1
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Kaur A, Biswas G. Internal mammary artery perforator flap in the management of tracheoesophageal fistulae. J Laryngol Otol 2024; 138:652-655. [PMID: 38185828 DOI: 10.1017/s0022215123002360] [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] [Indexed: 01/09/2024]
Abstract
BACKGROUND A pathological communication between the trachea and oesophagus - a tracheoesophageal fistula - may be congenital or acquired, benign or malignant, necessitating a multidisciplinary approach. Conservative attempts at closure of this abnormal connection are ineffective; the interposition of healthy vascular tissue offers the least chance of recurrence. METHODS Outcomes of an islanded fasciocutaneous internal mammary artery perforator flap applied for tracheoesophageal fistula management were assessed in four radiated patients with laryngeal carcinoma using retrospective records. RESULTS Four male patients, with an average age of 60.75 years, underwent tracheoesophageal fistula closure between September 2017 and February 2021. A left-sided second internal mammary artery perforator flap was used in all cases, with an average dimension of 10.5 × 4.5 cm. There were no complications of tracheoesophageal leak, flap issues or donor site morbidity on follow up. CONCLUSION Recent advances in angiosomal territory mapping and microvascular dissection techniques, combined with an understanding of tracheoesophageal fistula pathology, have changed management perspectives in these difficult-to-treat patients.
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Affiliation(s)
- Amrita Kaur
- Department of Plastic Surgery, Tata Medical Centre, Kolkata, India
| | - Gautam Biswas
- Department of Plastic Surgery, Tata Medical Centre, Kolkata, India
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2
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Singh AP, Seenu V, Krishna A, Radhakrishnan L. Local Flaps in Breast-Conserving Surgery in Early Breast Cancer Patients: Armamentarium for Breast Surgeon. Indian J Surg Oncol 2024; 15:258-263. [PMID: 38741625 PMCID: PMC11088574 DOI: 10.1007/s13193-024-01880-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 01/08/2024] [Indexed: 05/16/2024] Open
Abstract
To describe the technique and outcome of local perforator arteries advancement flap in breast-conserving surgeries (BCS) in patient of early breast cancer as our initial experience and review of literature on it. Patients who underwent (BCS) with local perforator artery flap reconstruction were reviewed in terms of their clinical, surgical, and post-operative follow-up details after taking written and informed consent. We have described 4 patients of early breast cancer out of which one patient was post-NACT while 3 were for upfront BCS. We have performed LICAP in 2 patients, AICAP in 1 patient, and IMAP in one patient, depending on the location of primary tumors. None of the patients had any major or minor surgical complications in the post-operative period and drains were removed on post-operative day 2. All patients received post-operative radiotherapy and tolerated well without any loco-regional complications. Patients are in routine follow-up with cosmetic satisfaction without any local recurrence over 1 year. The main advantages of pedicled perforator flaps are well-vascularized tissue, spares underlying muscle leading to lesser donor site morbidity like muscle function and seroma formation, easily reach the breast area with good match in terms of skin and subcutaneous tissue, faster recovery, and shorter learning curve in comparison to free flaps. Knowledge and skill about these flaps will help surgeon to give better surgical outcomes and satisfaction to patients.
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Affiliation(s)
| | - V. Seenu
- Department of Surgical Disciplines, AIIMS, New Delhi, India
| | - Asuri Krishna
- Department of Surgical Disciplines, AIIMS, New Delhi, India
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3
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Vasudevan SS, Rogers B, Adilbay D, Olinde L, Pang J, Nathan CAO, Asarkar AA. Outcomes of internal mammary artery perforator flap in head and neck reconstruction: A systematic review. Head Neck 2024. [PMID: 38769845 DOI: 10.1002/hed.27822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 05/15/2024] [Indexed: 05/22/2024] Open
Abstract
This study aims to evaluate the functional and prognostic outcomes associated with the internal mammary artery perforator (IMAP) flap in various head and neck defect repairs, given the current lack of clarity on its effectiveness. We performed a systematic review of various databases: PubMed, Embase, Scopus, Web of Science, and ScienceDirect using keywords such as "Internal mammary artery perforator flap" and "IMAP." Screening and data extractions were performed by two individual reviewers. Articles were considered eligible if they included sufficient information on IMAP flap features, their applications in the head and neck, and outcomes. From 264 articles analyzed, 24 studies were included for qualitative analysis. Out of which, 125 patients who received internal mammary artery perforator flaps were included. Most of the patients, 103 (88%), received pedicled IMAP flaps, and 22 (12%) received IMAP free flaps. The second internal mammary artery (IMA) was favored as the single perforator (81.5%), with the combination of the first and second IMA being the primary choice for dual perforators (92.5%). IMAP flaps were predominantly single perforator flaps (65%), with 35% being dual perforator flaps. Among various applications, IMAP flaps are commonly employed in the reconstruction of neck defects (25.5%), pharyngocutaneous fistula repair (20.8%), and burn scar contracture restoration (8%). Only seven (5.6%) patients had flap complications, including venous congestion (1.6%), partial necrosis (1.6%), complete necrosis (1.6%), and incision dehiscence (0.8%). Donor sites were predominantly closed by the primary closure (92%). 3.2% of donor sites had minor complications. The average follow-up was 12.6 (IQR: 6-18) months. This systematic review highlights the effectiveness and safety of IMAP flaps in head and neck reconstruction, with positive outcomes and minimal complications.
