-do, South Korea
| | - Seung Yong Song
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Tai Suk Roh
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Dae Hyun Lew
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Won Lee
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
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Kim DH, Kim CW, Lee JW, Kim U, Jung S, Hwang E. Distribution of internal thoracic artery perforators: A clincal anatomy study. Clin Anat 2018; 32:471-475. [PMID: 30421817 DOI: 10.1002/ca.23312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 10/11/2018] [Accepted: 11/09/2018] [Indexed: 11/09/2022]
Abstract
There are various modifications of the transverse rectus abdominis musculocutaneous flap and deep inferior epigastric perforator flap to reduce the morbidity of the donor site or to augment the vascularity of the flap. For microanastomosis of multiple pedicles, multiple recipient vessels or an intervening vein graft should be provided. In addition, alternative perforator-based flaps used in breast reconstruction have small caliber pedicles. Therefore, small recipient vessels such as internal thoracic artery perforators are more suitable for appropriate microanastomosis. Therefore, it is important to acquaint the distribution and anatomical characteristics of internal thoracic artery perforators. We researched the perforators running in the intercostal spaces under the pectoralis major muscle to provide an overview of the anatomical distribution and characteristics of the perforators in patients who underwent immediate subpectoral implant-based breast reconstructions. In our study, the major perforators (diameter > 1.5 mm) were easily found 2-7 cm medially between the third and fourth intercostal space and were sparse in the lateral area from the midline of the breast (usually 8-9 cm lateral to the midsternal line) and above the third rib. In each side of the breast, the average number of perforators greater than 1.5 mm was 1.6, and the average number of perforators between 1 mm and 1.5 mm in diameter was 3.2. Our results provide information about perforators in the anterior chest wall related to the breast area. Clin. Anat. 32:471-475, 2019. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Dae Hee Kim
- Department of Biomedical Engineering, College of Medicine, Seoul National University, Seoul, South Korea
| | - Chan Woo Kim
- Department of Plastic and Reconstructive Surgery, Bundang CHA Medical Center, School of Medicine, CHA University, Seongnam, South Korea
| | - Jang Won Lee
- Department of Plastic and Reconstructive Surgery, Bundang CHA Medical Center, School of Medicine, CHA University, Seongnam, South Korea
| | | | - Soyeon Jung
- Department of Plastic and Reconstructive Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Euna Hwang
- Department of Plastic and Reconstructive Surgery, Bundang CHA Medical Center, School of Medicine, CHA University, Seongnam, South Korea
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Kanoi AV, Panchal KB, Sen S, Biswas G. Computed tomography angiographic study of internal mammary perforators and their use as recipient vessels for free tissue transfer in breast reconstruction. Indian J Plast Surg 2017; 50:50-55. [PMID: 28615810 PMCID: PMC5469236 DOI: 10.4103/ijps.ijps_168_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT The internal mammary artery perforator vessels (IMPV) as a recipient in free flap breast reconstruction offer advantages over the more commonly used thoracodorsal vessels and the internal mammary vessels (IMV). AIMS This study was designed to assess the anatomical consistency of the IMPV and the suitability of these vessels for use as recipients in free flap breast reconstruction. PATIENTS AND METHODS Data from ten randomly selected female patients who did not have any chest wall or breast pathology but had undergone a computed tomography angiography (CTA) for unrelated diagnostic reasons from April 2013 to October 2013 were analysed. Retrospective data of seven patients who had undergone mastectomy for breast cancer and had been primarily reconstructed with a deep inferior epigastric artery perforator free flap transfer using the IMPV as recipient vessels were studied. RESULTS The CTA findings showed that the internal mammary perforator was consistently present in all cases bilaterally. In all cases, the dominant perforator arose from the upper four intercostal spaces (ICS) with the majority (55%) arising from the 2nd ICS. The mean distance of the perforators from the sternal border at the level of pectoralis muscle surface on the right side was 1.86 cm (range: 0.9-2.5 cm) with a mode value of 1.9 cm. On the left side, a mean of 1.77 cm (range: 1.5-2.1 cm) and a mode value of 1.7 cm were observed. Mean perforator artery diameters on the right and left sides were 2.2 mm and 2.4 mm, respectively. CONCLUSIONS Though the internal mammary perforators are anatomically consistent, their use as recipients in free tissue transfer for breast reconstruction eventually rests on multiple variables.
