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Jo T, Hur J, Min K, Kim EK, Han HH, Eom JS. Immediate breast reconstruction after salvage mastectomy: Case control outcome comparisons of DIEP flap and DTI reconstruction. J Plast Reconstr Aesthet Surg 2020; 74:1495-1502. [PMID: 33386262 DOI: 10.1016/j.bjps.2020.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 11/10/2020] [Accepted: 11/22/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cancer recurrence after breast-conserving therapy is most often managed by salvage mastectomy. Successful breast reconstruction immediately after salvage mastectomy, however, remains challenging because the reconstruction is performed on previously irradiated breast tissue. METHODS Records of patients who underwent breast reconstruction from June 2010 to June 2019 were reviewed, including their demographic characteristics, methods of breast reconstruction, and early and late outcomes. Deep inferior epigastric perforator (DIEP) flaps and direct-to-implant (DTI) reconstructions following salvage mastectomies were compared with reconstructions following completion or primary mastectomies. Patients who underwent reconstruction followed by postmastectomy radiotherapy (PMRT) and patients followed up for less than 6 months were excluded. RESULTS DIEP flaps in 27 breasts that underwent salvage mastectomy were compared with DIEP flaps in 32 breasts that underwent completion and 564 that underwent primary mastectomy. Rates of early complications, including microsurgical revision and total flap loss, and of late complications (>6 months after surgery), including fat necrosis and flap volume loss, did not differ significantly. DTI reconstruction in 20 breasts that underwent salvage mastectomy was compared with DTI reconstruction in 12 breasts that underwent completion and 351 that underwent primary mastectomy. Wound healing problems, including wound dehiscence and delayed wound healing (15% vs. 2.6%, P = 0.0022), and capsular contracture (30% vs. 5.4%, P = 0.0000), were significantly more frequent in breasts that underwent salvage than primary mastectomy. CONCLUSIONS DIEP flap is a successful reconstruction option after salvage mastectomy. DTI reconstruction is associated with higher rates of wound healing problems and capsular contracture after salvage than after primary mastectomy.
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Abdelfattah U, Elbanoby T, Kim EN, Park EJ, Suh HP, Hong JPJ. Effect of Simvastatin Use in Free Tissue Transfer: An Experimental Study in a Rat Epigastric Free Flap Model. J Reconstr Microsurg 2020; 36:281-288. [PMID: 31995818 DOI: 10.1055/s-0039-1701030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Statins are traditionally used in lowering cholesterol and low-density lipoprotein biosynthesis, but recent reports show their beneficial effect on microcirculation. The aim of this study was to investigate the effect of simvastatin on the microcirculation and in conjunction with aspirin in a rat free epigastric flap model. METHODS Thirty-six Sprague-Dawley rats were divided into group A (control, n = 12), group B (simvastatin treated, n = 12), and group C (simvastatin and aspirin, n = 12). Bilateral free epigastric skin flap was used to evaluate the effect. At 48 hours, flaps biopsies were evaluated for inflammatory activity, nitric oxide content, and thrombomodulin regulation in the endothelial lining of microvessels. Flap survival was evaluated on day 7. RESULTS The diameter of microvessels and nitric oxide activity in groups B and C were significantly higher than in group A (p < 0.005 and 0.015, respectively). The perivascular inflammatory cell infiltrates and intravascular adhesions were predominant in group A compared with groups B and C (p < 0.005). Groups B and C demonstrated significant higher degree of thrombomodulin expression. The flap survival rate on day 7 was 70.8% for group A, and 87.5% and 91.7%, respectively, for groups B and C without significance between the two (p = 0.675). CONCLUSION Simvastatin significantly improves the free flap survival by effective anti-inflammatory, vasodilator, and anticoagulant activities. Combined therapy did not have an antagonistic effect and further study is needed to see synergistic action through different mechanisms.
