Effect of corticosteroids on ischemia-reperfusion injury of deep inferior epigastric perforator flap after re-exploration for anastomosis thrombosis: A prospective randomized trial

Patients undergoing breast reconstruction with the deep inferior epigastric perforator (DIEP) flap are at risk of arterial and venous thrombosis, necessitating flap salvage surgery. However, this carries the risk of ischemia-reperfusion injury (IRI) and potential significant partial or complete flap loss. The objective of this study was to evaluate the potential benefit of corticosteroids in reducing IRI related complications in DIEP flaps that are returned to the operation theater for attempted salvage after venous or arterial failure. A double-blinded prospective randomized study was conducted between January 2012 and January 2023 on patients scheduled for secondary unilateral breast reconstruction using the DIEP flap technique. Patients were included if they developed post-operative venous or arterial flap thrombosis and experienced DIEP flap IRI following operative take-back and anastomosis revision. The treatment group (TG) received a 5-day course of corticosteroids, while the control group (CG) did not receive any specific treatment. Forty-six patients were enrolled in the study. In the CG, two cases of total flap loss and eight cases of partial flap necrosis were observed, while the TG had only 1 case of partial flap necrosis (p < 0.05). The complete resolution of clinical signs of IRI occurred within 13 ± 2.1 days for the TG and 21 ± 3.5 days for the CG (p = 0.00001). The TG had a significantly shorter hospital stay (11.13 ± 0.38 days) compared with the CG (15.47 ± 1.27 days; p < 0.0001). Targeted corticosteroid therapy following a salvage procedure for vascular thrombosis in DIEP flaps has shown promise as an effective treatment for subsequent IRI. This approach may be considered as a viable option for managing IRI in free flaps. However, further studies involving a larger number of patients are required to substantiate our hypothesis.

Impact of Comorbidities on Sensory Return After Breast Reconstruction

PURPOSE

Breast anesthesia after mastectomy and reconstruction has been an ongoing concern with few improvements made in recent years. At present, there is a lack of studies evaluating the impact of comorbidities on sensation restoration. Identifying risk factors (RF) will be helpful with preoperative counseling.

METHODS

This was a prospective study on patients who underwent mastectomy and immediate implant-based or neurotized deep inferior epigastric perforator (DIEP) flap-based reconstruction. Neurosensory testing was performed at predefined time points using a pressure specified device. Patients were stratified based on reconstruction type and comorbidities, including obesity (≥30 kg/m2), age (>55 years), hypertension, alcohol use, and smoking status. Sensory comparisons among the comorbidity groups were conducted using unpaired 2-sample t tests.

RESULTS

A total of 239 patients were included in this study with 109 patients in the implant cohort and 131 patients in the DIEP cohort. One patient underwent bilateral reconstruction using both reconstructive modalities. Preoperatively, age older than 55 years was identified as an RF for reduced breast sensation in the implant cohort (difference in threshold, 10.7 g/mm2), whereas obesity was identified as an RF in the DIEP cohort (difference in threshold, 8 g/mm2). During the first 2 years postreconstruction, age older than 55 years and tobacco use history were found to be negatively correlated with breast sensation for both cohorts. With DIEP reconstruction specifically, obesity was identified as an additional RF during the early postoperative period. Of note, none of the comorbidities were found to be long-term RFs for reduced breast sensitivity. All breast sensation levels returned to comparable levels across all comorbidities by 4 years postreconstruction.

CONCLUSIONS

Currently, various comorbidities have been recognized as RFs for several postoperative complications including extended postoperative stay, necrosis, infection, and reoperation. However, our findings suggest that, although age, smoking history, and obesity showed transient associations with reduced breast sensation during the initial years postreconstruction, they play no role in the long-term potential of sensory nerve regeneration.

Spatial Fidelity of Microvascular Perforating Vessels as Perceived by Augmented Reality Virtual Projections

BACKGROUND

Autologous breast reconstruction yields improved long-term aesthetic results but requires increased resources of practitioners and hospital systems. Innovations in radiographic imaging have been increasingly used to improve the efficiency and success of free flap harvest. Augmented reality affords the opportunity to superimpose relevant imaging on a surgeon's native field of view, potentially facilitating dissection of anatomically variable structures. To validate the spatial fidelity of augmented reality projections of deep inferior epigastric perforator flap-relevant anatomy, comparisons of three-dimensional (3D) models and their virtual renderings were performed by four independent observers. Measured discrepancies between the real and holographic models were evaluated.

METHODS

The 3D-printed models of deep inferior epigastric perforator flap-relevant anatomy were fabricated from computed tomographic angiography data from 19 de-identified patients. The corresponding computed tomographic angiography data were similarly formatted for the Microsoft HoloLens to generate corresponding projections. Anatomic points were initially measured on 3D models, after which the corresponding points were measured on the HoloLens projections from two separate vantage points (V1 and V2). Statistical analyses, including generalized linear modeling, were performed to characterize spatial fidelity regarding translation, rotation, and scale of holographic projections.

RESULTS

Among all participants, the median translational displacement at corresponding points was 9.0 mm between the real-3D model and V1, 12.1 mm between the 3D model and V2, and 13.5 mm between V1 and V2.

CONCLUSION

Corresponding points, including topography of perforating vessels, for the purposes of breast reconstruction can be identified within millimeters, but there remain multiple independent contributors of error, most notably the participant and location at which the projection is perceived.

A Machine Learning Approach to Predicting Donor Site Complications Following DIEP Flap Harvest

BACKGROUND

 The additional donor site incisions in autologous breast reconstruction can predispose to abdominal complications. The purpose of this study is to delineate predictors of donor site morbidity following deep inferior epigastric perforator (DIEP) flap harvest and use those predictors to develop a machine learning model that can identify high-risk patients.

METHODS

 This is a retrospective study of women who underwent DIEP flap reconstruction from 2011 to 2020. Donor site complications included abdominal wound dehiscence, necrosis, infection, seroma, hematoma, and hernia within 90 days postoperatively. Multivariate regression analysis was used to identify predictors for donor site complications. Variables found significant were used to construct machine learning models to predict donor site complications.

RESULTS

 Of 258 patients, 39 patients (15%) developed abdominal donor site complications, which included 19 cases of dehiscence, 12 cases of partial necrosis, 27 cases of infection, and 6 cases of seroma. On univariate regression analysis, age (p = 0.026), body mass index (p = 0.003), mean flap weight (p = 0.006), and surgery time (p = 0.035) were predictors of donor site complications. On multivariate regression analysis, age (p = 0.025), body mass index (p = 0.010), and surgery duration (p = 0.048) remained significant. Radiographic features of obesity, such as abdominal wall thickness and total fascial diastasis, were not significant predictors of complications (p > 0.05). In our machine learning algorithm, the logistic regression model was the most accurate at predicting donor site complications with the accuracy of 82%, specificity of 0.93, and negative predictive value of 0.87.