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Affiliation(s)
- Aditya V Kanoi
- Department of Plastic and Reconstructive Surgery, TATA Medical Center, Kolkata, West Bengal, India
| | - Karnav B Panchal
- Department of Plastic and Reconstructive Surgery, TATA Medical Center, Kolkata, West Bengal, India
| | - Saugata Sen
- Department of Radiodiagnosis, TATA Medical Center, Kolkata, West Bengal, India
| | - Gautam Biswas
- Department of Plastic and Reconstructive Surgery, TATA Medical Center, Kolkata, West Bengal, India
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Transverse Infraclavicular Approach to the Thoracoacromial Pedicle for Microsurgical Breast Reconstruction. Ann Plast Surg 2017; 78:299-303. [DOI: 10.1097/sap.0000000000000790] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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An Appraisal of Internal Mammary Artery Perforators as Recipient Vessels in Microvascular Breast Reconstruction-An Analysis of 515 Consecutive Cases. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e1144. [PMID: 28293504 PMCID: PMC5222649 DOI: 10.1097/gox.0000000000001144] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 10/05/2016] [Indexed: 11/25/2022]
Abstract
Background: The usage of internal mammary artery perforators (IMAPs) has been described in autologous breast reconstruction although IMAPS are not yet considered standard recipient vessels. It remains unclear if these vessels can be safely used in large flaps after radiation therapy or in delayed breast reconstruction. Methods: Over a 2-year period, 515 free flaps for autologous breast reconstruction were performed on 419 patients by 2 surgeons (S1 and S2). In a retrospective analysis, time of reconstruction, ischemia time, flap weight, diameter of couplers, and complications were analyzed. All 515 flaps were compared in a subset with regard to the 2 surgeons: S1 who always used the IMA as a recipient vessel and S2 who attempted IMAP use if possible. Results: Of all 515 flaps, 424 were abdominal flaps and 91 flaps were from the upper thigh. Three hundred six cases were immediate reconstructions, and 112 were delayed reconstructions. In 97 cases, implants were converted to autologous tissue. In 112 cases, the IMAPs were used; of these, 82 were immediate and 17 were delayed reconstructions, and in 13 cases, implants were removed. Thirty-five percent of all anastomoses to IMAPs had previous radiation therapy. The flap failure rate was 1.9%. In none of these cases, the IMAPs were used. S1 never used the IMAP, and S2 used the IMAP in 37% of all of his flaps. Conclusions: IMAPs were safely used in all kinds of reconstructions and after radiation therapy, with no flap failure or negative effects on mastectomy skin flap perfusion. Using the IMAPs as recipient vessels is a further step toward simplifying microsurgical breast reconstruction.
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O'Neill AC, Hayward V, Zhong T, Hofer SO. Usability of the internal mammary recipient vessels in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 2016; 69:907-11. [DOI: 10.1016/j.bjps.2016.01.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/05/2016] [Accepted: 01/28/2016] [Indexed: 10/22/2022]
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La Padula S, Hersant B, Noel W, Niddam J, Hermeziu O, Bouhassira J, Bosc R, Meningaud JP. Use of the retrograde limb of the internal mammary vein to avoid venous congestion in DIEP flap breast reconstruction: Further evidences of a reliable and time-sparing procedure. Microsurgery 2016; 36:447-52. [DOI: 10.1002/micr.30043] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 02/08/2016] [Accepted: 02/16/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Simone La Padula
- Plastic Surgery Department; Henri Mondor Hospital, UPEC; Creteil France
| | - Barbara Hersant
- Plastic Surgery Department; Henri Mondor Hospital, UPEC; Creteil France
| | - Warren Noel
- Plastic Surgery Department; Henri Mondor Hospital, UPEC; Creteil France