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Affiliation(s)
- Srivatsa Surya Vasudevan
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Brianna Rogers
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Dauren Adilbay
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Lindsay Olinde
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - John Pang
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Cherie-Ann O Nathan
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Ameya A Asarkar
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
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Sharbel D, Lin C, Topf MC, Mannion K. The internal mammary artery perforator flap in pharyngoesophageal, cervical tracheal, and cutaneous neck reconstruction. Head Neck 2024. [PMID: 38711230 DOI: 10.1002/hed.27769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/04/2024] [Accepted: 04/02/2024] [Indexed: 05/08/2024] Open
Abstract
The internal mammary artery perforator (IMAP) flap is an evolution of the deltopectoral flap that is harvested based upon a single perforator from the internal mammary artery. Its favorable characteristics include pliability as a fasciocutaneous flap, ease of harvest, and minimal donor site morbidity. In this paper, we report our harvest technique and the versatility of the IMAP flap for pharyngoesophageal, cervical tracheal, and cutaneous neck defects. We seek to highlight the IMAP as a useful regional reconstructive option in both the primary and salvage reconstructive setting. As such, this flap is an important option in the head and neck reconstructive surgeon's armamentarium.
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Affiliation(s)
- Daniel Sharbel
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Chen Lin
- Department of Otolaryngology-Head and Neck Surgery, University of Illinois-Chicago, Chicago, Illinois, USA
| | - Michael C Topf
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kyle Mannion
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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5
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Neligan PC. Innovation and Collaboration in Plastic Surgery. Arch Plast Surg 2024; 51:147-149. [PMID: 38596151 PMCID: PMC11001437 DOI: 10.1055/s-0043-1778669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/22/2023] [Indexed: 04/11/2024] Open
Affiliation(s)
- Peter C. Neligan
- Division of Plastic Surgery, University of Washington, Seattle, Washington
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6
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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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7
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Angrigiani C, Rancati A, Nahabedian MY, Spinelli E, Breppe P, Rancati A. Perforator-Based Cross-Midline Flaps of the Trunk: A Paradigm Shift in Flap Design. Plast Reconstr Surg 2023; 152:1333-1348. [PMID: 37075277 DOI: 10.1097/prs.0000000000010567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
BACKGROUND The traditional design for truncal perforator flaps is ipsilateral without midline decussation. The presumed rationale is to minimize the risk of distal flap necrosis. In this article, the authors present their experience and results with contralateral truncal perforator flaps designed and raised crossing the midline. METHODS This retrospective analysis included 43 patients (25 men and 18 women) who underwent reconstructive surgery from 1984 to 2021 using a contralateral flap design crossing the midline in the anterior trunk and upper back. Considerations included pathology, location, and the dimensions of the defect and flap. Arithmetic and weighted means with their 95% confidence intervals were estimated to compare ipsilateral and contralateral techniques. RESULTS Contralateral flaps used included the internal mammary perforator flap ( n = 28) superficial superior epigastric artery flap ( n = 8), superior epigastric perforator flap ( n = 2), and the second or ninth dorsal intercostal artery perforator flap ( n = 5). All of these flaps, excluding the superficial superior epigastric artery flap, demonstrated length and coverage surface averages that were significantly greater than those of traditional ipsilateral flaps. However, with the contralateral superficial superior epigastric artery, both measures were statistically similar to those of traditional ipsilateral flaps. CONCLUSION The anatomical variation design suggests that the trunk midline is not a barrier and that perforator flaps in these two regions may be raised on different longitudinal axes without compromising vitality. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Claudio Angrigiani
- From the Oncoplastic Surgery Program Hospital Gral San Martin, Universidad de Buenos Aires
| | - Alberto Rancati
- From the Oncoplastic Surgery Program Hospital Gral San Martin, Universidad de Buenos Aires
| | | | | | - Pablo Breppe
- Hospital San Martin, La Plata National University
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8
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Spinelli E, Angrigiani C, Rancati A, Dorr J, Rancati A, Nahabedian MY. The reverse LICAP flap: A laterally based submammary perforator flap for breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 84:157-164. [PMID: 37331037 DOI: 10.1016/j.bjps.2023.05.042] [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: 01/04/2023] [Accepted: 05/02/2023] [Indexed: 06/20/2023]
Abstract
INTRODUCTION The traditional donor sites for autologous breast reconstruction include the abdomen, thigh, buttock, and posterior thorax. Herein, we describe the use of the reverse lateral intercostal perforator (LICAP) flap originating from the submammary region as an option for breast reconstruction. METHODS Fifteen patients (30 breasts) were included in this retrospective review. The procedure was performed for immediate reconstruction following a nipple sparing mastectomy utilizing an inframammary incision or an inverted T pattern with preservation of the fifth anterior intercostal perforator (n = 8), volume replacement after implant explantation (n = 5), and partial lower pole resurfacing with exteriorization of a portion of the LICAP skin paddle (n = 2). RESULTS Flap survival was achieved in all patients. Three flaps (10%) had 1-2 cm of intraoperative distal tip ischemia, which was managed by excision prior to inset and closure. At the 12-month postoperative follow-up, stable results with good nipple position, breast shape, and projection were achieved in all patients. CONCLUSIONS The reverse LICAP flap is a safe, effective, and reliable option for breast reconstruction following mastectomy.
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Affiliation(s)
| | - Claudio Angrigiani
- Hospital San Martín University of Buenos Aires School of Medicine, Argentina.
| | - Alberto Rancati
- Hospital San Martín University of Buenos Aires School of Medicine, Argentina
| | - Julio Dorr
- Hospital San Martín University of Buenos Aires School of Medicine, Argentina
| | - Agustin Rancati
- Hospital San Martín University of Buenos Aires School of Medicine, Argentina
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9
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Sơn TT, Thúy TTH, Dung PTV, Nghĩa PT, Duy TT. Reconstruction of the thoracic radiation-induced ulcer with the pedicled internal mammary artery fasciocutaneous flap: Review of the literature and a case report. JPRAS Open 2023; 37:102-108. [PMID: 37520026 PMCID: PMC10372166 DOI: 10.1016/j.jpra.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/18/2023] [Indexed: 08/01/2023] Open
Abstract
Objective The pedicled Internal Mammary Artery Perforator (IMAP) flap is not yet a well-known technique. However, it seems practical for use in thoracic radiation-induced ulcer, especially in recurrence after the failure of convenient reconstructive techniques. This technique is applied to patients with breast hypertrophy. In this article, we present our experience with the indications, surgery details, and advantages of this technique. Materials and methods A 63-year-old woman had a right mastectomy 11 years ago. The patient's ulcers recurred after radiotherapy and were treated with a regional and local flap. The opposite breast was ptotic, and the patient was not eligible for microsurgery. The patient underwent reconstruction using the contralateral pedicle IMAP flap. Results The IMAP flap was designed with a size of 14 × 22 cm, including the inferior half of the breast and the areolar. The flap could completely cover the chest wall defect, and the contralateral breast was reduced to match. The final results were evaluated after two years of follow-up. Conclusion The contralateral breast pedicle IMAP flap is a reliable, versatile, and easy-to-perform technique. This flap is a useful technique for chest wall coverage after radiation-induced ulcers, particularly in elderly patients. The major limitation of this technique is the higher risk of second primary breast cancer as the transfer flap of the contralateral breast.