CONCLUSION

 This study demonstrates that body mass index is superior to radiographic features of obesity in predicting donor site complications following DIEP flap harvest. Other predictors include older age and longer surgery duration. Our logistic regression machine learning model has the potential to quantify the risk of donor site complications.

Local heating-induced cutaneous vasodilation in reinnervated and noninnervated deep inferior epigastric perforator flaps

INTRODUCTION

Cutaneous vascular reactivity to local heating in free flaps has not been characterized. We aimed to assess local heating-induced cutaneous vasodilation in reinnervated and noninnervated deep inferior epigastric perforator (DIEP) flaps.

METHODS

We conducted a cross-sectional study of 21 female patients with an uncomplicated unilateral delayed DIEP breast reconstruction at least 2 years after surgery. DIEP flaps and contralateral breasts were subjected to direct local heating, and skin blood flow was assessed using laser-Doppler flowmetry. To evaluate sensory-nerve-fiber function, touch perception thresholds were assessed using a 20-piece Touch-test™ Sensory Evaluator, and cutaneous warm detection and heat pain thresholds were measured using a TSA-II device.

RESULTS

Of the participants, 10 had a reinnervated DIEP flap with a single coapted nerve (mean flap weight, 610 ± 296 g) and 11 had a noninnervated DIEP flap (mean flap weight, 613 ± 169 g). Mean age was 58 ± 11 years, mean follow-up time was 5 ± 1 years, and mean BMI was 24 ± 3 kg/m2 . DIEP flaps exhibited significantly weaker cutaneous vasodilation in response to local heating than contralateral breasts (median peak skin blood flow, 59 [25th-75th percentile, 36-71] a.u. for DIEP flaps versus 94 [74-141] a.u. for contralateral breasts; p < .001). The magnitude of the response was similar between reinnervated and noninnervated flaps (median peak skin blood flow, 55 [25th-75th percentile, 39-68] a.u. for reinnervated DIEP flaps versus 66 [36-77] a.u. for noninnervated DIEP flaps; p = .75). Of participants with reinnervated DIEP flaps, 90% perceived heat pain below the 50°C safety threshold, as compared to 36% of participants with noninnervated DIEP flaps (two-tailed p = .02).

CONCLUSION

Our results suggest that free flap transfer causes longstanding impairment, yet not complete abolition, of both the sensory nerve-mediated and nitric oxide-dependent local heating-induced cutaneous vasodilatory systems. We found no statistical evidence that flap reinnervation improves the ability to raise skin blood flow in response to local heating.

Predictors and Consequences of Intraoperative Anastomotic Failure in DIEP Flaps

BACKGROUND

 Successful intraoperative microvascular anastomoses are essential for deep inferior epigastric perforator (DIEP) flap survival. This study identifies factors associated with anastomotic failure during DIEP flap reconstruction and analyzes the impact of these anastomotic failures on postoperative patient outcomes and surgical costs.

METHODS

 A retrospective cohort study was conducted of patients undergoing DIEP flap reconstruction at two high-volume tertiary care centers from January 2017 to December 2020. Patient demographics, intraoperative management, anastomotic technique, and postoperative outcomes were collected. Data were analyzed using Student's t-tests, Chi-square analysis, and multivariate logistic regression.

RESULTS

 Of the 270 patients included in our study (mean age 52, majority Caucasian [74.5%]), intraoperative anastomotic failure occurred in 26 (9.6%) patients. Increased number of circulating nurses increased risk of anastomotic failure (odds ratio [OR] 1.02, 95% confidence Interval [CI] 1.00-1.03, p <0.05). Presence of a junior resident also increased risk of anastomotic failure (OR 2.42, 95% CI 1.01-6.34, p <0.05). Increased surgeon years in practice was associated with decreased failures (OR 0.12, CI 0.02-0.60, p <0.05). Intraoperative anastomotic failure increased the odds of postoperative hematoma (OR 8.85, CI 1.35-59.1, p <0.05) and was associated with longer operating room times (bilateral DIEP: 2.25 hours longer, p <0.05), longer hospital stays (2.2 days longer, p <0.05), and higher total operating room cost ($28,529.50 vs. $37,272.80, p <0.05).

CONCLUSION

 Intraoperative anastomotic failures during DIEP flap reconstruction are associated with longer, more expensive cases and increased rates of postoperative complications. Presence of increased numbers of circulators and junior residents was associated with increased risk of anastomotic failure. Future research is necessary to develop practice guidelines for optimizing patient and surgical factors for intraoperative anastomotic success.

Comparison of patient-reported achievements of goals and core outcomes with delayed breast reconstruction in irradiated patients: latissimus dorsi with an implant versus DIEP

BACKGROUND

Different women's individual goals with a breast reconstruction vary, and few studies compare techniques in light of the different goals. This study aimed to compare patient-reported core outcomes in patients reconstructed with deep inferior epigastric artery perforator (DIEP) flaps and latissimus dorsi (LD) flaps. Second, breast-related factors that the patients were particularly satisfied/dissatisfied with were analyzed.

METHODS

This was a retrospective cross-sectional study, which includes women who had undergone mastectomy and radiation, followed by delayed breast reconstructions with either LD flap and implant or DIEP flap during 2007-2017. The patient-reported core outcomes of overall breast-specific quality of life, normality, women's cosmetic satisfaction, self-esteem, emotional well-being, and physical well-being were analyzed using BREAST-Q.

RESULTS

The patients were divided into LD and implant (n = 135 patients) and DIEP (n = 118 patients) groups, and both were demographically similar. The median follow-up was 8 years. The DIEP group scored significantly higher than the LD and implant group in five out of six domains. A high satisfaction was reported in questions regarding the feeling or appearance when having clothes on, whereas the greatest dissatisfaction was reported regarding questions entailing symmetry and the appearance without clothes.

CONCLUSION

After 7 years, patients' breast-specific quality of life, normality, women's cosmetic satisfaction, self-esteem, emotional well-being, and physical well-being seem to be higher in irradiated patients who have been reconstructed with DIEP flap as compared to patients reconstructed with LD flap and implant. In both groups, patient satisfaction is high regarding their appearance when clothed, whereas the lowest satisfaction scores were reported in situations without clothing.

DIEP flap in breast reconstruction: A morbidity study of bilateral versus unilateral reconstruction

BACKGROUND

The Deep Inferior Epigastric Perforator (DIEP) flap is a modality in breast reconstruction of choice. Despite its well-documented benefits and complications, a lack of evidence remains with regards to the risks of performing a bilateral versus a unilateral reconstruction. As such, we sought to compare the rates of adverse outcomes in the perioperative and postoperative periods associated with a unilateral versus a bilateral DIEP flap breast reconstruction.

METHODS

A retrospective cohort study of 178 consecutive patients undergoing unilateral versus. bilateral deep inferior epigastric perforator flap breast reconstruction was performed at our tertiary care center over a 3-year period. Data on demographics, operative time, intraoperative and postoperative complications, and surgical re-exploration, were extracted for both groups. Statistical analysis was performed on a per-flap basis.