| | - Jeremy Niddam
- Plastic Surgery Department; Henri Mondor Hospital, UPEC; Creteil France
| | - Oana Hermeziu
- Plastic Surgery Department; Henri Mondor Hospital, UPEC; Creteil France
| | | | - Romain Bosc
- Plastic Surgery Department; Henri Mondor Hospital, UPEC; Creteil France
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Bodin F, Brunetti S, Dissaux C, Sauleau EA, Facca S, Bruant-Rodier C, Liverneaux P. Venous coupler use for free-flap breast reconstructions: Specific analyses of TMG and DIEP flaps. Microsurgery 2014; 35:295-9. [DOI: 10.1002/micr.22350] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 10/22/2014] [Accepted: 10/24/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Frédéric Bodin
- Department of Plastic Surgery; Strasbourg Academic Hospital; Strasbourg France
| | - Stefania Brunetti
- Department of Hand Surgery; Strasbourg Academic Hospital; Strasbourg France
| | - Caroline Dissaux
- Department of Plastic Surgery; Strasbourg Academic Hospital; Strasbourg France
| | - Erik A. Sauleau
- Department of Biostatistics; Strasbourg Academic Hospital; Strasbourg France
| | - Sybille Facca
- Department of Hand Surgery; Strasbourg Academic Hospital; Strasbourg France
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Rickard RF, McPhaden AR, Hudson DA. Healing of two microarterial anastomoses with diameter mismatch. J Surg Res 2014; 191:239-49.e3. [DOI: 10.1016/j.jss.2014.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 02/26/2014] [Accepted: 03/05/2014] [Indexed: 11/25/2022]
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Internal Mammary Perforators as Recipient Vessels for Deep Inferior Epigastric Perforator and Muscle-Sparing Free Transverse Rectus Abdominis Musculocutaneous Flap Breast Reconstruction in an Asian Population. Ann Plast Surg 2014; 73:170-3. [DOI: 10.1097/sap.0b013e318270704b] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Munhoz AM, Ishida LH, Montag E, Saito FL, Mendes M, Alves H, Gemperli R. Internal mammary perforator vessels as recipient site for microsurgical breast reconstruction: a comparative histomorphometric analysis and incidence of degenerative vascular changes. Microsurgery 2014; 34:217-23. [PMID: 24745087 DOI: 10.1002/micr.22203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In microsurgical breast reconstruction, an adequate selection of recipient vessels is crucial for a successful outcome. Although the internal mammary (IM) vessels offer an attractive option, the internal mammary perforator (IMP) vessels are becoming a reliable alternative. The purpose of this study is to investigate the external diameters, lumen area, and atherosclerotic lesions changes of the IMP, IM, and deep inferior epigastric (DIE) vessels through quantitative and qualitative histomorphometric analysis. METHODS Ninety-six vessels of bilateral IM, IMP, and DIE vessels from 16 fresh female cadavers were evaluated. Mean age was 54.06 ± 5.7 years. External diameters, lumen area, and degenerative changes of the tunica intimae and media were analyzed by qualitative histomorphometric analysis. RESULTS Seventy-one vessels (20 IM, 31 IMP, and 20 DIE vessels) were included in the final histological analysis. A statistically lower external diameters and lumen area were presented by the IMP. The DIE vessels showed a lower incidence (10%) of moderate and severe intimal layer degenerative changes (P = 0.0589). The IMP and DIE vessels showed a lower incidence (9.4 and 25%, respectively) of major media layer degenerative changes (P = 0.0001). No major arterial degenerative lesions were observed in the IMP arteries. CONCLUSION Although the IMP external diameters and lumen area were lower than the IM, the results of this study indicated that the tunica media layer in the IMP is less damaged than the other recipient vessels. The results of the comparative histological study permitted to describe additional advantages and disadvantages of using IMP as a recipient vessel for free flap breast reconstruction.