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Affiliation(s)
- Trần Thiết Sơn
- Department of Plastic and Reconstructive Surgery, Hanoi Medical University, Hanoi, Viet Nam
- Department of Plastic Reconstructive and Aesthetic Surgery, Bach Mai Hospital, Hanoi, Viet Nam
- Department of Plastic Reconstructive and Aesthetic Surgery, University of Medecin and Pharmacy, Hanoi National University, Viet Nam
| | - Tạ Thị Hồng Thúy
- Department of Plastic and Reconstructive Surgery, Hanoi Medical University, Hanoi, Viet Nam
- Department of Plastic Reconstructive and Aesthetic Surgery, Bach Mai Hospital, Hanoi, Viet Nam
| | - Phạm Thị Việt Dung
- Department of Plastic and Reconstructive Surgery, Hanoi Medical University, Hanoi, Viet Nam
- Department of Plastic Reconstructive and Aesthetic Surgery, Bach Mai Hospital, Hanoi, Viet Nam
| | - Phan Tuấn Nghĩa
- Department of Plastic and Reconstructive Surgery, Hanoi Medical University, Hanoi, Viet Nam
| | - Trương Thế Duy
- Department of Plastic Reconstructive and Aesthetic Surgery, Bach Mai Hospital, Hanoi, Viet Nam
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10
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Scarabosio A, Tel A, Contessi Negrini F, Albanese R, Robiony M, Parodi P. The shark flap: a modified internal mammary artery perforator flap for composite defects in head and neck reconstruction. Case Reports Plast Surg Hand Surg 2023; 10:2178924. [PMID: 36818191 PMCID: PMC9937011 DOI: 10.1080/23320885.2023.2178924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
This report describes a multi-vector variant of IMAP flap which allows to reconstruct composite head and neck defects. It was named the 'shark flap' because of its shape: a main body (the regular IMAP) and a superior 'fin' based on a randomic vascular pathway.
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Affiliation(s)
- Anna Scarabosio
- Plastic Surgery Resident at Santa Maria della Misericordia Hospital, Udine, Italy,CONTACT Anna Scarabosio Plastic Surgery Resident at Santa Maria della Misericordia Hospital, Udine, Italy
| | - Alessandro Tel
- Maxillo-Facial Surgery Resident at Santa Maria della Misericordia Hospital, Udine, Italy
| | | | - Roberta Albanese
- Plastic Surgery Consultant at Santa Maria della Misericordia Hospital, Udine, Italy
| | - Massimo Robiony
- Maxillo-Facial Surgery Resident at Santa Maria della Misericordia Hospital, Udine, Italy
| | - Piercamillo Parodi
- Plastic Surgery Resident at Santa Maria della Misericordia Hospital, Udine, Italy
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11
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Amrillaeva V, Dralle H, Weber F, Deneken F, Farzaliyev F. The internal mammary artery perforator flap for neck reconstruction after palliative resection of advanced anaplastic thyroid cancer: a case report. J Med Case Rep 2023; 17:8. [PMID: 36624449 PMCID: PMC9830871 DOI: 10.1186/s13256-022-03712-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 12/07/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Defects of the neck after palliative resection of exulcerated tumors could be reconstructed with different skin flaps. CASE PRESENTATION The present report describes the case of a 40-year-old Caucasian female patient with advanced anaplastic thyroid cancer. The exophytically growing, bad-smelling massive exulcerated tumor caused an esthetic defect, neck mobility restrictions, and mental state deterioration. PRIMARY DIAGNOSIS, INTERVENTIONS, AND OUTCOMES Palliative debulking of the tumor was performed. The 10 × 5 cm skin defect of the neck was successfully reconstructed with an internal mammary artery perforator island flap. The donor site was closed primarily. The patient had an uneventful clinical course; the cosmetic results and mental state were very pleasing. CONCLUSIONS The present case illustrates that palliative resection of the tumor and plastic reconstruction of the neck defect promoted other treatments such as radiation or chemotherapy due to the improved local situation.
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Affiliation(s)
- Vera Amrillaeva
- grid.410718.b0000 0001 0262 7331Division of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Essen-Duisburg, Essen, Deutschland
| | - Henning Dralle
- grid.410718.b0000 0001 0262 7331Division of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Essen-Duisburg, Essen, Deutschland
| | - Frank Weber
- grid.410718.b0000 0001 0262 7331Division of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Essen-Duisburg, Essen, Deutschland
| | - Frauke Deneken
- grid.410718.b0000 0001 0262 7331Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital Essen, University Essen-Duisburg, Essen, Germany
| | - Farhad Farzaliyev
- grid.10392.390000 0001 2190 1447Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik, Eberhard Karls University Tuebingen, Schnarrenbergstraße 95, 72076 Tübingen, Germany
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12
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Useful Flaps for Plastic Surgeons to Know. Plast Reconstr Surg 2023; 151:148e-157e. [PMID: 36576829 DOI: 10.1097/prs.0000000000009765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe different useful flaps. 2. Identify pitfalls of specific flaps. 3. Incorporate tips that facilitate flap use. SUMMARY We have a wide selection of flaps to choose from for any given reconstruction. This article describes the use of different flaps that the author has found useful in his practice. Some of these flaps are mainstream, whereas others are not. The article does not suggest that these are the only flaps that one should use, nor does it go into great detail on the dissection of each flap except where the author has identified pitfalls or where he can offer tips and tricks that facilitate use of these flaps. Flaps are described from head to toe.
