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Changchien CH, Fang CL, Hsu CH, Yang HY, Lin YL. Creating a context for recipient vessel selection in deep inferior epigastric perforator flap breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 84:618-625. [PMID: 37453149 DOI: 10.1016/j.bjps.2023.06.049] [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: 03/24/2023] [Revised: 05/27/2023] [Accepted: 06/22/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND In autologous tissue breast reconstruction, recipient vessels are important for artery perfusion and venous drainage to ensure free flap survival. There are insufficient clinical outcomes to select efficient recipient vessels in bi-pedicled deep inferior epigastric perforator (DIEP) flap reconstruction. METHODS We presented a retrospective observational series of 108 patients regarding the diameter, anastomosis time, and re-anastomosis rate in internal mammary (IM), circumflex scapular (CS), thoracodorsal (TD), thoracoacromial (TA), lateral thoracic (LT), and internal mammary perforator (IMP) vessels of bi-pedicled DIEP flaps for breast reconstruction after mastectomy. The outcomes were the vessel re-anastomosis rate, flap failure rate, vessel anastomosis time, and complications. Data were gleaned from the chi-square test, Fisher's test, and analysis of variance using Scheffe's test as a post hoc analysis. The level of significance was p < 0.05. RESULTS There were no significant differences in the diameters of the artery, first vein, and second vein across the recipient vessels (p > 0.05). However, the anastomosis time was longer in IM and TA than in CS, TD, and LT (p < 0.001). Also, there were no significant differences for re-anastomosis, flap necrosis, and fat necrosis among different recipient vessels (p > 0.05). CONCLUSIONS Because of the altered mastectomy incisions, this study provides complete anatomical vascular properties and suggests that altering recipient vessel selection for bi-pedicled DIEP flaps can shorten anastomosis time and better conceal scars.
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Affiliation(s)
- Chih-Hsuan Changchien
- Division of Plastic and Reconstruction Surgery, Department of Surgery, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan; Department of Medical Laboratory Science and Biotechnology, College of Medical and Health Science, Asia University, Taichung City, Taiwan.
| | - Chien-Liang Fang
- Division of Plastic and Reconstruction Surgery, Department of Surgery, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan; Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung City, Taiwan.
| | - Chin-Hao Hsu
- Division of Plastic and Reconstruction Surgery, Department of Surgery, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan.
| | - Hsin-Yi Yang
- Clinical Medical Research Center, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan.
| | - Yi-Ling Lin
- Division of Plastic and Reconstruction Surgery, Department of Surgery, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan.
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Ahmed Z, Ioannidi L, Ghali S, Hamilton S, Shtarbanov P, Mosahebi A, Nikkhah D. A Single-center Comparison of Unipedicled and Bipedicled Diep Flap Early Outcomes in 98 Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5089. [PMID: 37361509 PMCID: PMC10289681 DOI: 10.1097/gox.0000000000005089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/02/2023] [Indexed: 06/28/2023]
Abstract
The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. One or two pedicles may be used. Our study is the first to compare unipedicled and bipedicled DIEP flaps on donor and recipient site outcomes in the same patient cohort. Methods This is a retrospective cohort study comparing DIEP flap outcomes between 2019 and 2022. Results There were 98 patients, categorized differently for recipient or donor site. The recipient groups were unilateral unipedicled (N = 52), bilateral unipedicled (N = 15), and unilateral bipedicled (N = 31), and donor site groups were unipedicled (N = 52) and bipedicled (N = 46, including bilateral unipedicled and unilateral bipedicled). Bipedicled DIEP flaps had 1.15 times greater odds of donor site complication (95% CI, 0.52-2.55). Adjusting for operative time that was longer in bipedicled DIEP flaps (P < 0.001), odds ratio decreased, and there was a lower probability of donor site complication for bipedicled flaps (OR, 0.84; 95% CI, 0.31-2.29). Odds of recipient area complication was not significantly different between groups. Unilateral unipedicled DIEP flaps had significantly higher rates of revisional elective surgery than unilateral bipedicled DIEP flaps (40.4% versus 12.9%; P = 0.029). Conclusions We demonstrate no significant difference in donor site morbidity between unipedicled and bipedicled DIEP flaps. Bipedicled DIEP flaps do have slightly higher rates of donor site morbidity, which can be partly explained by longer operative times. There is no significant difference in recipient site complications, and bipedicled DIEP flaps can reduce rates of further elective surgery.
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Affiliation(s)
- Zahra Ahmed
- From the Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
| | - Lydia Ioannidi
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Shadi Ghali
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Stephen Hamilton
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Petko Shtarbanov
- Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
| | - Afshin Mosahebi
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, United Kingdom
- Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
| | - Dariush Nikkhah
- Department of Plastic and Reconstructive Surgery, Royal Free London NHS Foundation Trust, London, United Kingdom
- Division of Surgery and Interventional Sciences, University College London, London, United Kingdom
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Analysis of Breast Aesthetic Revision Procedures after Unilateral Abdominal-based Free-flap Breast Reconstruction: A Single-center Experience with 1251 Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4861. [PMID: 36910732 PMCID: PMC9995106 DOI: 10.1097/gox.0000000000004861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/24/2023] [Indexed: 03/11/2023]
Abstract
Although autologous free-flap breast reconstruction is the most durable means of reconstruction, it is unclear how many additional operations are needed to optimize the aesthetic outcome of the reconstructed breast. The present study aimed to determine the average number of elective breast revision procedures performed for aesthetic reasons in patients undergoing unilateral autologous breast reconstruction and to analyze variables associated with undergoing additional procedures. Methods A retrospective review of all unilateral abdominal-based free-flap breast reconstructions performed from 2000 to 2014 was undertaken at a tertiary academic center. Results Overall, 1251 patients were included in the analysis. The average number of breast revision procedures was 1.1 ± 0.9, and 903 patients (72.2%) underwent at least one revision procedure. Multiple logistic regression analysis demonstrated that younger age, higher body mass index, and prior oncologic surgery on the reconstructed breast were factors associated with increased likelihood of undergoing a revision procedure. The probability of undergoing at least one revision increased by 4% with every 1-unit (kg/m2) increase in a patient's body mass index. Multiple Poisson regression modeling demonstrated that younger age, prior oncologic surgery on the reconstructed breast, and bipedicle flap reconstruction were significant factors associated with undergoing a greater number of revision procedures. Conclusions Most patients who undergo unilateral autologous breast reconstruction require at least one additional operation to optimize their breast aesthetic results. Young age and obesity increase the likelihood of undergoing additional operations. These findings can aid reconstructive microsurgeons in counseling patients and establishing patient expectations prior to their undergoing microvascular breast reconstruction.