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15
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Santanelli di Pompeo F, Longo B, Laporta R, Pagnoni M, Cavalieri E. The use of the serratus anterior muscle vascular pedicle as recipient site in DIEP flap transfer for breast reconstruction. J Plast Reconstr Aesthet Surg 2014; 67:456-60. [PMID: 24529692 DOI: 10.1016/j.bjps.2013.12.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/31/2013] [Accepted: 12/21/2013] [Indexed: 11/19/2022]
Affiliation(s)
- Fabio Santanelli di Pompeo
- Plastic Surgery Unit 'Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy.
| | - Benedetto Longo
- Plastic Surgery Unit 'Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Rosaria Laporta
- Plastic Surgery Unit 'Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Marco Pagnoni
- Plastic Surgery Unit 'Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Enrico Cavalieri
- Plastic Surgery Unit 'Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
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The Use of Retrograde Limb of Internal Mammary Vein in Autologous Breast Reconstruction With DIEAP Flap. Ann Plast Surg 2014; 72:281-4. [DOI: 10.1097/sap.0b013e3182605674] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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A clinical anatomic study of internal mammary perforators as recipient vessels for breast reconstruction. Arch Plast Surg 2013; 40:761-5. [PMID: 24286051 PMCID: PMC3840185 DOI: 10.5999/aps.2013.40.6.761] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 07/27/2013] [Accepted: 07/30/2013] [Indexed: 11/18/2022] Open
Abstract
Background Partially resecting ribs of the recipient site to facilitate easy anastomosis of the internal mammary vessels to free flaps during breast reconstruction can cause chest wall pain or deformities. To avoid this, the intercostal perforating branches of the internal mammary vessels can be used for anastomosis. The purpose of this study was to investigate the location and size of the internal mammary perforator vessels based on clinical intraoperative findings and to determine their reliability as recipient vessels for breast reconstruction with microsurgical free tissue transfer. Methods Twelve patients were preoperatively screened for the presence of internal mammary perforators using Doppler tracing. After modified radical mastectomy was performed by a general surgeon, the location and size of the internal mammary perforator vessels were microscopically investigated. The external diameter was examined using a vessel-measuring gauge from a mechanical coupling device, and the distance from the mid-sternal line to the perforator was also measured. Results The largest arterial perforator averaged 1.5 mm, and the largest venous perforator averaged 2.2 mm. Perforators emerging from the second intercostal space had the largest average external diameter; the second intercostal space also had the largest number of perforators arising from it. The average distance from the mid-sternal line to the perforator was 20.2 mm. Conclusions Internal mammary perforators presented consistent and reliable anatomy in this study. Based on these results, the internal mammary perforators appear to have a suitable diameter for microvascular anastomosis and should be considered as an alternative recipient vessel to the internal mammary vessel.
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Tan O, Yuce I, Aydin OE, Kantarci M. A radioanatomic study of the internal mammary artery and its perforators using multidetector computed tomography angiography. Microsurgery 2013; 34:277-82. [DOI: 10.1002/micr.22185] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Revised: 08/09/2013] [Accepted: 08/16/2013] [Indexed: 11/05/2022]
Affiliation(s)
- Onder Tan
- Faculty of Medicine; Department of Plastic Reconstructive and Aesthetic Surgery; Ataturk University; 25240 Erzurum Turkey
| | - Ihsan Yuce
- Faculty of Medicine; Department of Radiology; Ataturk University; 25240 Erzurum Turkey
| | - Osman Enver Aydin
- Faculty of Medicine; Department of Plastic Reconstructive and Aesthetic Surgery; Ataturk University; 25240 Erzurum Turkey
| | - Mecit Kantarci
- Faculty of Medicine; Department of Radiology; Ataturk University; 25240 Erzurum Turkey
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Can previous diagnostic examinations prevent preoperative angiographic assessment of the internal mammary perforators for (micro)surgical use? Ann Plast Surg 2013; 72:560-5. [PMID: 23486113 DOI: 10.1097/sap.0b013e318268a896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIM Preoperative assessment of the internal mammary artery perforating (IMAP) branches enhances IMAP-based reconstructive procedures. Conventionally, color-flow Doppler, selective catheter arteriography, or CT angiography is used for such assessment. We studied how often these examinations may be rendered superfluous by assessment of previously performed diagnostic examinations. METHODS A radiologist and a plastic surgeon jointly assessed whether information on the dominant IMAP could sufficiently be obtained from the thoracic CT scans of 12 head and neck cancer patients and 12 breast cancer patients, and from the mammary MRI of 12 breast cancer patients. Secondly, we retrospectively assessed in how many of the 10 patients who underwent an IMAP-flap head and neck reconstruction, and in how many of the 10 women who consecutively underwent a deep inferior epigastric perforator (DIEP) flap mammary reconstruction such previous diagnostic examinations were available and informative regarding the level of the dominant perforator. RESULTS All 24 CT scans and 11 of the 12 MRI scans sufficiently allowed assessment of the level of the dominant IMAP. Previous information had already been available in all 10 DIEP flap patients and 6 of the 10 IMAP-flap patients. The distribution of IMAP dominance over the intercostal levels on the scans differed from that found by cadaveric or intraoperative assessment. CONCLUSIONS Previously performed diagnostic CT scans and MRI scans that included the parasternal region usually allow sufficient preoperative assessment of the internal mammary perforators for reconstructive procedures. We advocate re-assessment of such previous examinations before ordering additional angiography. Additionally, we suggest to include the parasternal region in diagnostic scans.