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13
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Chartier C, Safran T, Alhalabi B, Murphy A, Davison P. "Locoregional perforator flaps in breast reconstruction: An anatomic review & quadrant algorithm". J Plast Reconstr Aesthet Surg 2022; 75:1328-1341. [PMID: 35181248 DOI: 10.1016/j.bjps.2022.01.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 12/14/2021] [Accepted: 01/18/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Plastic surgeons' firm grasp of perforator anatomy allows them to be increasingly mindful of esthetic outcomes, patient satisfaction, and donor-site function when approaching breast reconstruction. Mindfulness of these outcomes has contributed to the widespread use of locoregional perforator flaps in post-mastectomy and post-BCS reconstruction. METHODS A literature search of the PubMed database was performed to identify relevant studies reporting the use of locoregional perforator flaps in post-mastectomy breast reconstruction. Selected manuscripts were analyzed and grouped by pedicled flap category. Articles were additionally assessed for the advantages and disadvantages of each flap and reported complications. RESULTS Following three rounds of review, 30 of 101 (29.7%) articles were retained as specifically pertinent to the use of locoregional flaps in breast reconstruction surgery. They were categorized by locoregional perforator flap used (TDAP, LICAP, AICAP, LTAP, or IMAP). In total, the included studies reported on the use of perforator flaps in 829 patients, with complications occurring in 73 of 418 patients (17.5%). Commonly reported complications across all included studies were hematomas (n = 10), infection (n = 7), fat necrosis/steatofibrosis (n = 31), extruded expanders (n = 1), dehiscence (n = 2), seroma (n = 2), required cosmetic correction of the donor area (n = 5), flap congestion (n = 11), flap failure (n = 2), poor esthetic outcome (n = 4), grade II capsular contracture (n = 3, all of whom received postoperative radiation), and keloid scars(n = 1). CONCLUSIONS Though the available literature remains anecdotal, locoregional flap-based reconstruction may provide some benefit in post-BCS reconstruction by sparing donor-site musculature and nerve supply and by minimizing adverse events.
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Affiliation(s)
- Christian Chartier
- McGill University, Faculty of Medicine, "Division of Plastic and Reconstructive Surgery, Jewish General Hospital, Montreal, Canada
| | - Tyler Safran
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, Canada.
| | - Becher Alhalabi
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, Canada
| | - Amanda Murphy
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, Canada
| | - Peter Davison
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, Canada.
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14
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Angrigiani C, Rancati A, Varela I, Rancati A, Nahabedian MY, Neligan P. The Deltopectoral/Internal Mammary Artery Perforator Flap Revisited: Design Variations Based on Cadaveric and Clinical Investigation. Ann Plast Surg 2022; 88:88-92. [PMID: 33883437 DOI: 10.1097/sap.0000000000002863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Current understanding of the vascular anatomy of the anterior chest wall suggests that perfusion of the deltopectoral flap may be compromised when crossing the midline at the anterior thoracic wall. The traditional deltopectoral flap is designed longitudinally over the ipsilateral side to avoid the risk of distal flap necrosis. The purpose of this article is to present our experience and results with 26 deltopectoral flaps that were designed and raised with the perforating vessels on the ipsilateral side with the majority of the flap crossing the midline extending to the contralateral side. This anatomic variation in flap design indicates that the sternal midline is not a barrier and that the internal mammary perforator flap may be raised on different longitudinal axes.
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Affiliation(s)
- Claudio Angrigiani
- From the VCU College of Medicine-Ionova Branch, National Center for Plastic Surgery, McLean, VA
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15
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Han B, Han Z, Wu J, Fang J. Regional pedicled flaps in prevention and repair of pharyngocutaneous fistulas. Am J Otolaryngol 2021; 42:103119. [PMID: 34175692 DOI: 10.1016/j.amjoto.2021.103119] [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: 04/05/2021] [Revised: 05/31/2021] [Accepted: 06/13/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pharyngocutaneous fistula (PCF) is a common complication after laryngopharyngeal surgery. It presents incredible difficulties to both doctors and patients and can lead to prolonged hospitalization. OBJECTIVE To analyze the pros and cons of the pedicled skin flap in the prevention and repair of PCF and put forward the authors' views and experience about the selection and application of flaps for the treatment of PCF. METHODS A literature review of pedicled flap application in PCF was carried out. RESULTS Based on the analysis of the characteristics of the pedicled flap in PCF treatment, the advantages and disadvantages are compared. RESULTS In the literature, the pectoralis major myocutaneous flap is the most widely used regional pedicled flap for PCF. Many other flaps can be used to prevent and treat PCF. Each kind of pedicled flap has advantages and limitations. This plays a role in the individualized selection and design of PCF to maximize the benefits of patients. CONCLUSIONS Taking unity of function, aesthetics, and proficiency of operators into account, choosing the appropriate flap to repair PCF can reduce the occurrence rate of PCF and improve the patient's quality of life.