RESULTS

A total of 157 unilateral and 42 bilateral deep inferior epigastric perforator flaps were identified. The rate of intra-operative complications was 12.1% for unilateral versus. 4.8% for bilateral flaps (P=0.26). Total post-operative complications rates were 30.6% for unilateral versus 54.7% for bilateral flaps (P=0.003). Surgical re-exploration was performed in 12.7% of unilateral and 11.9% of bilateral cases (P=0.88). The rate of total flap loss was similar between types of reconstruction, occurring in 2.5% of unilateral vs. 2.4% of bilateral flaps (P=1).

CONCLUSION

This study demonstrates the rate of complications per flap is significantly higher in bilateral versus unilateral deep inferior epigastric perforator flap breast reconstruction. Bilateral DIEP breast reconstruction should be decided on a case-by-case basis.

LEVEL OF EVIDENCE

Prognostic/Risk Study, Level II.

Replacing an Implant-Based with a DIEP Flap Breast Reconstruction: Breast Sensation and Quality of Life

BACKGROUND

In this cohort study, the authors compared breast sensation and quality of life (QoL) after replacement of an implant-based breast reconstruction with a deep inferior epigastric perforator (DIEP) flap reconstruction in a singular sample of women.

METHODS

Women with implant-based breast reconstruction before their DIEP flap were included. Women formed their own control. Breast sensation was measured using Semmes-Weinstein monofilaments. QoL was evaluated using BREAST-Q questionnaires. Preoperative (T0) sensation and QoL were compared with postoperative values at 6 months (T1), at 12 months (T2), and at maximum follow-up (Tmax, sensation only). A linear mixed effects regression was used for Semmes-Weinstein monofilaments measurements; a paired samples t test was used for BREAST-Q scores. Most women chose replacement of their implant by a DIEP flap because of implant-related complaints.

RESULTS

Postoperative sensation decreased significantly compared with preoperative sensation after T1 (mean, 5.1 months), T2 (mean, 14.6 months), and Tmax (mean, 17.6 months) for the total breast but recovers to preoperative levels for the native skin after an average of 1.5 years. Nerve coaptation positively influenced recovery of sensation. BREAST-Q scores increased significantly after 6 and 12 months over the domains Satisfaction with Breasts, Psychosocial Well-Being, Physical Well-Being of the Chest, and Sexual Well-Being. Scores decreased significantly in Physical Well-Being of the Abdomen after 6 months.

CONCLUSION

Replacing an implant with a DIEP flap initially causes a decrease in overall breast sensation, gradually recovering to preoperative levels for native skin, and can significantly increase QoL with the right indication. Superior recovery of sensation and QoL may be obtained by accompanying the DIEP flap with nerve coaptation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Comparing Autologous to Device-Based Breast Reconstruction: A Pilot Study of Return in Breast Sensation

BACKGROUND

Poor breast sensation is common after mastectomy and reconstruction. In this study, we aim to define the temporal pattern of sensory changes after reconstruction and to compare the return in sensation between autologous and device-based reconstruction.

METHODS

Women undergoing mastectomy with immediate reconstruction, with either tissue expander (TE) or neurotized deep inferior epigastric perforator (DIEP) flap, were prospectively identified at their preoperative or postoperative visit at defined time points. Neurosensory testing was performed in 9 breast regions using the AcroVal pressure-specified sensory device to determine 1 point-static cutaneous thresholds. Sensitivity data were averaged between patients at each time point and plotted over time.

RESULTS

Eighty-seven patients (153 breasts) were included in this study, including 41 women (75 breasts) with DIEP flap and 46 women (78 breasts) with TE. The groups were comparable in age, body mass index, breast size, chemotherapy, radiotherapy, and number of revisional breast surgeries (P > 0.05). Compared with preoperative baseline, mean cutaneous thresholds in DIEP flap patients were comparable in most outer breast regions at 18 months postoperatively and in the entire breast, except the inner inferior region, at 3 years (P > 0.05). In contrast, mean cutaneous thresholds in TE patients continued to be significantly worse in the entire breast at 5 years postoperatively compared with baseline (P < 0.05).

CONCLUSIONS

Autologous breast reconstruction is superior in sensory recovery. Patients undergoing DIEP flap can expect sensory return to preoperative levels by 3 years, with sensation returning by 18 months in some areas of the breast. Patients undergoing device reconstruction should expect a slower and more unpredictable return in breast sensation.

Breast reconstruction with autologous abdomen-based free flap with prior abdominal liposuction - a case-based review

BACKGROUND

Over recent years, liposuction has become the most commonly used surgical procedure used to refine male and female body contours. In the last four decades, the incidence of breast cancer has increased. Of these patients, there are more women requiring breast reconstruction who have undergone liposuction in the past. There is little in the literature that discusses harvesting perforator flaps from previously liposuctioned donor sites. The authors report on their experience and review the current literature on the autologous abdominal-based free flap for breast reconstruction after previous liposuction of the abdominal wall.

METHODS

Five electronic databases were searched (Medline (PubMed), Scopus, Web of Science, Cochrane) from inception to March 2021. Also, we searched our patients records and included our experience.

RESULTS

We included three cases who had previous liposuction prior to their breast reconstruction procedure. We report no flap loss in our cases. Moreover, the database search showed 30 patients (83.33%) underwent deep inferior epigastric perforator (DIEP) reconstruction. The age ranged from 32 to 73 years (mean of 51.7 years). The mean length of reconstruction after liposuction is 8.9 years, ranging from 1.5 years to 23 years reported in 23 patients. Seven patients (19.4%) had partial loss of the flap. Twenty patients (55.55%) had CT angiography pre-operatively for the assessment of the perforators.

CONCLUSION

A careful combination of preoperative scanning, handheld Doppler and clinical examination reduce the chance of an unsuccessful outcome.

Survival in breast cancer patients with a delayed DIEP flap breast reconstruction after adjustment for socioeconomic status and comorbidity

Purpose

Overall survival in breast cancer patients receiving a delayed deep inferior epigastric perforator (DIEP) flap breast reconstruction is better than in those without delayed breast reconstruction. This study aimed at determining the impact of socioeconomic status (SES) and comorbidity on these observations.

Materials and methods

This matched cohort study included all consecutive women undergoing a delayed DIEP flap reconstruction at Karolinska University Hospital, Sweden, between 1999 and 2013. Controls had not received any delayed breast reconstruction and were relapse-free after a corresponding follow-up interval. Matching was by year of and age at mastectomy, tumour stage and lymph node status. Charlson Comorbidity Index (CCI) and socioeconomic data were obtained from national registers. Associations with breast cancer-specific (BCSS) and overall survival (OS) were investigated by Kaplan-Meier survival estimates and Cox proportional hazard regression analysis.