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Bipedicled SIEA Flap with Deep Inferior Epigastric Artery and Vein Grafts for Breast Reconstruction. Plast Reconstr Surg Glob Open 2022; 10:e4484. [PMID: 36032370 PMCID: PMC9400944 DOI: 10.1097/gox.0000000000004484] [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: 05/11/2022] [Accepted: 06/30/2022] [Indexed: 11/25/2022]
Abstract
A superficial inferior epigastric artery (SIEA) flap can be an alternative to a deep inferior epigastric artery perforator (DIEAP) flap in cases where SIEAs are relatively well developed. Although an SIEA flap is less invasive than a DIEAP flap, the pedicles of the former are anatomically shorter, making it more difficult to choose recipient vessels when bilateral SIEAs are necessary. A 45-year-old female diagnosed with cancer of the left breast underwent mastectomy (specimen weight: 750 g) and immediate two-stage breast reconstruction using a free abdominal flap with bilateral pedicles was planned. Preoperative computed tomographic angiography showed that the bilateral DIEAPs in the flap were less than one millimeter in diameter, whereas the bilateral SIEAs were well developed enough for us to opt for a double-pedicled stacked SIEA flap. After the double-pedicled SIEA flap was elevated, folded, and temporarily placed in the subcutaneous pocket, the pedicle length on one side was found to be insufficient. Therefore, portions of the right composite deep inferior epigastric artery (DIEA) and vein (DIEV) grafts (roughly 7 cm) were collected from a short fasciotomy and anastomosed to the peripheral ends of the right SIEA and SIEV, respectively. Following this, the left SIEA and SIEV were antegradely anastomosed to the internal mammary artery and vein (IMA/IMV), while the DIEA/DIEV grafts were retrogradely anastomosed to the IMA/IMV, respectively. We recommend the proactive use of this method, as pedicle extension using the DIEA/DIEV grafts enables a higher degree of freedom in unilateral breast reconstruction using bilateral SIEA flaps.
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Bigdeli AK, Momeni A, Kneser U. [Increasing Safety in Microsurgical Breast Reconstruction - Technique and Technology]. HANDCHIR MIKROCHIR P 2022; 54:314-325. [PMID: 35785806 DOI: 10.1055/a-1858-5214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Microsurgical reconstruction has established itself as a standard procedure in breast reconstruction as it permits creation of a natural and aesthetically appealing breast mound, even after modified radical mastectomy and radiation. In the past few decades numerous new free flap donor-sites have been described that permit an individualized approach to reconstruction, thus, resulting in a high level of patient satisfaction. Paralleling these technical innovations, the focus of microsurgical breast reconstruction has shifted from mere "flap success" to "aesthetic outcome", while also taking into account the respective donor-site morbidity. Here, the authors discuss contemporary developments in the field with a particular focus on surgical techniques and technologies that contribute to increasing the safety of microsurgical breast reconstruction.