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Affiliation(s)
- Bo Han
- Department of General Surgery, Beijing TongRen Hospital, Capital Medical University, No.1 Dong Jiao MinXiang Street, Dongcheng District, Beijing City 100730, China; Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, No.1 Dong Jiao MinXiang Street, Dongcheng District, Beijing City 100730, China; Department of Head and Neck Surgery, BaoTou Cancer Hospital, 18th,Tuanjie Street, Qingshan District, BaoTou, Inner Mongolia 014000, China
| | - Zhengxue Han
- Department of Oral and Maxillofacial-Head and Neck Oncology, Beijing Stomatological Hospital, Capital Medical University, Beijing 100050, China
| | - Jixiang Wu
- Department of General Surgery, Beijing TongRen Hospital, Capital Medical University, No.1 Dong Jiao MinXiang Street, Dongcheng District, Beijing City 100730, China.
| | - Jugao Fang
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, No.1 Dong Jiao MinXiang Street, Dongcheng District, Beijing City 100730, China
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Marsden N, Shukla L, Grinsell D. Case Report: Revisiting the Internal Mammary Artery Perforator Flap: Salvage Option for Circumferential Pharyngo-Esophageal Defects. Front Surg 2021; 8:638345. [PMID: 33816547 PMCID: PMC8011658 DOI: 10.3389/fsurg.2021.638345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 02/22/2021] [Indexed: 11/13/2022] Open
Abstract
Patients that present with pharyngeal strictures and pharyngocutaneous fistulas in the context of previous reconstruction and post-operative radiotherapy often report significant morbidity and reduction in quality of life. Reconstruction of such defects present a substantial clinical challenge requiring the importation of unirradiated vascularized tissue to facilitate healing in a friable, fibrotic, and vessel depleted tissue bed. The authors present a case report demonstrating an adaptation of the internal mammary artery perforator (IMAP) flap for reliable reconstruction of circumferential pharyngeal defects with primary tension free closure of the donor site. This technique avoids the use of free tissue transfer in a hostile, irradiated neck. The tubed IMAP flap is an excellent option, serving the purposes of reconstruction as well as addressing the patient's presenting issues of a chronic sinus and pharyngeal stricture inhibiting oral intake.
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Affiliation(s)
- Nicholas Marsden
- Department of Plastic Surgery, Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Plastic Surgery, St. Vincent's Hospital, Fitzroy, VIC, Australia
| | - Lipi Shukla
- Department of Plastic Surgery, Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Plastic Surgery, St. Vincent's Hospital, Fitzroy, VIC, Australia
| | - Damien Grinsell
- Department of Plastic Surgery, Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Plastic Surgery, St. Vincent's Hospital, Fitzroy, VIC, Australia
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17
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Ogawa R. Propeller Flaps for the Anterior Trunk. Semin Plast Surg 2020; 34:171-175. [PMID: 33041687 PMCID: PMC7542203 DOI: 10.1055/s-0040-1714270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Various types of propeller flaps from multiple donor sites can be used to reconstruct anterior trunk skin defects. The actual selection depends on the condition and location of the recipient site, especially if it is to be the chest or abdomen that requires attention. Before surgery commences, it is always important to use an imaging analyses such as computed tomography angiography to examine and identify perforators that could perfuse a perforator-pedicled propeller flap (PPPF), as it is the most multifaceted imaging technique. Clusters of perforators that can be commonly used for the "workhorse" PPPFs for the thoracic and abdominal regions are the internal mammary artery perforator, the musculophrenic artery perforator, and the deep inferior epigastric perforator. These perforators are reliable and large enough to support long and large propeller flaps that will cover most defects in this region, while still allowing primary donor-site closure.
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Affiliation(s)
- Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
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18
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Almadori G, De Corso E, Visconti G, Almadori A, Di Cintio G, Mele DA, Settimi S, Paludetti G, Salgarello M. Impact of internal mammary artery perforator propeller flap in neck resurfacing and fistula closure after salvage larynx cancer surgery: Our experience. Head Neck 2019; 41:3788-3797. [PMID: 31397524 DOI: 10.1002/hed.25903] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/27/2019] [Accepted: 07/22/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Salvage total laryngectomy (TL) and laryngopharyngectomy (LP) after chemoradiotherapy may produce disfiguring defects with severe complications that require complex reconstructions. METHODS Between January 2012 and December 2018, we enrolled 25 patients who underwent internal mammary artery perforator (IMAP) flap reconstruction after salvage TL or LP. We performed retrospective review of clinical charts to collect information such as history, timing of reconstruction, type of defect, follow-up, donor and recipient site complications, and overall flap survival (OFS) rate. Three years overall survival (OS), relapse-free survival (RFS), and disease-specific survival (DSS) were calculated. RESULTS The OFS rate was 95%. One partial flap necrosis was recorded. No donor-site complications were found. The mean follow-up was 18 months. Three years OS was 44%, RFS was 47%, and DSS was 54%. CONCLUSIONS IMAP flap appears to be safe, versatile, and easy to harvest, with minimal donor site morbidity. It is a reliable option in Head&Neck reconstruction, in salvage surgery as well.
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Affiliation(s)
- Giovanni Almadori
- Cervico-Facial Oncological Surgery Unit, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Eugenio De Corso
- Otorhinolaryngology, Head and Neck Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Visconti
- Plastic and Reconstructive Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Aurora Almadori
- Plastic and Reconstructive Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Giovanni Di Cintio
- Otorhinolaryngology, Head and Neck Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Dario A Mele
- Otorhinolaryngology, Head and Neck Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Stefano Settimi
- Otorhinolaryngology, Head and Neck Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Gaetano Paludetti
- Otorhinolaryngology, Head and Neck Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Marzia Salgarello
- Plastic and Reconstructive Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
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Clinical Application of the Internal Mammary Artery Perforator Adipofascial Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2062. [PMID: 31044102 PMCID: PMC6467605 DOI: 10.1097/gox.0000000000002062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 10/17/2018] [Indexed: 11/28/2022]
Abstract
Background: Skin ulcers on the anterior chest wall are caused mainly by radiation therapy for breast cancer and anterior mediastinitis after thoracotomy, and they are often refractory. Some muscle flaps are commonly used for anterior chest wall reconstruction, but muscle flaps accompany high invasion. We used the internal mammary artery perforator (IMAP) adipofascial flap and IMAP skin flap for the anterior chest wall reconstruction. Methods: We examined the IMAPs using a handheld Doppler device and contrast-enhanced computerized tomography preoperatively. Each flap was designed based on the location of the IMAP and the size of the flap was dependent on the coverage required by the size and location of the skin ulcer. The location of the IMAPs functioned as the pivot point of the flap and the flap was flipped or swung on the defect. Results: We used IMAP adipofascial flap for 2 cases and IMAP skin flap for 1 case. In those 3 cases, we could elevate the flap with no complications even after the internal mammary artery had been harvested. There was no recurrence of the skin ulcer or wound infection after the operation. Conclusions: In this study, we reported 3 cases of skin ulcer on the anterior chest wall reconstructed with the IMAP adipofascial and skin flap. To our knowledge, this is the first report of the use of the IMAP flap as an adipofascial flap. The IMAP adipofascial flap accompanies less invasion than muscle flaps and the surgical procedure is relatively easy. The IMAP adopofascial flap is considered as one of the effective means for anterior chest wall reconstruction.