Results

Women in the DIEP group (N = 254) more often continued education after primary school (88.6% versus 82.6%, P = 0.026), belonged to the high-income group (76.0% versus 63.1%, P < 0.001), were in a partnership (57.1% versus 55.7%, P = 0.024) and healthier (median CCI 1.00 (range 0–13) versus 2.00 (range 0–16), P = 0.021) than the control group (N = 729). After adjustment for tumour and treatment factors, SES and comorbidity, OS remained significantly better for the DIEP group than the control group (HR 2.27, 95% CI 1.44–3.55).

Conclusion

Women with a delayed DIEP flap reconstruction are a subgroup of higher socioeconomic status and better health. Higher survival estimates for the DIEP group persisted after adjusting for those differences, suggesting the presence of further unmeasured covariates.

•

Women with a delayed DIEP flap reconstruction have a higher socioeconomic status.

•

They also have less comorbidity than women with no delayed reconstruction.

•

Superior survival in DIEP patients is not eliminated by adjustments for such differences.

•

Unmeasured selection to the reconstructive process may explain observed survival differences.

New Chimeric Groin Flap: Experimental Model in Rats

AIM

Increased emphasis is on using tissue substitutes and stem cells to improve flap applicability and survival rates. To accomplish this, the first step is to have a versatile experimental flap, easy to harvest and use as a template. We sought to develop a reliable experimental chimeric groin flap with free mobility and reliable bloods supply that can be twisted, relocated, and integrated easily with other materials.

MATERIALS AND METHODS

Ten male Wistar rats were included. The flap consists of a 2.5-cm skin paddle centered on the medial branch of the inferior epigastric artery and a 4.5/2-cm fat pad supplied by the lateral branch of the inferior epigastric artery. After being raised, flaps were resutured in their anatomical position. Flaps were followed up for 15 days. At the end of the study, the viability of flaps was analyzed by ultrahigh-frequency ultrasound, nontargeted contrast study, and histology assessment.

RESULTS

All flaps survived without significant complications. Nontargeted microbubbles spread evenly in both the superficial and deep flap. Ultrasound assessment at day 15 showed no significant areas of necrosis or edema. Histology examination of 3 random flaps confirmed vessel patency and flap viability.

CONCLUSION

We propose a simple, easy to harvest and reliable experimental flap which offers a main advantage of all-around mobility through its chimeric design. It is a suitable model for bioengineering studies as it can be used as a template for integration of tissue substitutes or stem cells, between its 2 components.

Ameliorating Effects of β-Glucan on Epigastric Artery Island Flap Ischemia-Reperfusion Injury

BACKGROUND

Ischemia-reperfusion injury has been one of the culprits of tissue injury and flap loss after island flap transpositions. Thus, significant research has been undertaken to study how to prevent or decrease the spread of ischemia-reperfusion injury. Preventive effects of β-glucan on ischemia-reperfusion injury in the kidney, lung, and small intestine have previously been reported. In this study, we present the ameliorating effects of β-glucan on ischemia-reperfusion injury using the epigastric artery island-flap in rats.

MATERIALS AND METHODS

Thirty Wistar-Albino rats were equally divided into three groups: sham, experimental model, and treatment groups. In the sham group, an island flap was elevated and sutured back to the original position without any ischemia. In the experimental model group, the same-sized flap was elevated and sutured back with 8 h of ischemia and consequent 12 h of reperfusion. In the treatment group, 50 mg per kilogram β-glucan was administered to the rats using an orogastric tube for 10 d before the experiment. The same-sized flap is elevated and sutured back to its original position with 8 h of ischemia and 12 h of consequent reperfusion in the treatment group. Tissue biopsies were taken on the first day of the experimental surgery. Tissue neutrophil aggregation and vascular responses were evaluated by histological examinations. Tissue oxidant and antioxidant enzyme levels are evaluated biochemically after tissue homogenization. Topographic follow-up and evaluation of the flaps were maintained, and photographs were taken on the first and seventh day of the experimental surgery.

RESULTS

Topographic flap survival was significantly better in the β-glucan administered group. The neutrophil number, malondialdehyde, and myeloperoxidase levels were significantly lower while glutathione peroxidase and superoxide dismutase levels were significantly higher in the β-glucan administered group respective to the experimental model group.

CONCLUSIONS

Based on the results of our study, we can conclude that β-glucan is protective against ischemia-reperfusion injury. Our study presents the first experimental evidence of such an effect on skin island flaps.

Unusual Adverse Event of Tetanus: Rectus Sheath Hematoma

Tetanus is a nervous system disorder characterized by muscular spasms and autonomic hyperactivity, such as unstable blood pressure. We herein report a case of tetanus in a patient in shock complicated with a rectus sheath hematoma caused by rupture of a pseudo-aneurysm of the inferior epigastric artery. A rectus sheath hematoma might be misdiagnosed as unstable blood pressure associated with autonomic hyperactivity, which is usually observed in patients with tetanus. The possibility of the occurrence of bleeding complications should be considered if a patient with tetanus has severe and persistent blood pressure reduction.

Laparoscopically Assisted DIEP Flap Harvest Minimizes Fascial Incision in Autologous Breast Reconstruction

BACKGROUND

Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric vessels permits a decrease in myofascial dissection in deep inferior epigastric artery perforator flap breast reconstruction. The authors present a reliable technique that further decreases donor-site morbidity in autologous breast reconstruction.

METHODS

The authors conducted a retrospective cohort study of female subjects presenting to the senior surgeon (S.K.K.) from March of 2018 to March of 2019 for autologous breast reconstruction after a newly diagnosed breast cancer. The operative technique is summarized as follows: a supraumbilical camera port is placed at the medial edge of the rectus muscle to enter the retrorectus space; the extraperitoneal plane is developed using a balloon dissector and insufflation; two ports are placed through the linea alba below the umbilicus to introduce dissection instruments; the deep inferior epigastric vessels are dissected from the underside of the rectus muscle; muscle branches and the superior epigastric are ligated using a Ligasure; and the deep inferior epigastric pedicle is ligated and the vessels are delivered through a minimal fascial incision. The flap(s) is transferred to the chest for completion of the reconstruction.

RESULTS

Thirty-three subjects totaling 57 flaps were included. All flaps were single-perforator deep inferior epigastric artery perforator flaps. Mean fascial incision length was 2.0 cm. Sixty percent of subjects recovered without narcotics. Mean length of stay was 2.5 days. Flap salvage occurred in one subject after venous congestion. Two pedicle transections occurred during harvest that required perforator-to-pedicle anastomosis.