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Affiliation(s)
- Amir Khosrow Bigdeli
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie - Schwerbrandverletztenzentrum BG Klinik Ludwigshafen, Ludwigshafen, Germany.,Klinik für Hand- und Plastische Chirurgie der Ruprecht-Karls-Universität Heidelberg Heidelberg, Heidelberg, Germany
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Ulrich Kneser
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie - Schwerbrandverletztenzentrum BG Klinik Ludwigshafen, Ludwigshafen, Germany.,Klinik für Hand- und Plastische Chirurgie der Ruprecht-Karls-Universität Heidelberg Heidelberg, Heidelberg, Germany
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6
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Zoccali G, Blackburn A, Francesca R, Alexandra M, Farhadi J. Safe mobilisation of transverse upper gracilis flap in patients with hip replacements. J Plast Reconstr Aesthet Surg 2022; 75:2970-2973. [DOI: 10.1016/j.bjps.2022.06.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 04/30/2022] [Accepted: 06/10/2022] [Indexed: 11/28/2022]
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7
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Khattab NR. Complications of free bipedicled DIEP flaps in breast reconstruction: a systematic review and meta-analysis. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01862-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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8
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Zoccali G, Farhadi J. Abdominal perforator exchange flap (APEX): A classification of pedicle rearrangements. Microsurgery 2021; 41:607-614. [PMID: 34387913 DOI: 10.1002/micr.30796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/27/2021] [Accepted: 08/05/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Abdominal-based reconstruction is the most commonly performed method for breast reconstruction after mastectomy using the patient's own tissues. DIEP flap has allowed to reduce the donor site morbidity but the incidence of bulging or hernia remains still high, especially when flap is based on multiple perforators. Abdominal Perforator Exchange flap (APEX) represents a further step forward in preserving the abdominal wall structures by disassembling the pedicle components and their reconstitution at the end of the dissection. In this study, we explore the possible anatomical configurations of perforators exchange for APEX, providing a simple classification of perforators reconstitution patterns and the possible clinical implications. MATERIALS AND METHODS A retrospective study was conducted on patients who received APEX flap for abdominal based breast reconstruction. Preoperative CT scans and procedure descriptions were analyzed to identify the vascular patterns during flap harvesting and the pedicle reconstitution sites. The onset of abdominal wall and flap related complications were investigated. RESULTS APEX flap was performed on 51 women and four vascular patterns were identified. We identified the Type A pattern in 36 cases (70.6%), the Type B pattern in 8 (15.7%), and the Type C pattern in 5 (9.8%). We performed an extra-anatomical reanastomosis (Type D) in only two case (3.9%) (p = .09). We recorded anastomotic problems in five pedicles' reconstitution and the odds ratio showed a possible correlation between the localization of pedicle division and the anastomosis problems (p > .05). No total or partial flap loss was recorded during this study. Marginal fat necrosis was clinically observed in three cases, which had very large flaps. No bulging or hernia was recorded. CONCLUSION Our perforators exchange classification for abdominal-based flap helps clinician in planning the surgery and also in describing the procedure easily allowing a more efficient communication. This classification could be used to approach perforator flaps with multiple vessels at other anatomical locations as well.
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Affiliation(s)
- Giovanni Zoccali
- Plastic and Reconstructive Surgery Department, Queen Victoria Hospital, East Grinstead, UK
| | - Jian Farhadi
- Plastic Surgery Group, Zurich, Switzerland.,University of Basel, Faculty of Medicine, Basel, Switzerland
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Di Pace B, Khan F, Patel M, Serlenga G, Sorotos M, Alfano C, Santanelli di Pompeo F, Rubino C, Malata CM. A multicentre study of the relationship between abdominal flap and mastectomy weights in immediate unilateral free flap breast reconstruction and the effect of adjuvant radiotherapy. J Plast Reconstr Aesthet Surg 2021; 75:61-68. [PMID: 34272176 DOI: 10.1016/j.bjps.2021.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/04/2021] [Accepted: 06/02/2021] [Indexed: 12/15/2022]
Abstract
Abdominal free flaps are considered the gold standard for post-mastectomy autologous breast reconstruction. A key element of outcome assessment is breast symmetry often achieved by approximating the reconstructed breast dimensions such as weight (wt) to those of the mastectomy. However, the ideal relationship between these two entities remains unclear. 525 immediate unilateral abdominal free flap breast reconstruction (FFBR) patients were enrolled in a multicentre study (UK 141; Italy 384) and subdivided into Group A (flap wt < mastectomy wt, n = 163), Group B (flap wt > mastectomy wt, n = 260) and Group C (flap wt = mastectomy wt, n = 102). Their rates of contralateral balancing and ipsilateral revision surgeries were compared using Chi-Square tests. Radiotherapy influence on these adjustment procedures was also assessed. More contralateral balancing procedures (17%) were performed than ipsilateral revisions (10%). Group A rates of contralateral balancing procedures were three times higher than Group B's with a ratio of 37 to 1 versus Group C (37% vs 11% vs 1% respectively, p < 0.001). Similarly, the ipsilateral breast revision surgery rate in Group A was double that of Group B and almost three times that of Group C (17% vs 8% vs 6% respectively, p = 0.01). Adjuvant radiotherapy disproportionately increased ipsilateral revisions versus contralateral balancing surgeries (p = 0.028). A flap-to-mastectomy weight ratio of less than 1 (Group A) significantly increases subsequent adjustments on both contralateral and reconstructed breasts whilst irradiation predisposes to ipsilateral revisions. This is important in patient counselling and intraoperative flap contouring. Flap weight should ideally approximate or exceed mastectomy weight in unilateral FFBR.