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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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21
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Myllykangas HMP, Mustonen PK, Halonen JK, Berg LT. Modified internal mammary artery perforator flap in treatment of sternal wound complications. SCAND CARDIOVASC J 2019; 52:275-280. [DOI: 10.1080/14017431.2018.1546897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Heidi-Mari P. Myllykangas
- Department of Plastic Surgery, Kuopio University Hospital, Kuopio, Finland
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Paula K. Mustonen
- Department of Plastic Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Jari K. Halonen
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Department of Cardiothoracic Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Leena T. Berg
- Department of Plastic Surgery, Kuopio University Hospital, Kuopio, Finland
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22
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Kubo T, Seike S, Kiya K, Hosokawa K. Cutaneous resurfacing around a permanent tracheostoma with an internal mammary artery perforator flap. J Surg Case Rep 2018; 2018:rjy183. [PMID: 30093987 PMCID: PMC6077789 DOI: 10.1093/jscr/rjy183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/27/2018] [Accepted: 07/11/2018] [Indexed: 11/14/2022] Open
Abstract
When soft tissue reconstruction near a permanent tracheostoma is needed, transfer of a thin and pliable flap is preferable in order to avoid occlusion of the newly created tracheostomal opening. Although microsurgical fasciocutaneous flap transfer may be desirable for such reconstruction, it is not always an option due to lack of recipient vessels for vascular anastomosis or a patient’s poor medical condition that would prohibit a lengthy procedure. An alternative option is the internal mammary artery perforator flap, which is easy to elevate, has a long arc of rotation, and has a reliable blood supply. Here, we report three cases of cutaneous resurfacing around a permanent tracheostoma with an internal mammary artery perforator flap.
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Affiliation(s)
- Tateki Kubo
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita-shi, Osaka, Japan
- Correspondence address. Department of Plastic Surgery, Osaka University Graduate School of Medicine, 2-2-C11 Yamadaoka, Suita-shi, Osaka 565-0871, Japan. Tel: +81-6-6879-6056; Fax: +81-6-6879-6059; E-mail:
| | - Shien Seike
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita-shi, Osaka, Japan
| | - Koichiro Kiya
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita-shi, Osaka, Japan
| | - Ko Hosokawa
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita-shi, Osaka, Japan
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A New Pedicled Internal Mammary Osteomyocutaneous Chimeric Flap (PIMOC) for Salvage Head and Neck Reconstruction: Anatomic Study and Clinical Application. Sci Rep 2017; 7:12960. [PMID: 29021615 PMCID: PMC5636798 DOI: 10.1038/s41598-017-13428-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 09/25/2017] [Indexed: 11/08/2022] Open
Abstract
Well-vascularized composite tissue offers improved outcomes for complex head and neck reconstruction. Patients with vessel-depleted necks and failed reconstructions require alternative reconstructive options. We describe a pedicled internal mammary artery osteomyocutaneous chimeric flap (PIMOC) for salvage head and neck reconstruction. Bilateral dissections of 35 fresh cadavers were performed to study individual tissue components and vascular pedicles to develop the PIMOC technique. The flap was then utilized in a series of patients with vessel-depleted neck anatomy. The PIMOC was dissected bilaterally in all cadavers and there were no statistical differences in vascular pedicle caliber or length with regards to laterality or gender. Five patients subsequently underwent this procedure. The flaps included a vertical rectus abdominis myocutaneous component and a 6th or 7th rib with adjacent muscle and skin to restore bone defects, internal lining, and external coverage. All donor sites were closed primarily. There were no flap losses and all patients gained improvements in facial contour, speech and swallow. Although technically complex, the PIMOC is reproducible and provides a safe and reliable option for salvage head and neck reconstruction. The harvest of the 6th or 7th rib and rectus abdominis muscle renders an acceptable donor site.
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24
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The Simultaneous Use of Breast Reduction and Internal Mammary Artery Perforator Flap in Sternal Wound Reconstruction. Ann Plast Surg 2017; 78:236-239. [DOI: 10.1097/sap.0000000000000858] [Citation(s) in RCA: 4] [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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25
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Wong S, Goggin JD, Webster ND, Saint-Cyr MH. Pre-expanded Internal Mammary Artery Perforator Flap. Clin Plast Surg 2017; 44:65-72. [DOI: 10.1016/j.cps.2016.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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26
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Li H, Zhou Y, Du Z, Gu B, Liu K, Xie F, Xie Y, Herrler T, Li Q, Zan T. Strategies for customized neck reconstruction based on the pre-expanded superficial cervical artery flap. J Plast Reconstr Aesthet Surg 2015; 68:1064-71. [PMID: 25964230 DOI: 10.1016/j.bjps.2015.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 03/19/2015] [Accepted: 04/06/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND It is still highly challenging to restore the esthetic neck contour for postburn deformities. In many patients with burns, the back skin remains intact, which is a useful donor site for extensive contracture release. As the main technique, the refinement of the pre-expanded superficial cervical artery (SCA) flaps may improve its application in diverse neck contractures. METHODS This study reviewed the cases of three types of neck contractures that were reconstructed with pre-expanded SCA flaps: (1) for unilateral neck contractures, the flaps were harvested as pedicled perforator flaps including a small amount of muscle; (2) for lateral and anterior neck contractures, vascular augmentation with circumflex scapular vessels was used to increase the flap size; (3) for contractures of the entire neck, maximal flap release with pedicle dissection toward the origin of the superficial cervical vessels allowed for reaching contralateral defects. RESULTS From March 2010 to September 2012, pre-expanded SCA flaps were recommended in 15 patients with severe neck contracture. Tip necrosis occurred in one patient. The donor sites were closed primarily in all cases. One patient had donor-site wound dehiscence that healed within 2 weeks by conservative management. All patients had restored neck extension to a near-normal position without the sense of restricted neck flexion or rotation. CONCLUSIONS Pre-expanded SCA flaps are practical and flexible for the reconstruction of diverse scar contractures ranging from unilateral to total neck lesions. Considering the reconstructive efficiency and the reduced donor-site morbidity, this flap may be an ideal option for the reconstruction of severe neck scar contractures.