CONCLUSION

Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric pedicle is a reliable method that decreases the donor-site morbidity of autologous breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Effects of Adrenomedullin and Glucagon-like Peptide on Distal Flap Necrosis and Vascularity: The Role of Receptor Systems and Nitric Oxide

OBJECTIVE

Flap necrosis in the distal area due to the deficiency of blood circulation is a major complication in flap treatment. In many previous studies, some natural substances such as chlorogenic acid, adrenomedullin (ADM), and glucagon-like peptide-1 (GLP-1) have been used to improve flap viability via their vasodilator, angiogenic, and antioxidant effects. The aim of this study is to clarify the mechanism through the use of selective antagonists for calcitonin gene-related peptide (CGRP) receptors and GLP-1 receptors such as CGRP-(8-37), exendin-(9-39), respectively, in the flap healing effects of ADM and GLP-1. The role of nitric oxide (NO) was investigated in the mechanism as well.

MATERIALS AND METHODS

Seventy adult female Wistar rats (200 g-250 g) were used in the study. The cutaneous skin flap (8 cm x 3 cm) on the abdominal wall was raised based on the superficial inferior epigastric artery (SIEA). Single-dose substance injections were administered into the SIEA. Necrosis in the flap area was evaluated on postoperative day 7. The proportion of the necrosis area (necrosis area % = [necrosis area/flap area] x 100) and vascularity (vascular number/cm2) in the distal area were calculated.

RESULTS

The administrations of ADM or GLP-1 increased the vascularity and decreased the necrosis area in the distal flap region. The ADM receptor antagonist, CGRP-(8-37), did not prevent the positive effects of ADM on flap healing and vascularity. A GLP-1 receptor antagonist, exendin-(9-39), prevented the effect of GLP-1 on flap healing and vascularity. Nitric oxide mediated the beneficial effects of both peptides on flap healing.

CONCLUSION

The CGRP receptors have no direct role, but NO acts as a mediator in the beneficial effect of ADM on flap healing. The GLP-1 specific receptors and NO act as important interagents for the effects of GLP-1 on flap healing.

Immediate simultaneous bilateral breast reconstruction with deep inferior epigastric (DIEP) free flap and transverse rectus abdominis musculocutaneous (TRAM) pedicled flap

Breast reconstructive surgery has evolved tremendously since its inception. Following tumour clearance surgery, physical restoration with breast reconstruction is an important aspect of physical and emotional rehabilitation. Various methods have been described to suit patients demand for the best aesthetic outcome. Surgeon's preference, experience and practicality of differing procedures must be considered. We describe a simultaneous bilateral breast reconstruction with free deep inferior epigastric (DIEP) flap and pedicled transverse rectus abdominis musculocutaneous (TRAM) flap immediately post mastectomies for bilateral breast cancers. The surgery described has resulted in a reasonable technical ease, acceptable flap and abdominal morbidity and good aesthetic outcome.

Efficacy of intra-arterial neoadjuvant chemotherapy through the superior epigastric artery in the treatment of locally advanced triple negative breast cancer

Triple negative breast cancer (TNBC) is associated with aggressive behaviour and poor prognosis, but has limited treatment options. To explore novel and effective therapies against TNBC, we retrospectively analyzed the efficacy of neoadjuvant intra-arterial chemotherapy through the superior epigastric artery in the treatment of locally advanced TNBC. Fifty-one locally advanced TNBC patients who received this neoadjuvant therapy from Mar 2001 to Mar 2012 were included in this study. The superior epigastric artery was selected for cannulation to deliver chemotherapy drugs. The regimen for intra-arterial chemoinfusion consisted of 75 mg/m2 epirubicin and 75 mg/m2 docetaxel. Clinical and pathological tumor responses, disease free survival (DFS), overall survival (OS), and toxicity profiles were recorded and retrospectively analyzed. In 51 patients treated with neoadjuvant intra-arterial chemoinfusion through the superior epigastric artery, the overall response rate (ORR) was 84.3%; 16 patients achieved pathological complete response (pCR). Following surgical treatment and adjuvant chemotherapy, 5-year DFS and OS were 72.4% and 75.9%, respectively, in the study population. In addition, this neoadjuvant approach showed favorable toxicity profiles. Moreover, patients who achieved pCR showed a superior survival outcome compared with those who did not. Cox regression analysis indicated that Ki-67 expression is an independent predictor for DFS and OS. Our results suggest that intra-arterial chemotherapy through the superior epigastric artery has great therapeutic potential for the treatment of locally advanced TNBC. This approach merits further clinical evaluation and may become a novel therapeutic option for locally advanced TNBC.

[The effect of hyperbaric oxygen preconditioning on the expression of ICAM-1, VCAM-1, NF-κB and flap survival rate during ischemia-reperfusion injury in rat abdominal skin flap]

OBJECTIVE

To evaluate the effect of hyperbaric oxygen preconditioning on the expression of intercellular adhesion molecule-1 (ICAM-1),vascular cell adhesion molecule-1 (VCAM-1),NF-κB and flap survival rate during Ischemia-Reperfusion Injury in Rat Abdominal Skin Flap.

METHODS

18 male adult SD rats were divided randomly into sham group (SH),ischemia-reperfusion group (IR) and hyperbaric oxygen preconditioning group (HBO),6 rats in each group. The rats in HBO group received regular hyperbaric oxygen treatment for three days (twice a day with an interval of 12 h) before operation. An abdominal skin flap pedicled with superficial epigastric artery was established. Ischemia lasted for 3 hours in the IR group and HBO group.On the third postoperative day,samples were taken to evaluate the expression of ICAM-1,VCAM-1 and NF-κB by immunohistochemistry staining and Western Blot.

RESULTS

In the IR group, the flap survival rate and average blood perfusion were (22.38 ±4.35) ％ and (32.61 ±5.68) PU, while in the HBO group they were (45.34 ±3.15) ％ and (61.78 ±3.61) PU, showing significant difference between the two groups (P ＜0.01).The inflammatory cell infiltration condition in IR group was much higher than that in the HBO group from the HE staining observation. Compared with the HBO group,ICAM-1,VCAM-1 and NF-κB showed (+ + +) with higher positive cells in the IR group (P ＜ 0.01). Results of Western Blot showed similar conclusion. The relative expression of ICAM-1,VCAM-1 and NF-κB was much higher in the IR group than that in the HBO group (P ＜ 0.01).

CONCLUSIONS

Hyperbaric oxygen preconditioning could decrease the expression of ICAM-1,VCAM-1,NF-κB and promote flap survival rate during the process of ischemia-reperfusion injury on a rat abdominal skin flap model.

[The influence of estradiol on histomorphology of skin flaps with ischemia reperfusion injury]

OBJECTIVE

To study the influence of estradiol on histomorphology of skin flaps with ischemia reperfusion injury.

METHODS

48 adult male Wistar rats aged 12-14 weeks old, were randomly divided into control group (group I), ischemia-reperfusion group (group II), saline group (group III), estradiol group (group IV). Superficial epigastric artery axial flap, 3 cm x 6 cm in size, was made in the left lower quadrant abdominal of each rat. Flap model with ischemia-reperfusion injury was established by using the nondestructive micro vascular clamp to clamp the superficial epigastric artery. The general condition of the flap was observed after operation. At 7 days after operation, the survival rate of the flap was detected, the flaps were harvested to receive histology and ultrastructural observation. The neutrophils level of the superficial epigastric vein were tested.