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Affiliation(s)
- Bruno Di Pace
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", PhD School of Translational Medicine of Development and Active Aging, University of Salerno, Salerno, Italy; Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, UK
| | - Farhaan Khan
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Manal Patel
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Gabriella Serlenga
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", San Giovanni di Dio e Ruggi D'Aragona University Hospital, University of Salerno, Salerno, Italy
| | - Michail Sorotos
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", PhD School of Translational Medicine of Development and Active Aging, University of Salerno, Salerno, Italy; Plastic Surgery Unit, Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Carmine Alfano
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", San Giovanni di Dio e Ruggi D'Aragona University Hospital, University of Salerno, Salerno, Italy
| | - Fabio Santanelli di Pompeo
- Plastic Surgery Unit, Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Corrado Rubino
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy; Plastic Surgery Unit, Department of Oncology and Haematology, University Hospital Trust of Sassari, Sassari, Italy
| | - Charles M Malata
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, UK; Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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10
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Bond ES, Soteropulos CE, Yang Q, Poore SO. The Impact of Prior Abdominal Surgery on Complications of Abdominally Based Autologous Breast Reconstruction: A Systematic Review and Meta-Analysis. J Reconstr Microsurg 2021; 37:566-579. [PMID: 33648009 DOI: 10.1055/s-0041-1723816] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Approximately half of all patients presenting for autologous breast reconstruction have abdominal scars from prior surgery, the presence of which is considered by some a relative contraindication for abdominally based reconstruction. This meta-analysis examines the impact of prior abdominal surgery on the complication profile of breast reconstruction with abdominally based free tissue transfer. METHODS Literature search was conducted using PubMed, Scopus, and Web of Science. Included studies examined patients with a history of prior abdominal surgery who then underwent abdominally based free flap breast reconstruction. Prior liposuction patients and those with atypical flap designs were excluded. The Newcastle-Ottawa Scale was used to assess study quality. Flap complications included total and partial flap loss, fat necrosis, infection, and reoperation. Donor-site complications included delayed wound healing, infection, seroma, hematoma, and abdominal wall morbidity (hernia, bulge, laxity). Relative risk and 95% confidence intervals (CIs) between groups were calculated. Forest plots, I 2 statistic heterogeneity assessments, and publication bias funnel plots were produced. Publication bias was corrected with a trim-and-fill protocol. Overall effects were assessed by fixed-effects and random-effects models. RESULTS After inclusion and exclusion criteria were applied, 16 articles were included for final review. These included 14 cohort and 2 case-control studies, with 1,656 (46.3%) patients and 2,236 (48.5%) flaps having undergone prior surgery. Meta-analysis showed patients with prior abdominal surgery were significantly more likely to experience donor-site delayed wound healing with a risk ratio of 1.27 (random 95% CI [1.00; 1.61]; I 2= 4) after adjustment for publication bias. No other complications were statistically different between groups. CONCLUSION In patients with a history of prior abdominal surgery, abdominally based free tissue transfer is a safe and reliable option. Abdominal scars may slightly increase the risk of delayed donor-site wound healing, which can aid the surgeon in preoperative counseling.
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Affiliation(s)
- Evalina S Bond
- Department of Surgery, Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Carol E Soteropulos
- Department of Surgery, Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Qiuyu Yang
- Department of Surgery, Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Samuel O Poore
- Department of Surgery, Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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11
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Salibian AA, Nolan IT, Bekisz JM, Frey JD, Karp NS, Choi M, Levine JP, Thanik VD. A Systematic Review and Meta-Analysis of Microvascular Stacked and Conjoined-Flap Breast Reconstruction. J Reconstr Microsurg 2021; 37:631-642. [PMID: 33592635 DOI: 10.1055/s-0041-1723820] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Stacked and conjoined (SC) flaps are a useful means of increasing flap volume in autologous breast reconstruction. The majority of studies, however, have been limited to smaller, single-center series. METHODS A systematic literature review was performed to identify outcomes-based studies on microvascular SC-flap breast reconstruction. Pooled rates of flap and operative characteristics were analyzed. Meta-analytic effect size estimates were calculated for reconstructive complication rates and outcomes of studies comparing SC flaps to non-SC flaps. Meta-regression analysis identified risk factors for flap complications. RESULTS Twenty-six studies were included for analysis (21 case series, five retrospective cohort studies) for a total of 869 patients, 1,003 breasts, and 2006 flaps. The majority of flaps were harvested from the bilateral abdomen (78%, 782 breasts) followed by combined abdomen-thigh stacked flaps (22.2%, 128 breasts). About 51.1% of flaps were anastomosed to anterograde/retrograde internal mammary vessels (230 breasts) and 41.8% used internal mammary/intraflap anastomoses (188 breasts). Meta-analysis revealed a rate of any flap complication of 2.3% (95% confidence interval: 1.4-3.3%), Q-statistic value p = 0.012 (I 2 = 43.3%). SC flaps had a decreased risk of fat necrosis compared with non-SC flaps (odds ratio = 0.126, p < 0.0001, I 2 = 0.00%), though rates of any flap and donor-site complication were similar. Age, body mass index, flap weight, and flap donor site and recipient vessels were not associated with increased risk of any flap complication. CONCLUSION A global appraisal of the current evidence demonstrated the safety of SC-flap breast reconstruction with low complication rates, regardless of donor site, and lower rates of fat necrosis compared with non-SC flaps.
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Affiliation(s)
- Ara A Salibian
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Ian T Nolan
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Jonathan M Bekisz
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Jordan D Frey
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Nolan S Karp
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Mihye Choi
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Jamie P Levine
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Vishal D Thanik
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
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12
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Muñoz KDR, Powers JM, Zhang S, Kale SS. Prevalence and Utilization of Obturator Artery Anatomic Variant in Autologous Breast Reconstruction. J Reconstr Microsurg 2020; 37:256-262. [PMID: 33032357 DOI: 10.1055/s-0040-1717153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The objective of this study is to quantify the prevalence and describe the utilization of an anatomic vascular variant in which the obturator artery (OA) arises from the trunk of the deep inferior epigastric artery (DIEA) in stacked/dual-pedicled autologous breast reconstruction. When this variant is identified preoperatively on computed tomography angiography (CTA), it may be utilized in a "flow-through" fashion to direct antegrade internal mammary artery (IMA) flow into a second free flap to facilitate anastomotic arrangement and optimize perfusion. METHODS Preoperatively obtained abdomen/pelvis CTA imaging of 121 autologous breast reconstruction patients were retrospectively reviewed for the unilateral or bilateral presence of the OA branch arising from the DIEA (OA variant). The results were analyzed using descriptive statistics. RESULTS Our analysis revealed the presence of the OA variant in 60 of the 121 (49.6%) breast reconstruction candidates, either unilaterally or bilaterally. Out of these patients, the variant was present unilaterally in 33 (55%) and bilaterally in 27 (45%) patients. Of the unilateral variants, 12 (36.4%) patients demonstrated right-sided laterality, while 21 (63.6%) patients demonstrated left-sided laterality. Clinically, this anatomic variant has been utilized in several cases of autologous breast reconstruction with flap survival in all cases. CONCLUSION Utilization of this anatomic variant in stacked or dual-pedicled autologous breast reconstruction results in antegrade IMA perfusion of both primary and secondary flaps, as well as improved size match compared with other anastomotic options. Knowledge of the vascular anatomy and variations in the inferior epigastric system is crucial to both preventing complications and optimizing flap planning and outcome.