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Rib-Sparing and Internal Mammary Artery–Preserving Microsurgical Breast Reconstruction with the Free DIEP Flap. Plast Reconstr Surg 2013; 131:327e-334e. [DOI: 10.1097/prs.0b013e31827c6d38] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Autologous microsurgical breast reconstruction and coronary artery bypass grafting: an anatomical study and clinical implications. Breast Cancer Res Treat 2012; 134:181-98. [PMID: 22270931 DOI: 10.1007/s10549-011-1948-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 12/26/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To identify possible avenues of sparing the internal mammary artery (IMA) for coronary artery bypass grafting (CABG) in women undergoing autologous breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps. BACKGROUND Optimal autologous reconstruction of the breast and coronary artery bypass grafting (CABG) are often mutually exclusive as they both require utilisation of the IMA as the preferred arterial conduit. Given the prevalence of both breast cancer and coronary artery disease, this is an important issue for women's health as women with DIEP flap reconstructions and women at increased risk of developing coronary artery disease are potentially restricted from receiving this reconstructive option should the other condition arise. METHODS The largest clinical and cadaveric anatomical study (n=315) to date was performed, investigating four solutions to this predicament by correlating the precise requirements of breast reconstruction and CABG against the anatomical features of the in situ IMAs. This information was supplemented by a thorough literature review. RESULTS Minimum lengths of the left and right IMA needed for grafting to the left-anterior descending artery are 160.08 and 177.80 mm, respectively. Based on anatomical findings, the suitable options for anastomosis to each intercostals space are offered. In addition, 87-91% of patients have IMA perforator vessels to which DIEP flaps can be anastomosed in the first- and second-intercostal spaces. CONCLUSION We outline five methods of preserving the IMA for future CABG: (1) lowering the level of DIEP flaps to the fourth- and fifth-intercostals spaces, (2) using the DIEP pedicle as an intermediary for CABG, (3) using IMA perforators to spare the IMA proper, (4) using and end-to-side anastomosis between the DIEP pedicle and IMA and (5) anastomosis of DIEP flaps using retrograde flow from the distal IMA. With careful patient selection, we hypothesize using the IMA for autologous breast reconstruction need not be an absolute contraindication for future CABG.
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Schwabegger AH, Piza-Katzer H, Pauzenberger R, Del Frari B. The internal mammary artery perforator (IMAP) breast-flap harvested from an asymmetric hyperplastic breast for correction of a mild funnel chest deformity. Aesthetic Plast Surg 2011; 35:928-32. [PMID: 21461629 DOI: 10.1007/s00266-011-9697-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 02/28/2011] [Indexed: 11/25/2022]
Abstract
Pectus excavatum deformity is the most frequent congenital anomaly of the thoracic wall. If the invasive surgical procedures of thoracoplasty are not indicated or the patient refuses them, alternative treatment options should be considered. In such cases, local or distant transposition of autologous tissue could be appropriate. This report presents a selected case of funnel chest deformity and concomitant unilateral breast hyperplasia. Both deformities were corrected simultaneously using a pedicled internal mammary artery perforator (IMAP) flap dissected from the hyperplastic breast. This is a safe, reliable, low-morbidity, one-stage option for adult women that uses an easy-to-harvest flap for simultaneous correction of mild funnel chest deformity and concomitant breast hyperplasia with a single resulting scar.