RESULTS

7 days after operation, the survival rate of the flap in group IV was significantly higher than that in group II, III (P < 0.05). The neutrophils level in group IV was lower than that in group II, III (P < 0.05). The histological observation showed that the degree of tissue swelling and inflammatory exudation in group IV was more slight than that in group II, III. Presence of high neutrophils density were observed in group II, III, while slight inflammation and necrosis were observed in group IV. In group I, collagen fibers in flap are regularly arranged with no significant necrosis. Oganelles structure disappeared and apoptotic bodies were shown in group II and group III, even the lysosome could be seen in the cell. Collagen fibers in flap are regularly arranged with slight swelling and no obvious ultrastructural necrocytosis was seen in the cell of group IV.

CONCLUSION

The estradiol can significantly increase flap survival rate by inhibiting neutrophils infiltration and improving the pathological changes of organization structure in flap.

[EFFECTIVENESS OF DEEP INFERIOR EPIGASTRIC ARTERY PERFORATOR FLAP FOR REPAIR OF PERINEAL AND PERIANAL CICATRICIAL CONTRACTURE]

OBJECTIVE

To discuss the effectiveness of deep inferior epigastric artery perforator flap to repair perineal and perianal cicatricial contracture.

METHODS

Between March 2007 and December 2013, 23 patients with perineal and perianal cicatricial contracture were treated with deep inferior epigastric artery perforator flap. There were 15 males and 8 females, aged from 21 to 62 years (mean, 42 years). Burn depth was III degree. The burning scars involved in the fascia, even deeper, which was rated as peripheral type (mild stenosis of the anal region and perianal cicatricial contracture) in 13 cases and as central type (severe stenosis of the anal region and anal canal with shift or defect of external genitalia) in 10 cases. All patients had limited hip abduction and squatting. Repair operation was performed at 3 months to 2 years (mean, 6 months) after wound healing. The size of soft tissue defects ranged from 10 cmx6 cm to 28 cm x 13 cm after scar excision and release. The size of flaps ranged from 12 cmx7 cm to 30 cmx15 cm. The donor site was sutured directly in 16 cases and repaired by autograft of skin in 7 cases.

RESULTS

The flap had distal necrosis, distal cyanosis, and spotted necrosis in 1 case, 2 cases, and 1 case respectively, which were cured after symptomatic treatment; the other flaps survived and wound healed primarily. Twenty-one patients were followed up 6 months to 2 years (mean, 1 year). Nineteen patients had good appearance of the perinea and position of external genitalia, normal function of defecation function; stenosis of the anal region was relived, and the flaps had good texture and elasticity. Linear scar contracture was observed at the edge of flap in 2 cases, and the appearance of the perineum was restored after Z plasty. The hip abduction reached 30-40°. No abdominal hernia was found at donor site.

CONCLUSION

Deep inferior epigastric artery perforator flap has stable blood supply and flexible design, which is similar to the perianal and perineal tissues. The good effectiveness can be obtained to use this flap for repair of perineal and perianal cicatricial contracture.

Safely combining abdominoplasty with aggressive abdominal liposuction based on perforator vessels: technique and a review of 300 consecutive cases

BACKGROUND

There continues to be controversy about performing abdominoplasty concurrently with abdominal liposuction. The concern is that liposuction on the already vascularly compromised abdominal flap will lead to increased complications and flap necrosis. The central abdomen is supplied by the epigastric system. If perforator vessels from this system are spared, the blood supply to the abdomen can be spared and liposuction should be able to be safely performed on the elevated abdominal flap. The purpose of this study was to evaluate the safety of abdominoplasty with concurrent abdominal liposuction when a perforator vessel is spared.

METHODS

A standard abdominoplasty was performed, sparing one or two perforator vessels from the deep superior epigastric artery system. A retrospective chart review of 300 consecutive patients who underwent abdominoplasty surgery combined with concurrent abdominal liposuction was performed. Complications, total volume of abdominal liposuction, and results were reviewed.

RESULTS

The overall complication rate was 17.3 percent (52 patients). Sixteen percent (48 patients) suffered minor complications and 1.3 percent (four patients) suffered major complications.

CONCLUSIONS

Abdominoplasty can be combined safely with concurrent abdominal liposuction when a perforator vessel is spared. The combination of concurrent liposuction with abdominoplasty showed no increase in complication rates when a perforator vessel was spared. The perforator vessels are located consistently in a 2-cm radius located 4 cm from the midline and 6 cm from the subcostal margin. The potential advantages of abdominoplasty with concurrent liposuction include a better postoperative cosmetic result.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A new technique of closing a gastroatmospheric fistula with a rectus abdominis muscle flap

Proximal enteroatmospheric fistulae are difficult to manage and carry high mortality from sepsis and electrolyte imbalances. Conservative management with total parenteral nutrition, exclusion of fistula, resection and anastomosis are conventional methods of treatment with low success rate. Providing muscle cover to manage an enteroatmospheric fistula is a noble concept. A postoperative high-output gastroatmospheric fistula (GAF) was repaired by superior epigastric artery-based rectus abdominis muscle flap (RAMF). Postoperative recovery was uneventful. This technique may be useful for closure of proximal enteroatmospheric fistulae that fail to heal through medical and conventional surgical management.

[REPAIRING SKIN AND SOFT TISSUE DEFECT IN PALM OR DORSUM OF HAND AND FOREARM WITH EPIGASTRIC BILOBED FLAP]

OBJECTIVE

To introduce the surgical method and effectiveness of repairing skin and soft tissue defect in the palm or dorsum of the hand and forearm with epigastric bilobed flap.

METHODS

Between October 2010 and December 2013, 4 male patients with skin and soft tissue defect in the palm or dorsum of the hand and forearm were treated, aged from 36 to 62 years. Of them, 3 cases had degloving injury caused by machines and 1 case had necrosis of fingers and skin after surgery of crush injury. The time from injury to hospitalization was from 3 hours to 15 days. Among the 4 cases, the size of palmar defect was 7 cmx4 cm to 16 cmx6 cm, and the size of dorsal defect was 10 cmx7 cm to 20 cmx10 cm. The epigastric bilobed flap was designed based on the axial vessel which was formed by inferior epigastric artery, superior epigastric artery, and intercostals arteries. The size of flap ranged from 12 cmx4 cm to 18 cmx6 cm in the vertical direction, 15 cmx8 cm to 22 cmx11 cm in the oblique direction. The donor site was directly closed. The pedicles were cut at 22 to 24 days after repairing operation.

RESULTS

All the flaps survived well with the wound healing by first intention. Four patients were followed up 3 months to 1 year and 2 months. The other flaps had good appearance and texture except 1 bulky flap. The flap sensation basically restored to S2-S3. The function of the hands recovered well.