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Affiliation(s)
- Haizhou Li
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, China
| | - Yiwen Zhou
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, China
| | - Zijing Du
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, China
| | - Bin Gu
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, China
| | - Kai Liu
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, China
| | - Feng Xie
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, China
| | - Yun Xie
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, China
| | - Tanja Herrler
- Hand, Plastic, and Aesthetic Surgery, Department of General, Trauma, Hand, and Plastic Surgery, University of Munich, Munich, Germany
| | - Qingfeng Li
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, China.
| | - Tao Zan
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, China.
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Reconstructive options in patients with late complications after surgery and radiotherapy for head and neck cancer: remember the deltopectoral flap. Ann Plast Surg 2014; 71:181-5. [PMID: 22868303 DOI: 10.1097/sap.0b013e3182414612] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
During the past 40 years, free vascularized flaps have become the golden standard in the reconstruction of postoncologic head and neck defects. When there is a need for an osteofasciocutaneous free flap, the free fibula flap is the first choice because of the advantages of its long bone structure, high reliability, and minimal donor-site morbidity. However, most of these patients receive adjuvant radiation therapy, which sometimes causes symptomatic fibrosis, contractures, and (osteo)radionecrosis. In case of these late complications, locoregional reconstructive options are often limited, and complex secondary free flap procedures are not always feasible or preferred by the patient. The present paper discusses regional and free flap reconstructive options and demonstrates with 3 cases that the delayed deltopectoral flap remains a very safe, reliable, and easy flap, which still has a place in the management of these complex reconstructive challenges.
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28
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Schmidt M, Tinhofer I, Duscher D, Huemer GM. Perforasomes of the upper abdomen: An anatomical study. J Plast Reconstr Aesthet Surg 2014; 67:42-7. [DOI: 10.1016/j.bjps.2013.08.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 08/17/2013] [Accepted: 08/22/2013] [Indexed: 10/26/2022]
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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: 7] [Impact Index Per Article: 0.6] [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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30
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Huguier V, Dagrégorio G, Darsonval V, Arnaud D, Potier B, Rousseau P. [Cheek reconstruction]. ANN CHIR PLAST ESTH 2013; 58:457-514. [PMID: 24125779 DOI: 10.1016/j.anplas.2013.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 07/03/2013] [Indexed: 11/29/2022]
Abstract
We describe the different cheek reconstruction techniques with primary emphasis on the superficial layers. In addition to the clinical context, location and size of the lesion will be taken into account to choose the best method that will optimize the functional and aesthetic results while minimizing potential sequelae. Main evaluation criteria include absence of natural orifice deformation, scar location, skin cover quality and respect of volumes.
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Affiliation(s)
- V Huguier
- Service de chirurgie plastique, CHU, 2, rue de la Milétrie, 86021 Poitiers cedex, France.
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31
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Mirghani H, Leymarie N, Amen F, Qassemyar Q, Leclère FM, Kolb F. Pharyngotracheal fistula closure using the internal mammary artery perforator island flap. Laryngoscope 2013; 124:1106-11. [DOI: 10.1002/lary.24372] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/29/2013] [Accepted: 07/29/2013] [Indexed: 11/06/2022]
Affiliation(s)
- Haïtham Mirghani
- Department of Head and Neck Surgery; Institut de Cancérologie Gustave Roussy; Villejuif Amiens France
| | - Nicolas Leymarie
- Department of Plastic Surgery; Institut de Cancérologie Gustave Roussy; Villejuif Amiens France
| | - Furrat Amen
- Department of Head and Neck Surgery; Institut de Cancérologie Gustave Roussy; Villejuif Amiens France
| | - Quentin Qassemyar
- Department of Maxillofacial Surgery; Amiens North Hospital; Amiens France
| | - Franck Marie Leclère
- Department of Plastic Surgery; Institut de Cancérologie Gustave Roussy; Villejuif Amiens France
| | - Frederic Kolb
- Department of Plastic Surgery; Institut de Cancérologie Gustave Roussy; Villejuif Amiens France
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Zan T, Li H, Du Z, Gu B, Liu K, Xie F, Xie Y, Li Q. Reconstruction of the face and neck with different types of pre-expanded anterior chest flaps: A comprehensive strategy for multiple techniques. J Plast Reconstr Aesthet Surg 2013; 66:1074-81. [DOI: 10.1016/j.bjps.2013.04.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 03/25/2013] [Accepted: 04/01/2013] [Indexed: 10/26/2022]
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Kim KS, Kim ES, Hwang JH, Lee SY. Internal mammary artery perforator-based V-Y advancement flap for the reconstruction of soft tissue defects in the sternal region. J Plast Surg Hand Surg 2013; 47:543-4. [PMID: 23848419 DOI: 10.3109/2000656x.2012.748305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We successfully reconstructed a large defect that had been created by resection of an unstable, contracted, and hypertrophic scar with a chronic ulcer on the lower sternal area of a 67-year-old man. We used bilateral V-Y advancement flaps based on internal mammary artery perforators.