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Affiliation(s)
- Anton H Schwabegger
- Department of Plastic, Reconstructive and Aesthetic Surgery, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria.
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Rickard RF, Engelbrecht GHC, Hudson DA. Experimental investigation of two techniques of arterial microanastomosis used to manage a small-to-large diameter discrepancy. J Plast Reconstr Aesthet Surg 2011; 64:1088-95. [PMID: 21450544 DOI: 10.1016/j.bjps.2011.03.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 03/02/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION A limiting factor in the use of perforators as recipient vessels is the small-to-large diameter mismatch often encountered. Mismatches less than 1:1.5 may be managed by dilatation of the smaller vessel and by differentially-spaced suture bites. Beyond this ratio, little evidence exists to direct the choice of end-to-end anastomotic technique. Following in silico work and the characterisation of a rodent superficial caudal epigastric/femoral artery model, we conducted an experimental series examining two techniques - an oblique section of the smaller vessel and invaginating the smaller vessel inside the larger. MATERIALS AND METHODS A paired design was used. To test for a difference in patency of >5% required a total of 156 animals (312 anastomoses). Side and technique were randomised. Two investigators performed the anastomoses. A single revision was permitted. Anastomoses were timed and patency was tested at one hour, one week and at six weeks. RESULTS There was no significant difference in patency at each of the three time points (p = 0.8026, 0.2963 and 0.8137). The invagination technique was significantly faster to perform (p < 0.0001). There was a significant association between the investigator and both patency and the time taken to complete an anastomosis. Independent of the investigator, a revision was more likely to be necessary with the oblique end-to-end technique, and a revision having been performed showed a highly significant association with an anastomosis having failed at 1 h (p < 0.0001, OR 33.333). CONCLUSIONS In the management of microarterial size discrepancy between 1:1.5 and 1:2.5, an invaginating anastomosis is faster to perform and produces comparable patency in a rat model.
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Affiliation(s)
- R F Rickard
- Department of Plastic Surgery, Derriford Hospital, Plymouth, PL6 8DH, UK.
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Tips for Successful Microvascular Abdominal Flap Breast Reconstruction Utilizing the “Total Rib Preservation” Technique for Internal Mammary Vessel Exposure. Ann Plast Surg 2011; 66:36-42. [DOI: 10.1097/sap.0b013e3181e19daf] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Internal Mammary Intercostal Perforators instead of the True Internal Mammary Vessels as the Recipient Vessels for Breast Reconstruction. Plast Reconstr Surg 2011; 127:34-40. [DOI: 10.1097/prs.0b013e3181f95865] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Schellekens PP, Hage JJ, Paes EC, Kon M. Clinical application and outcome of the internal mammary artery perforator (IMAP) free flap for soft tissue reconstructions of the upper head and neck region in three patients. Microsurgery 2010; 30:627-31. [DOI: 10.1002/micr.20803] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Internal mammary artery perforators for the salvage of a superficially dominant free flap breast reconstruction. Plast Reconstr Surg 2010; 125:254e-255e. [PMID: 20517071 DOI: 10.1097/prs.0b013e3181cb680f] [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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The anatomic basis of the internal mammary artery perforator flap: a cadaver study. J Plast Reconstr Aesthet Surg 2010; 63:191-6. [DOI: 10.1016/j.bjps.2008.09.019] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Revised: 08/31/2008] [Accepted: 09/23/2008] [Indexed: 11/23/2022]
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The use of a pectoralis major flap to improve internal mammary vessels exposure and reduce contour deformity in microvascular free flap breast reconstruction. Ann Plast Surg 2008; 61:30-4. [PMID: 18580146 DOI: 10.1097/sap.0b013e318151f9fa] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Internal mammary vessels are commonly used in microvascular breast reconstruction. Most surgeons resect a portion of the rib to expose these vessels. This resection can lead to contour abnormalities in the chest wall that are difficult to correct. In addition, exposure of these vessels deep in the wound can be problematic. The purpose of this study was to evaluate our experience with a pectoralis major flap designed to improve exposure and fill in the defect created