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Affiliation(s)
| | - Jeremy M Powers
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Virginia Commonwealth University Health, Richmond, Virginia
| | - Shuhao Zhang
- Department of Plastic Surgery, Mercy Medical Group, Sacramento, California
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14
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Salibian AA, Bekisz JM, Frey JD, Nolan IT, Kaoutzanis C, Yu JW, Levine JP, Karp NS, Choi M, Thanik VD. Comparing outcomes between stacked/conjoined and non-stacked/conjoined abdominal microvascular unilateral breast reconstruction. Microsurgery 2020; 41:240-249. [PMID: 32997369 DOI: 10.1002/micr.30659] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 08/29/2020] [Accepted: 09/10/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Stacked and conjoined free flaps are increasingly utilized in autologous breast reconstruction to augment tissue transfer volume. However, there is a paucity of comparative data on abdominally-based stacked/conjoined versus non-stacked/conjoined flaps. The purpose of this study was to compare ability to match native breast size, complications, recovery, and symmetrizing procedures between these two cohorts in unilateral breast reconstruction. METHODS A retrospective review of all stacked (two separate hemiabdominal)/conjoined (bipedicled full abdominal) flaps and non-stacked/conjoined (unipedicled hemiabdominal) flaps in unilateral abdominally-based autologous breast reconstructions was performed from 2011 to 2018. Variables including demographics, operative characteristics, complications, and revisions were compared in 36 stacked/conjoined patients versus 146 non-stacked/conjoined patients. RESULTS The stacked/conjoined cohort had more DIEP flaps (91.7 vs. 65.1%) and the non-stacked/conjoined group more MS-TRAMs (34.2 vs. 6.9%, p = .000). Additionally, non-stacked/conjoined flaps had greater utilization of combined medial and lateral row perforators (p = .000). Mean flap weight was significantly higher than mastectomy weight in stacked/conjoined flaps (+110.7 g) when compared to non-stacked/conjoined flaps (-40.2) (p = .023). Average follow-up was 54.7 ± 27.5 and 54.6 ± 29.3 months, respectively. Stacked/conjoined flaps had lower fat necrosis rates (8.3 vs. 25.4%, p = .039) and had a decreased risk of fat necrosis on multivariable regression analysis (OR 0.278, p = 0.045). There were otherwise no differences in flap, breast, or donor-site complications. Stacked/conjoined flaps also had a lower rate of contralateral breast reduction (p = .041). CONCLUSION Stacked/conjoined flaps were associated with a lower risk of fat necrosis compared with non-stacked/conjoined flaps and had a lower rate of contralateral symmetrizing reductions in patients undergoing unilateral abdominally-based breast reconstruction.
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Affiliation(s)
- Ara A Salibian
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Jonathan M Bekisz
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Jordan D Frey
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Ian T Nolan
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Christodoulos Kaoutzanis
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Jason W Yu
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Jamie P Levine
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Nolan S Karp
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Mihye Choi
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Vishal D Thanik
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
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15
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Orienting the superficial inferior epigastric artery (SIEA) pedicle in a stacked SIEA-deep inferior epigastric perforator free flap configuration for unilateral tertiary breast reconstruction. Arch Plast Surg 2020; 47:473-482. [PMID: 32971600 PMCID: PMC7520240 DOI: 10.5999/aps.2019.01319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 12/29/2019] [Indexed: 11/08/2022] Open
Abstract
Superficial inferior epigastric artery (SIEA) flaps represent a useful option in autologous breast reconstruction. However, the short-fixed pedicle can limit flap inset options. We present a challenging flap inset successfully addressed by de-epithelialization, turnover, and counterintuitive rotation. A 47-year-old woman underwent left tertiary breast reconstruction with stacked free flaps using right deep inferior epigastric perforator and left SIEA vessels. Antegrade and retrograde anastomoses to the internal mammary (IM) vessels were preferred; additionally, the thoracodorsal vessels were unavailable due to previous latissimus dorsi breast reconstruction. Optimal shaping required repositioning of the lateral ends of the flaps superiorly, which would position the ipsilateral SIEA hemi-flap pedicle lateral to and out of reach of the IM vessels. This problem was overcome by turning the SIEA flap on its long axis, allowing the pedicle to sit medially with the lateral end of the flap positioned superiorly. The de-epithelialized SIEA flap dermis was in direct contact with the chest wall, enabling its fixation. This method of flap inset provides a valuable solution for medializing the SIEA pedicle while maintaining an aesthetically satisfactory orientation. This technique could be used in ipsilateral SIEA flap breast reconstructions that do not require a skin paddle, as with stacked flaps or following nipple-sparing mastectomy.