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Haddock NT, Teotia SS. Deconstructing the Reconstruction: Evaluation of Process and Efficiency in Deep Inferior Epigastric Perforator Flaps. Plast Reconstr Surg 2020; 145:717e-724e. [PMID: 32221202 DOI: 10.1097/prs.0000000000006630] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND With advances in technology and technique, the goal of microvascular breast reconstruction has transitioned from flap success to minimizing complications and maximizing aesthetic outcome and efficiency. In an effort to evaluate efficiency, the authors implemented a rigorous process analysis in their practice to evaluate deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS A prospective implementation of process analysis was instituted on 147 DIEP flaps. The eight critical maneuvers for a DIEP flap are (1) skin to perforator identification, (2) perforator decision making, (3) perforator dissection, (4) pedicle dissection, (5) flap harvest, (6) preparation for microsurgery, (7) venous anastomosis, and (8) arterial anastomosis. Surgeons with variable experiences (faculty, faculty with senior resident/fellow, and supervised chief resident) used these eight steps to perform DIEP flap reconstruction. The outcomes and time of each maneuver were tracked. RESULTS The total flap harvest time among the three groups was 54.8 minutes for faculty surgeons, 98.3 minutes for senior resident/fellow working with faculty, and 178.8 minutes for supervised chief resident (p < 0.001). The largest difference was seen in perforator dissection. Increasing the number of perforators resulted in longer flap harvest times. Perforator location did not have an impact on times, but harvesting multiple rows took longer for less experienced surgeons. Body mass index and flap weight did not have an impact on time. CONCLUSIONS The authors share their experience using process analysis for DIEP flap reconstruction. They defined eight critical maneuvers to maximize efficiency and safety. By communicating efficient processes and integrating them into the workflow of a given operation, surgeons can continue to improve throughout the arc of their careers.
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Pafitanis G, Pawa A, Mohanna PN, Din AH. The Butterly iQ: An ultra-simplified color Doppler ultrasound for bedside pre-operative perforator mapping in DIEP flap breast reconstruction. J Plast Reconstr Aesthet Surg 2020; 73:983-1007. [PMID: 32005639 DOI: 10.1016/j.bjps.2020.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/05/2020] [Indexed: 11/17/2022]
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Wong KK, Stubbs E, McRae M, McRae M. CTA in preoperative planning for DIEP breast reconstruction: what the reconstructive surgeon wants to know. A modified Delphi study. Clin Radiol 2019; 74:973.e15-973.e26. [PMID: 31492417 DOI: 10.1016/j.crad.2019.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 07/19/2019] [Indexed: 11/19/2022]
Abstract
AIM To gather expert reconstructive surgical opinion to define and rank the surgically most important anatomy and provide guidance for report content to radiologists when reading a preoperative computed tomography angiography (CTA). MATERIALS AND METHODS A modified Delphi approach was used, involving a panel of 13 microsurgery experts across North America. Data from three consecutive online surveys were collected and returned to the respondents in the subsequent survey, allowing each respondent to see the range of opinions from other field experts. RESULTS Response rates were 62%, 77%, and 69% for each of the three survey rounds, respectively. The panel identified that the most important perforator characteristics in selecting the optimal perforator are diameter of the vein, perforator location within the flap, and diameter of the artery, respectively. The stated preference was for perforators located below the umbilicus. If no suitable perforator was located below the umbilicus, the panel would consider perforators up to 2 cm above the umbilicus. The most important considerations for the preoperative radiology planning report are: the size of the perforator vein, perforator location relative to landmarks, and the size of the perforator artery. DISCUSSION Based on the panel of expert reconstructive microsurgeons, the most surgically important anatomical considerations to be assessed and included in preoperative CTA reports for DIEP flap breast reconstruction were determined. The recommendations for reporting of preoperative DIEP breast reconstructions are presented, which, in consultation with local surgeons, can be used to form a template for reporting.