by rib resection. All consecutive patients who underwent autologous breast reconstruction using the internal mammary vessels as recipient vessels between 2000 and 2005 were identified. All procedures were performed by a single surgeon. In each case, a superiorly based flap within the pectoralis major muscle spanning the bottom of the second rib to the top of the fourth costal cartilage was raised. This "L"-shaped flap was reflected and a portion of the third rib cartilage was excised. At the conclusion of the microsurgical anastomosis the pectoralis major flap was repaired and used to cover the defect created by rib resection. Patient demographic, operative details, and postoperative complications were obtained from a prospectively maintained clinical database. Deformity around sternal border was evaluated from the patients' photographs. There were 99 autologous reconstructions in 90 patients. In 71 cases the internal mammary artery/vein were used as recipient vessels. There were no cases of microvascular thrombosis or flap loss. A portion of the third rib was excised in all patients who underwent microsurgical anastomoses to the internal mammary vessels. In 3 patients a portion of both the second and third ribs was removed because of branching of the internal mammary vein proximal to the level of the third rib. A contour deformity was noted in 4 patients (4.4%) after a mean follow-up of 27 months. Of the 4 patients with contour deformity, 2 had a portion of both the third and second costal cartilage removed because of venous branching above the level of the third rib cartilage. The modified pectoralis major L-shaped flap is a useful technique for safe and clear exposure of the internal mammary vessels. In addition, the use of this flap to cover the segment of resected rib cartilage can decrease the contour deformities associated with rib resection as compared with reported rates in the literature. Resection of multiple rib segments, though unavoidable at times because of anatomic considerations, may be associated with an increased rate of postoperative contour deformities.
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Rad AN, Flores JI, Rosson GD. Free DIEP and SIEA breast reconstruction to internal mammary intercostal perforating vessels with arterial microanastomosis using a mechanical coupling device. Microsurgery 2008; 28:407-11. [DOI: 10.1002/micr.20515] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Internal Mammary Perforator Recipient Vessels for Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps. Plast Reconstr Surg 2007; 120:1769-1773. [DOI: 10.1097/01.prs.0000287132.35433.d6] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Beahm EK, Walton RL. The Efficacy of Bilateral Lower Abdominal Free Flaps for Unilateral Breast Reconstruction. Plast Reconstr Surg 2007; 120:41-54. [PMID: 17572543 DOI: 10.1097/01.prs.0000263729.26936.31] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In large-breasted women, those with midline abdominal scars, or those with scant abdominal tissue, a unipedicled lower abdominal flap may be insufficient for breast reconstruction. In these circumstances, bipedicled flaps may best satisfy the reconstructive requirements, but outcomes with bilateral free flaps for unilateral breast reconstruction are generally lacking. METHODS A retrospective review of patients in whom two vascular pedicles/flaps were used to simultaneously reconstruct a single breast was used to assess operative outcomes. RESULTS Forty patients (80 flaps) for whom two free tissue transfers were used to simultaneously reconstruct a single breast were identified. The majority of patients had a native breast cup size of C or larger. The flaps used included the superficial inferior epigastric artery (SIEA) flap (n = 29; 36 percent), the transverse rectus abdominis musculocutaneous (TRAM) flap (n = 9; 11 percent), the muscle-sparing TRAM flap (n = 15; 19 percent), and the deep inferior epigastric perforator (DIEP) flap (n = 27; 34 percent). Flaps were paired in a variety of configurations, most commonly using a muscle-sparing TRAM flap in conjunction with a DIEP flap or an SIEA flap. Recipient vessels included a combination of the internal mammary and thoracodorsal vessels and the pedicles of combined flaps (turbocharged). There were no flap losses. Two flaps required reexploration for microsurgical anastomotic revision, and both were successfully salvaged. Isolated fat necrosis was encountered in only three of 80 flaps. CONCLUSIONS This study suggests that bilateral, bipedicled, abdominal free flaps for unilateral breast reconstruction can be used safely with a high degree of success. These combined flaps provide for enhanced vascular perfusion of the lower abdominal flap territory, allowing for harvest of larger volumes of tissue for reconstruction.