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16
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Ismagilov A, Vanesyan A, Ovchinnikova I, Khamitov A, Basiashvili G, Zinchenko S. New technique of dissection of internal mammary vessels for breast reconstruction. Gland Surg 2020; 9:886-892. [PMID: 32953597 DOI: 10.21037/gs-20-104] [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: 11/06/2022]
Abstract
Background Although internal mammary vessels are considered the best recipients for free flap breast reconstruction, they present the notable drawback of limited accessibility. The aim of this study was to develop a minimally invasive surgical technique for the dissection of internal mammary vessels as recipients for breast reconstruction. Methods From 2008 to 2018, we performed 32 unilateral microsurgical breast reconstructions (mean patient age: 40.1±8.7 years; range, 23-58 years). As internal mammary vessels were exclusively used as recipients, they were dissected using a technique of minimally invasive video-assisted thoracoscopic surgery (VATS) developed in our hospital. Results The mean surgery time was 5.4±0.55 hours (range, 4.5-6.5 hours), and the mean duration of VATS dissection of internal mammary vessels was 20.6±2.9 minutes (range, 16-27 minutes). Of the specific complications associated with VATS, we only observed reductions in forced expiratory volume in the first second of >15% in 3 patients (9.4%), 10-15% in 8 patients (25%), and <10% in 21 patients (65.63%). We did not have any cases of significant bleeding or postoperative infection in this series of patients. With regard to aesthetic complications, we observed 1 and 2 cases of total necrosis and partial necrosis of the deep inferior epigastric perforator (DIEP) flap, respectively and 2 cases of partial necrosis of supercharged transverse rectus abdominis muscle flap. Conclusions Endoscopic dissection of internal mammary vessels is a simple and feasible technique. When performed by experienced surgeons, it is a fast procedure that is associated with low rate of complications.
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Affiliation(s)
- Arthur Ismagilov
- Department of Surgery, Kazan Federal University, Kazan, Russia.,Department of Plastic Surgery, Kazan State Medical Academy, Kazan, Russia.,Department of Breast Surgery, Regional Clinical Oncological Center of Tatarstan, Kazan, Russia
| | - Anna Vanesyan
- Department of Breast Surgery, Regional Clinical Oncological Center of Tatarstan, Kazan, Russia
| | - Irina Ovchinnikova
- Department of Breast Surgery, Regional Clinical Oncological Center of Tatarstan, Kazan, Russia
| | - Airat Khamitov
- Department of Plastic Surgery, Kazan State Medical Academy, Kazan, Russia.,Department of Breast Surgery, Regional Clinical Oncological Center of Tatarstan, Kazan, Russia
| | - George Basiashvili
- Department of Plastic Surgery, Kazan State Medical Academy, Kazan, Russia.,Department of Breast Surgery, Regional Clinical Oncological Center of Tatarstan, Kazan, Russia
| | - Sergei Zinchenko
- Department of Surgery, Kazan Federal University, Kazan, Russia.,Department of Plastic Surgery, Kazan State Medical Academy, Kazan, Russia.,Department of Breast Surgery, Regional Clinical Oncological Center of Tatarstan, Kazan, Russia
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17
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Christopoulos G, Berner JE, Sergentanis TN, Blackburn A, Mackey SP. The use of bi-pedicled DIEP flap for unilateral breast reconstruction: a 5-year retrospective study. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01742-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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18
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Samaras S, Sasaki Y, Malata C. Letter to the editor: applications of rib sparing technique in internal mammary vessels exposure of abdominal free flap breast reconstructions: a 12-year single-center experience of 215 cases. Gland Surg 2020; 9:498-500. [PMID: 32420283 DOI: 10.21037/gs.2019.12.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Stavros Samaras
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Plastic & Reconstructive Surgery, 401 Military Hospital of Athens, Greece
| | - Yoshie Sasaki
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Plastic Surgery, Showa University Hospital, Tokyo, Japan
| | - Charles Malata
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Anglia Ruskin University School of Medicine, Cambridge and Chelmsford UK
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19
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Revisiting Anastomosis to the Retrograde Internal Mammary System in Stacked Free Flap Breast Reconstruction. Plast Reconstr Surg 2020; 145:880-887. [DOI: 10.1097/prs.0000000000006712] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Suh YC, Ahn MR, Kim SY, Kim YJ, Lee JH. Superficial inferior epigastric artery‐supercharged deep inferior epigastric artery perforator flap‐based breast reconstruction for a thin patient: A case report. Microsurgery 2019; 39:651-654. [DOI: 10.1002/micr.30503] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 07/29/2019] [Accepted: 08/02/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Young Chul Suh
- Department of Plastic and Reconstructive Surgery, Bucheon St. Mary's Hospital, College of MedicineThe Catholic University of Korea Bucheon‐si Gyeonggi‐do South Korea
| | - Ma Rhip Ahn
- Department of Plastic and Reconstructive Surgery, Bucheon St. Mary's Hospital, College of MedicineThe Catholic University of Korea Bucheon‐si Gyeonggi‐do South Korea
| | - Seong Yeon Kim
- Department of Plastic and Reconstructive Surgery, Bucheon St. Mary's Hospital, College of MedicineThe Catholic University of Korea Bucheon‐si Gyeonggi‐do South Korea
| | - Young Jin Kim
- Department of Plastic and Reconstructive Surgery, Bucheon St. Mary's Hospital, College of MedicineThe Catholic University of Korea Bucheon‐si Gyeonggi‐do South Korea
| | - Jung Ho Lee
- Department of Plastic and Reconstructive Surgery, Bucheon St. Mary's Hospital, College of MedicineThe Catholic University of Korea Bucheon‐si Gyeonggi‐do South Korea
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21
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Oni G, Malata CM. New surgical technique: Simultaneous use of contiguous intercostal spaces during total rib preservation exposure of the internal mammary vessels in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 2019; 72:1525-1529. [PMID: 31266736 DOI: 10.1016/j.bjps.2019.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 05/16/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Microvascular free tissue transfer is the gold standard for autologous breast reconstruction. For many surgeons, the internal mammary vessels (IMV) are the preferred recipient vessels. The merits of the rib preservation technique have been previously discussed. There are, however, instances in which greater access than afforded by one intercostal space (ICS) may be required, for example, multiple or redo anastomoses or inadvertent recipient vessel damage. We therefore have refined this technique further to allow exposure of two ICSs without sacrifice of the intervening rib cartilage. METHOD We identified all patients who had simultaneous contiguous ICSs dissected whilst preserving the intervening costal cartilage for microvascular anastomoses for breast free flaps. The indications, surgical technique, and its refinements are described. RESULTS Simultaneous exposure of the IMVs in both the second and third ICSs whilst preserving the intervening costal cartilage for microvascular anastomoses was successfully performed in 15 patients with no flap failures. Indications included bipedicled DIEP flaps (9), bipedicled DIEA/SIEA flap (1), stacked DIEP flaps (4), and salvage (1). One flap was successfully re-explored for venous congestion. There were no intraoperative complications. CONCLUSION We have demonstrated that simultaneous contiguous ICS exposure of the internal mammary recipient vessels with total rib preservation is technically feasible, has no adverse patient sequelae, and has the benefit of allowing multiple anterograde and retrograde microvascular anastomoses (even in patients with narrow ICSs). This technique preserves the intervening rib and is of particular utility in bipedicled flaps when multiple "extra-flap" anastomoses may be required.