CONCLUSION

Skin and soft tissue defect in the palm or dorsum of the hand and forearm can be repaired with the epigastric bilobed flap, because it has such advantages as big dermatomic area and adequate blood supply. Besides, the operation is practical, safe, and simple.

[Flow-through deep inferior epigastric perforator flaps transplantation for reconstruction of large defects at the extremities]

OBJECTIVE

To investigate the clinical application of flow-through deep inferior epigastric perforator flaps for reconstruction of large defects at the extremities.

METHODS

The deep inferior and superior epigastric arteries were designed as the axial vessel and the arterial supply to the flap was the paraumbilical perforator artery. Free deep inferior epigastric perforator flaps were harvested in flow- through manners to reconstruct associated arterial defect in the wound. The sensation assessment,Enneking score,and questionnaire of the flap aesthetic were all performed during follow-up period.

RESULTS

From December 2011 to September 2012, 5 patients with large defects at extremities were treated. The deep inferior and superior epigastric arteries were designed as the axial vessel and the arterial supply to the flap was the paraumbilical perforator artery. The wound defects ranged form 11 cm x 5 cm to 30 cm x 11 cm. And the flap size ranged from 13 cm x7 cm to 33 cm x 13 cm. All flaps survived completely. The recipient arteries were all bypassed well documented by color Doppler examinations. All cases had 12-24 months' follow-up period. The flaps had good appearance and high aesthetic satisfactory(100%). 12 months after operations, sensation assessment were all S3+, and the Enneking score ratios were 82%-95% ,with 87.2% in average.

CONCLUSIONS

Flow-through deep inferior epigastric perforator flaps are reliable and effective for reconstruction of large defects at the extremities with maintenance of the vascular status of the extremities. The flaps can also be designed in transverse or oblique mode for clinical application.

Three-dimensional prediction of free-flap volume in autologous breast reconstruction by CT angiography imaging

PURPOSE

The diagnostic use of computer tomography angiography (CTA) to identify perforating blood vessels for abdominal free-flap breast reconstruction was extended to estimate the three-dimensional (3D) preoperative flap volume and to compare it with the real intraoperative flap weights in order to (1) evaluate the accuracy of CTA-based 3D flap volume prediction, and (2) to analyze abdominal tissue estimation for required breast volume reconstruction.

METHODS

Preoperative CTA was performed in 54 patients undergoing unilateral breast reconstruction with a free, deep, inferior epigastric artery perforator flap. 3D flap volumes ([Formula: see text]) based on CTA data were calculated and compared with the actual intraoperative flap weight (g). In addition, a breast volume to flap volume ratio was calculated to analyze whether the estimated 3D abdominal flap volume would match that of the breast to be removed.

RESULTS

40 CTA data sets (74.1 %) fulfilled the technical requirements for a reliable determination of flap volume. 3D CTA flap volume prediction showed no relevant differences to the actual flap weight (p = 0.44) and high correlations (r = 0.998, [Formula: see text]), allowing a prediction accuracy within 0.29 [Formula: see text] 3.0 % (range: from [Formula: see text]8.77 to 5.67 %) of the real flap weight. Significantly larger flap volumes were harvested compared with the actually required breast volumes ([Formula: see text]), leading to an average of 21 % of the remnant flap tissue potentially being discarded.

CONCLUSIONS

CTA-based 3D flap volume prediction provides accurate preoperative guidelines concerning the needed amount of abdominal tissue that can be harvested to achieve acceptable symmetry.

Diagnostic and management of spontaneous rectus sheath hematoma

BACKGROUND

Spontaneous rectus sheath hematoma is an uncommon and often misdiagnosed cause of abdominal pain. The aim of this study is to describe our experience in their management.

METHODS

Retrospective analysis of the characteristics and outcomes of the spontaneous rectus sheath hematomas diagnosed over the last 12years was conducted.

RESULTS

24 patients were included (66% women; mean age: 74years; range: 54-87). All cases presented predisposing factors mainly anticoagulant therapy in 21 (87.5%) patients, hypertension in 19 (79.1%) and abdominal surgery in 12 (50%) cases. Eighteen (75%) referred triggering factors like coughing being the most common one, present in 17 (70.8%) patients. The main clinical findings were abdominal pain in 21 (87.5%) cases and the existence of an abdominal mass in 20 (83.3%). The diagnosis was confirmed by abdominal ultrasonography and/or computerized tomography in 23 (95.8%) patients. Nineteen cases (79.1%) responded to conservative management while 5 (20.8%) required interventional treatment, which consisted in an arteriography with selective embolization of the epigastric arteries in all cases. Four (80%) of the patients needing interventional treatment were receiving low molecular weight heparin. Nine (37.5%) patients developed hypovolemic shock and 1 (4%) died.

CONCLUSIONS

Spontaneous rectus sheath hematomas should be considered in the differential diagnosis of abdominal pain, particularly in elderly women under anticoagulant therapy with onset of symptoms after a bout of cough. Most cases respond to conservative management, although those related to low molecular weight heparin might require interventional treatment; arteriography with selective embolization of the epigastric arteries is the first therapeutic option.

Free deep inferior epigastric perforator flap used for management of post-pneumonectomy space empyema

Various solutions exist for management of post-pneumonectomy space empyema. We describe the use of a free deep inferior epigastric perforator (DIEP) flap to fill the space and close a pleural window. Previously, flaps involving abdominal muscle or omentum have been used for this purpose. Abdominal surgery to harvest such flaps can impair ventilatory mechanics. The DIEP flap--harvested from the abdomen, and composed primarily of skin and muscle avoids this problem, thus is a desirable technique in patients with impaired lung function. We believe this is the first report of the DIEP flap to close a postpneumonectomy empyema space.

Rectus sheath hematoma of the abdomen. Case report

BACKGROUND

Rectus sheath hematoma in the vast number of cases is due to an inferior epigastric artery tear occasionally due to trauma (not considered serious) or alterations in coagulation or use of anticoagulant therapy. It is an unlikely and difficult to diagnose pathology.

CLINICAL CASE

We present the case of a 61-year-old female patient. The patient presented in emergency service with sudden abdominal pain caused by coughing as a result of an upper respiratory tract infection. The culmination was a spontaneous rectus sheath hematoma.

CONCLUSIONS

Rectus sheath hematoma is a diagnosis to consider in a previously asymptomatic patient who presents with clinical features of acute pain and appearance of increase of volume in the abdominal wall involving the rectus muscles.

[The design of inferior rectus abdominis flap and its study of applied anatomy]

OBJECTIVE

To describe the anatomy of inferior epigastric artery and its correlation with rectus abdominis muscle in order to provide anatomical basis for reconstruction of defect in the oral and maxillofacial region.

METHODS

10 Chinese adult specimens fixed by 10% formalin were simulated for the design of inferior rectus abdominis flap, and then observing, taking a photograph during the cadavers were being operated and measuring by image analysis software in the end.