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Affiliation(s)
- Elisabeth K Beahm
- Houston, Texas; and Chicago, Ill. From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center, and Section of Plastic Surgery, University of Chicago Hospitals
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Posch NAS, Mureau MAM, Flood SJ, Hofer SOP. The combined free partial vastus lateralis with anterolateral thigh perforator flap reconstruction of extensive composite defects. ACTA ACUST UNITED AC 2005; 58:1095-103. [PMID: 16043151 DOI: 10.1016/j.bjps.2005.04.022] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2004] [Accepted: 04/22/2005] [Indexed: 11/22/2022]
Abstract
Myocutaneous (MC) free flaps are useful for many reconstructive indications. Perforator flaps have become standard of care. The anterolateral thigh flap (ALT) donor site is popular. With the ALT flap varying sizes of vastus lateralis (VL) muscle can be harvested as a MC flap. The skin islands of these flaps have a great range of freedom when dissected on their perforator. It was hypothesised that the VL-ALT perforator flap would offer adequate tissue volume combining maximal freedom in planning with minimal donor site morbidity. From November 2001 to February 2003 a free partial VL with ALT perforator flap was used in 11 patients to reconstruct large defects. Indications for adding a muscular component were exposed bone, skull base, (artificial) dura, or osteosynthesis material, open sinuses, and lack of muscular bulk. Flaps were planned as standard ALT flaps, after which three types of dissection were performed: I. true MC flap; II. muscle flap with a skin island on one perforator, which could be rotated up to 180 degrees ; III. chimera skin perforator flap with muscle being harvested on a separate branch from the source vessel or on a side branch of the skin perforator. Mean skin size of the MC-ALT flaps was 131 cm2. Mean muscle part size of the MC-ALT flaps was 268 cm3. Muscular parts were custom designed for all defects. No total or partial flap failures were seen. Colour mismatch was seen in 6 of 8 patients, when skin was used in the facial area in this all white population. Excessive flap bulk was found in 8 of 11 patients at 6 weeks, however, only in 2 of 11 patients after 6 months. Patients were satisfied with the functional result (8 of 11 patients) as well as the cosmetic result of their reconstruction (7 of 11 patients). All less satisfied patients had received their flap for external facial skin reconstruction. Donor site morbidity was minimal. The combined free partial VL with ALT perforator flap proved valuable as a (chimera type) MC flap with maximal freedom of planning to meet specific reconstructive demands and minimal donor site morbidity.
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Affiliation(s)
- N A S Posch
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
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Hamdi M, Blondeel P, Van Landuyt K, Monstrey S. Algorithm in choosing recipient vessels for perforator free flap in breast reconstruction: the role of the internal mammary perforators. ACTA ACUST UNITED AC 2004; 57:258-65. [PMID: 15006528 DOI: 10.1016/j.bjps.2003.12.004] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2003] [Accepted: 12/02/2003] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Although the internal mammary (IM) vessels are our first choice as recipient vessels for free flap breast reconstruction, attempts to reduce surgical morbidity led us to adopt an algorithm when choosing recipient vessels. MATERIALS AND METHODS The IM vessels give direct perforators to the breast. They can be found either superficial or deep to the pectoralis major muscle. If they are of a reasonable calibre they can be considered as recipient vessels. When the perforators are not suitable, the IM vessels are used for the microanastomosis. This protocol was adopted for our patients between June 1999 and December 2002. RESULTS Breast reconstruction with free flaps was performed on 298 patients with perforator flaps. IM and thoracodorsal (TD) vessels are used in 88% and 3% of cases, respectively. IM perforators were successfully used in 30 cases (9%). The IM perforators used were located at the level of the second and third intercostal space in nine (30%) and 21 (70%) cases, respectively. The average diameters of those perforators were 1 mm (0.5-1.3 mm) for the artery and 1.7 mm (1-3 mm) for the vein. CONCLUSIONS The IM perforators can be used as recipient vessels for free flaps. This spares the IM vessels for eventual cardiac bypass surgery, avoiding recipient site morbidity and decreasing the postoperative discomfort.
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Affiliation(s)
- Moustapha Hamdi
- Department of Plastic Surgery, Gent University Hospital, De Pintelaan 185, B-9000 Gent, Belgium
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