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Affiliation(s)
- Georgette Oni
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Charles M Malata
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK; Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK; Anglia Ruskin University School of Medicine, Cambridge and Chelmsford, UK.
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22
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Takumi I, Akimoto M, Hironaka K, Adachi K, Kon T, Matsumori T, Tanaka Y, Morita A. Pedicle Galeo-pericranial Flap Augmentation in Salvage Frontotemporal Cranioplasty: Additional 'Neurosurgeon-friendly' Reconstruction Technique of Aesthetic Neurosurgery in Superficial Temporal Artery Branch Compromised Host. Neurol Med Chir (Tokyo) 2018; 58:350-355. [PMID: 29998933 PMCID: PMC6092603 DOI: 10.2176/nmc.tn.2017-0252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This technical note aims to demonstrate the usefulness, indications and its limitations of augmentation technique by bipedicle galeo-pericranial rotation flap and by monopedicle galeo-pericranial flap, both in STA (superficial temporal artery) branch compromised hosts in salvage frontotemporal cranioplasty. Although these flaps are not always idealistically vascularized owing to accidental injuries to the STA branches during previous surgeries, they are properly augmenting after salvage frontotemporal craniotomy when infection is not active. The procedure is indicated for salvage frontotemporal craniotomy when vasculature is needed at the surgical site, such as beneath the skin incision line in a thin injured scalp, onto the titanium plates or beneath the fragile fibrous scar. We do not apply this technique by neurosurgeons alone where infection is active or if the host is irradiated. This technique is recommended as a reconstructive aesthetic neurosurgical procedure. It is a ‘neurosurgeon-friendly’ simple procedure, as it does not require any special tools or complicated techniques.
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Affiliation(s)
- Ichiro Takumi
- Department of Neurosurgery, St. Marianna University School of Medicine.,Department of Neurological Surgery, Nippon Medical School Musashi Kosugi Hospital
| | - Masataka Akimoto
- Department of Plastic Surgery, Nippon Medical School Chiba Hokuso Hospital
| | - Kouhei Hironaka
- Department of Neurological Surgery, Nippon Medical School Musashi Kosugi Hospital
| | - Koji Adachi
- Department of Neurological Surgery, Nippon Medical School Musashi Kosugi Hospital
| | - Takashi Kon
- Department of Neurosurgery, Murakami General Hospital
| | - Takashi Matsumori
- Department of Neurosurgery, St. Marianna University School of Medicine
| | - Yuichiro Tanaka
- Department of Neurosurgery, St. Marianna University School of Medicine
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School
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23
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Oni G, Nabulyato W, Malata C. Combined intraflap and extraflap microvascular anastomoses to facilitate bipedicled DIEP/SIEA free flap for unilateral breast reconstruction. Microsurgery 2018; 38:720-721. [DOI: 10.1002/micr.30340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 04/03/2018] [Accepted: 05/08/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Georgette Oni
- Department of Plastic & Reconstructive Surgery; Cambridge University Hospitals NHS Foundation Trust; Cambridge United Kingdom
| | - William Nabulyato
- Department of Plastic & Reconstructive Surgery; Cambridge University Hospitals NHS Foundation Trust; Cambridge United Kingdom
| | - Charles Malata
- Department of Plastic & Reconstructive Surgery; Cambridge University Hospitals NHS Foundation Trust; Cambridge United Kingdom
- Postgraduate Medical Institute, Faculty of Health Sciences; Anglia Ruskin University; Cambridge United Kingdom
- Cambridge Breast Unit; Cambridge University Hospitals NHS Foundation Trust; Cambridge United Kingdom
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24
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Kazzazi F, Ching R, Malata C. Postmastectomy Breast Reconstruction With the Totally Autologous Latissimus Dorsi Flap in the Thin, Small-Breasted Woman: Give It More Thought! EPLASTY 2018; 18:e13. [PMID: 29564032 PMCID: PMC5838613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Introduction: Thin women have fewer autologous tissue breast reconstructive options than their higher body mass index counterparts-due to a lack of adequate donor sites. They are therefore usually offered expander/implant techniques. The total autologous latissimus dorsi flap is generally used in "well-padded" individuals, as they have enough fat on their back on which a completely autologous reconstruction could be based. When implant-based reconstruction is contraindicated (for instance due to planned adjuvant radiotherapy) or unacceptable to the patient, the total autologous latissimus dorsi flap can provide adequate tissue volume by utilizing the additional back fat deposits even in the thin, small-breasted patient. This option is often overlooked by many surgeons. Our case series assesses indications and patient and surgeon satisfaction with the cosmetic outcome of this technique. Methods: The oncological and clinical details of 6 patients with breast cancer who underwent total autologous latissimus dorsi myocutaneous flap immediate breast reconstruction by a single surgeon over an 8-year period were reviewed. An objective assessment of satisfaction with the cosmetic result was made by whether any additional surgical interventions (ipsilateral fat grafting/implant augmentation or contralateral liposuction/ reduction) were needed or not. A subjective assessment of breast symmetry by the surgeon using photographic records was also undertaken. The