RESULTS

The original external diameters of inferior epigastric artery and length of its trunk were (2.58 +/- 0.60) mm and (85.87 +/- 14.90) mm respectively. Its perforators distribute intensively toward hilum.

CONCLUSION

Whether rectus abdominis myocutaneous flap or deep inferior epigastric perforator flap adapts to reconstruct the defect of oral and maxillofacial region due to invariable traveling of inferior epigastric artery and its wide original external diameters relatively.

[Distribution of deep inferior epigastric perforator vessel and application of the expanded perforator flaps]

OBJECTIVE

To explore the distribution of deep inferior epigastric perforator vessel and application of the expanded perforator flap for large scar on hand and forearm.

METHODS

20 healthy adults were selected to detect the distribution of deep inferior epigastric perforator vessel. 10 cases with cicatricial constriction on hand and forearm were treated with expanded perforator flap.

RESULTS

425 perforator points were detected on the skin surface of abdomen in 20 adults. 80% of the points are located within the area which is 1.1 -5.8 cm far from the mid-line of abdomen. According to the Rand method, the percentage of the points in zone I , II , III were 26%, 43%, and 30%, respectively. There were few points in zone IV. The area around navel had a high density of points. The points were distributed asymmetrically at the two sides of abdomen. 10 cases were treated. Vascular deficiency happened at the distal end of one flap. All the other 9 flaps survived.

CONCLUSIONS

The expanded deep inferior epigastric perforator flap is thin and has a large size. It is very suitable for large scar on forearm or hand.

Ten years’ experience of free flaps for breast reconstruction in a Danish microsurgical centre: An audit

We have done a total of 292 breast reconstructions using a free flap over a period of 10 years (1994-2003). During the last five years the number of deep inferior epigastric perforator (DIEP) flaps has increased. However, to secure an optimal blood supply we still use a muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flap sometimes. Our results with the two flaps were identical as far as operating time and length of hospital stay were concerned, but the DIEP flap has less donor site morbidity. Our results are influenced by our selection of patients and our technique but we think that muscle-sparing TRAM flaps may be used as an alternative to DIEP flaps.

Use of deep inferior epigastric artery flaps for reconstruction of the female genitalia

Free skin grafts have been the most conventional choice for reconstructing the female genital area after excision of malignant tumours. However, some patients have developed scar contractures, or depressed deformities or ectropion of the mucosal membrane of the urethra or vagina. We discuss here the use of deep inferior epigastric artery (DIEA) flaps. Although the method leaves a scar in the abdominal region, it can be hidden by underwear. We have operated on six patients with satisfactory results.

Salvage of a congested DIEAP flap with subcutaneous recombinant tissue plasminogen activator treatment

Thrombolytic agents are frequently employed in the treatment of thrombosis in combination with early surgical exploration and management. Recombinant tissue plasminogen activator is a second generation thrombolytic agent, which acts specifically at the site of the haemostatic clot with minimal side effects. In this paper, we present a case with venous congestion of the deep inferior epigastric artery perforator (DIEAP) flap, despite a patent anastomosis, in which we achieved a successful outcome with subcutaneous recombinant tissue plasminogen activator treatment.

The rare case of a symptomatic atherosclerotic aneurysm of the superior epigastric artery mimicking an acute cholecystitis

True aneurysms of the epigastric artery are rare. We report a case of a 65-year-old female who was admitted for increasing upper abdominal pain. A leukocytosis, pyrexia, breathing stop on inspiration, and a palpable mass next to the right costal arch with severe local pain were suspicious for acute cholecystitis. Surprisingly, sonography and CT scan revealed a 5 x 4 cm structure limited to the abdominal wall directly above the gallbladder, which showed an arterial flow in the duplex scan. After resection and an uneventful postoperative course, the histological findings confirmed the diagnosis of a symptomatic true atherosclerotic aneurysm.

The versatility of the SIEA flap: a clinical assessment of the vascular territory of the superficial epigastric inferior artery

Following the TRAM and the DIEP the SIEA flap is the next logical step to reduce the donor site morbidity in autologous breast reconstruction. The vascular axis of the SIEA flap, however, is completely different from the deep epigastric pedicle, on which previous lower abdominal flaps were based. Therefore, a mapping of the vascular territory, which can be reliably harvested on this pedicle, seems mandatory before this new technique can become established.

AIM

To chart the angiosome of the superficial inferior epigastric artery with regard to breast reconstruction and to evaluate the random extension of the vascular territory, which can be reliably raised on this pedicle.

STUDY DESIGN

Clinical, prospective study in a university-affiliated department of plastic surgery.

PATIENTS

Ten patients undergoing autologous breast reconstruction with the superficial inferior epigastric perforator flap and five patients undergoing aesthetic abdominoplasty with isolation of the abdominal flap on the superficial epigastric vessels.

MATERIAL AND METHODS

After isolation of the abdominal panniculus on a single superficial inferior epigastric artery pedicle, the flap was divided in the four conventional zones according to Hartrampf. Perfusion in each of the four zones was measured on the table using the technique of dynamic laser-fluorescence videoangiography.

RESULTS

Perfusion of Hartrampf Zone III occurred first (25s post-injection) and the perfusion index amounted median 89% of reference. Perfusion of Zone I occurred median 5s later and the relative perfusion was 80%. Perfusion of the contralateral zones II and IV was dramatically reduced to 8% and zero, respectively, and this reduction was statistically significant (p<0.0001).

CONCLUSION

The true angiosome of the superficial epigastric artery is located laterally on the ipsilateral hemiabdomen. Its random extension is unreliable and ranges most frequently only to the midline. Based on the results of this study, survival of the skin and subcutaneous fat taken laterally to the border of the contralateral rectus sheath seems questionable. Therefore, the versatility of the SIEA flap for autologous breast reconstruction seems limited when compared with the conventional methods based on the deep inferior epigastric system.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A New Technique of Vaginal Reconstruction with the Deep Inferior Epigastric Perforator Flap: A Preliminary Report

BACKGROUND

Vaginal reconstruction after tumor resection or in congenital vaginal agenesis remains a challenging area in surgery, with many techniques previously described underlining the continued search for an ideal method. In this preliminary report, a series of patients are presented who underwent vaginal reconstruction using a deep inferior epigastric artery perforator (DIEP) flap.

METHODS

Between May of 2004 and February of 2005, five patients underwent vaginal reconstruction using the pedicled DIEP flap. Four patients had congenital vaginal agenesis and one had a complete vaginal resection because of a tumor.

RESULTS

The flaps ranged in size from 9 x 10 cm to 11 x 12 cm. All flaps survived, although one patient developed a posterior space hematoma that required draining. Of the five patients, two were sexually active and enjoyed satisfactory penetrative intercourse after reconstruction.

CONCLUSIONS

This series demonstrates that a new vagina can be created from the pedicled DIEP flap and that the reconstruction is reliable, with low donor-site morbidity. The major disadvantage of this technique is the conspicuous abdominal scar.