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Affiliation(s)
- Kwang Seog Kim
- Department of Plastic and Reconstructive Surgery, Chonnam National University Medical School , Gwangju , Korea
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Takeuchi M, Sakurai H. Internal mammary artery perforator flap for reconstruction of the chest wall. J Plast Surg Hand Surg 2013; 47:328-30. [DOI: 10.3109/2000656x.2012.718893] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Masaki Takeuchi
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University Yachiyo Medical Center, Chiba.
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Clinical Application of the Internal Mammary Artery Perforator Flap in Head and Neck Reconstruction. Plast Reconstr Surg 2013; 131:520e-526e. [DOI: 10.1097/prs.0b013e3182818c08] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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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Shayan R, Syme D, Grinsell D. The IMAP flap for pharygoesophageal reconstruction following stricture release. J Plast Reconstr Aesthet Surg 2012; 65:810-3. [DOI: 10.1016/j.bjps.2011.11.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 11/07/2011] [Indexed: 11/26/2022]
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Rüegg EM, Lantieri L, Marchac A. Dual perforator propeller internal mammary artery perforator (IMAP) flap for soft-tissue defect of the contralateral clavicular area. J Plast Reconstr Aesthet Surg 2012; 65:1414-7. [PMID: 22503312 DOI: 10.1016/j.bjps.2012.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Revised: 03/04/2012] [Accepted: 03/05/2012] [Indexed: 10/28/2022]
Abstract
The internal mammary artery perforator (IMAP) flap represents the evolution from axially pedicled flaps (deltopectoral flap) to perforator flaps. Both flaps are typically used for neck and tracheostoma reconstruction in male patients. We present the case of a 68-year-old obese female patient with a right upper thoracic radionecrosis secondary to breast irradiation. Soft-tissue defect measured 12×18 cm. She also complained of left breast hypertrophy. Following radical debridement, a left IMAP flap extending from midline to the anterior axillary fold was raised, based on the second and fourth IMAP vessels. The flap was rotated 180° on its second and fourth perforators to cover the defect and the left breast was reshaped. The flap survived entirely and wound healing was uneventful. Ptosis and breast hypertrophy were corrected at the same time. The IMAP flap can be harvested all the way to the anterior axillary fold and used as a large propeller flap, which makes this flap suitable for contralateral thoracic reconstructions, even in female patients.
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Affiliation(s)
- Eva Meia Rüegg
- Department of Plastic Surgery, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
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Chen WF, Tsao CK, Cheng MH. A novel salvage approach for pedicle axial flap-free-ization of pedicle internal mammary artery perforator flap. Microsurgery 2012; 32:314-7. [DOI: 10.1002/micr.21962] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 12/25/2011] [Accepted: 12/28/2011] [Indexed: 11/07/2022]
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Abou-Gamrah S, Abdel-Monem K, Elshahat A, Abol-Atta HE, Eltawab RA, Massoud K. Role of color duplex sonography in pre-operative internal mammary artery perforators assessment for breast reconstruction using contralateral lower pole flap. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2012. [DOI: 10.1016/j.ejrnm.2011.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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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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A Cadaver Study of the Vascular Territories of Dominant and Nondominant Internal Mammary Artery Perforators. Ann Plast Surg 2011; 67:68-72. [DOI: 10.1097/sap.0b013e3181e5bf67] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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44
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Use of the Internal Mammary Artery Perforator Flap for Repair of Pharyngocutaneous Fistulas in the Vessel-Depleted Neck. J Oral Maxillofac Surg 2011; 69:1225-8. [DOI: 10.1016/j.joms.2010.04.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Accepted: 04/24/2010] [Indexed: 11/18/2022]
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Schellekens PP, Paes EC, Hage JJ, van der Wal MB, Bleys RL, Kon M. Anatomy of the vascular pedicle of the internal mammary artery perforator (IMAP) flap as applied for head and neck reconstruction. J Plast Reconstr Aesthet Surg 2011; 64:53-7. [DOI: 10.1016/j.bjps.2010.03.054] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Accepted: 03/28/2010] [Indexed: 11/29/2022]
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46
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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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Schellekens P, Hage J, Paes E, Kon M. CORRESPONDENCE: HOW WE DO IT: The internal mammary artery perforator pedicled island flap for reconstruction of the lower head and neck and supraclavicular region: how we do it. Clin Otolaryngol 2010; 35:332-6. [DOI: 10.1111/j.1749-4486.2010.02171.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Iyer NG, Clark JR, Ashford BG. Internal mammary artery perforator flap for head and neck reconstruction. ANZ J Surg 2010; 79:799-803. [PMID: 20078529 DOI: 10.1111/j.1445-2197.2009.05097.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The internal mammary artery perforator (IMAP) flap is a useful modification of the classic deltopectoral flap that has a number of important roles in head and neck reconstruction. METHODS AND RESULTS In this report, we describe the technique used to plan and raise the flap and demonstrate its use in three different clinical scenarios. RESULTS AND CONCLUSIONS The IMAP flap is a pedicled fasciocutaneous flap that is based on single or multiple internal mammary artery perforators. As such, it provides thin pliable tissue with a wide arc of rotation that is suitable for cutaneous, pharyngeal and tracheostomal reconstruction. Moreover, the flap is well-vascularised, reliable and the donor site can be closed primarily.
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Affiliation(s)
- N Gopalakrishna Iyer
- Sydney Head and Neck Cancer Institute, Sydney Cancer Centre, Royal Prince Alfred Hospital, New South Wales, Australia.
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50
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Neligan PC. Discussion of: The anatomic basis of the internal mammary artery perforator flap: a cadaver study. J Plast Reconstr Aesthet Surg 2010; 63:197. [DOI: 10.1016/j.bjps.2008.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 09/29/2008] [Indexed: 10/21/2022]
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