aesthetic outcomes were also objectively quantified using the BCCT.core software, initially developed for assessing the results of breast conservation surgery. Results: All 6 patients had small breasts and a low or normal body mass index. The mastectomies were performed for invasive carcinoma (n = 3) and extensive high-grade ductal carcinoma in situ (n = 3). Four had axillary surgery (2 sentinel lymph node biopsies and 2 axillary clearances), and 3 received adjuvant radiotherapy. All were happy with their reconstructive outcomes, and none suffered major postoperative complications or disease recurrence. None requested or needed any subsequent ipsilateral adjustment or contralateral symmetrizing procedures. Subjectively, the reconstructions provided acceptable or excellent cosmetic results. The cosmetic results were categorized as excellent or good on the BCCT.core scoring system. Conclusion: This underutilized method of totally autologous breast reconstruction in thinner patients with lower body mass indexes yielded good, well-accepted cosmetic results without recourse to adjustment procedures, contralateral balancing surgery, or complex microvascular surgery. We recommend that the total autologous latissimus dorsi flap should be given more consideration when planning immediate breast reconstruction in this challenging group of thin, small-breasted patients.
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Affiliation(s)
- Fawz Kazzazi
- Clinical School of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Rosanna C. Ching
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Charles M. Malata
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge
- Anglia Ruskin University School of Medicine, Cambridge and Chelmsford, United Kingdom
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25
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See JL, Przybylska J, MacLennan L, Malata CM. Letter to the Editor regarding "Use of both anterograde and retrograde internal mammary vessels in the bipedicled deep inferior epigastric perforator flap for unilateral breast reconstruction". J Plast Reconstr Aesthet Surg 2018; 71:431-433. [PMID: 29329744 DOI: 10.1016/j.bjps.2017.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Jia Le See
- University of Auckland, Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Julia Przybylska
- Poznań University of Medical Sciences, Faculty of Medicine, Poznań, Poland
| | - Louise MacLennan
- Cambridge Breast Unit, Addenbrooke's University Hospital, Cambridge, UK; Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Charles M Malata
- Cambridge Breast Unit, Addenbrooke's University Hospital, Cambridge, UK; Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK; Anglia Ruskin University School of Medicine, Chelmsford & Cambridge, UK.
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26
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Samargandi OA, Winter J, Corkum JP, Al Youha S, Frank S, Williams J. Comparing the thoracodorsal and internal mammary vessels as recipients for microsurgical autologous breast reconstruction: A systematic review and meta-analysis. Microsurgery 2017; 37:937-946. [PMID: 28949034 DOI: 10.1002/micr.30244] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 08/14/2017] [Accepted: 09/05/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND Our aim was to determine whether the thoracodorsal (Td) vessels have comparable clinical outcomes to the internal mammary (IM) vessels as recipients for autologous free tissue transfer for breast reconstruction. METHODS Systematic searches of MEDLINE, EMBASE, CENTRAL, and World of Science from inception to June 2016 were performed by two independent reviewers. Studies that included adult females undergoing autologous free tissue transfer for breast reconstruction were selected. The two comparison groups were the use of IM or Td as recipient vessels. Our primary outcome was rate of flap survival. We assessed the methodologic quality of included studies using the JADAD and MINOR scales. RESULTS A total of 1897 patients underwent 2644 free abdominal flap tissue transfer in the 10 articles that were included in our analysis. There was one randomized controlled study (Jadad score 2/5) and 9 nonrandomized controlled studies (MINORS scores 11-19/24). There was no difference between the uses of either vessel in terms of flap loss (1.18; 95% CI 0.71-1.95). Complication rate among the IM vessels ranged from 5 to 12%, compared with 3.4-12% among Td vessels. Hematoma and seroma rates were variable. Fat necrosis was higher with Td vessels in two studies. Performing Td vessels anastomosis was associated with shorter operative time and higher risk of encountering unusable vessel. CONCLUSION Both recipient vessels are safe, reliable and demonstrate equivocal results in the absence of contraindications. Utilizing either as a first-line vessel is reasonable, depending on surgeons' preference or certain clinical scenarios. QUESTION Therapeutic, Level of evidence: III.
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Affiliation(s)
- Osama A Samargandi
- Division of Plastic Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Division of Plastic and Reconstructive Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Jessica Winter
- Department of Surgery, Section of Plastic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joseph P Corkum
- Division of Plastic Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sarah Al Youha
- Division of Plastic Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Simon Frank
- Division of Plastic Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Division of Plastic Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Jason Williams
- Division of Plastic Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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