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Myung Y, Choi B, Yim SJ, Yun BL, Kwon H, Pak CS, Heo C, Jeong JH. The originating pattern of deep inferior epigastric artery: anatomical study and surgical considerations. Surg Radiol Anat 2018; 40:873-879. [PMID: 29926133 DOI: 10.1007/s00276-018-2055-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 06/14/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Studies focusing on the originating patterns of the deep inferior epigastric artery (DIEA) have not been conducted. Here, we analyzed the vascular anatomy of the DIEA with computed tomographic angiography (CTA) to provide assistance during proximal pedicle dissection of a DIEA-based flap. METHODS We conducted a retrospective study on patients who had undergone breast reconstruction with the transverse rectus abdominis musculocutaneous flap and the deep inferior epigastric perforator flap from March 2006 to October 2016. Preoperative three-dimensional computed tomographic angiograms of the abdominal wall (hemi-abdominal walls) were employed in this study, and three independent surgeons reviewed all CTA images. The originating angles and the distance from the originating point to the DIEA turning point were analyzed. Moreover, we assessed the relationship between the measured values and patients' characteristics, such as abdominal surgery history. RESULTS CTA data of 184 patients and 368 hemiabdomens were reviewed and analyzed. Most of the DIEAs originated from the external iliac artery in the medial direction, proceeded caudally, and curved in a cephalic direction. The average descending length was 11.29 mm. As the DIEA origin angle decreased (toward the caudal direction), the distance of the initial descent increased (r = 0.382, p < 0.01). In addition, the descending length was significantly larger (p < 0.01) in the operation group (12.22 mm) than in the non-operation group (9.86 mm). CONCLUSIONS Surgeons should consider DIEA-originating patterns to ensure safe pedicle dissection during flap elevation.
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Guo E, Xie Q, Zhu Z, Jin P, Jin P, Wang L. Laparoscopy-assisted Chimeric Peritoneal-deep Inferior Epigastric Perforator Flap for Reconstruction of Hand and Foot. WOUNDS : A COMPENDIUM OF CLINICAL RESEARCH AND PRACTICE 2018; 30:36-40. [PMID: 29481328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
UNLABELLED Management of hand and foot defects with exposed tendons is a big challenge for plastic surgeons. Thin vascularized tissue offers an ideal surface for tendon excursion. OBJECTIVE This study examines the reconstructive benefits of a laparoscopy-assisted chimeric peritoneal-deep inferior epigastric artery perforator (DIEP) flap in the treatment of hand and foot injury defects. MATERIALS AND METHODS A retrospective review was performed on 8 patients (6 men, 2 women) that received hand or foot reconstruction with laparoscopy-assisted chimeric peritoneal-DIEP flap. Soft tissue defects of the hand or foot ranged from 16 cm x 10 cm to 22 cm x 14 cm. The peritoneum supplied by the peritoneal branches of the deep inferior epigastric artery was retrieved by laparoscopy to cover exposed extensor tendons, while the DIEP flap consisted of the cutaneous component part of this chimeric flap. RESULTS The flaps survived in 7 of 8 patients. Partial necrosis of the chimeric flap was observed in 1 patient due to venous thrombosis. A split-thickness skin graft then was performed to achieve wound closure on that patient. Motor and sensory functions of these 8 patients improved gradually within the first-year follow-up. CONCLUSIONS The laparoscopy-assisted chimeric peritoneal-DIEP flap is useful for reconstructing defects of the hand and foot with exposed tendons.
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Erdmann-Sager J, Wilkins EG, Pusic AL, Qi J, Hamill JB, Kim HM, Guldbrandsen GE, Chun YS. Complications and Patient-Reported Outcomes after Abdominally Based Breast Reconstruction: Results of the Mastectomy Reconstruction Outcomes Consortium Study. Plast Reconstr Surg 2018; 141:271-281. [PMID: 29019862 PMCID: PMC5785552 DOI: 10.1097/prs.0000000000004016] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Abdominal flap reconstruction is the most popular form of autologous breast reconstruction. The current study compared complications and patient-reported outcomes after pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps. METHODS Patients undergoing abdominally based breast reconstruction at 11 centers were prospectively evaluated for abdominal donor-site and breast complications. Patient-reported outcomes were measured by the BREAST-Q and Patient-Reported Outcomes Measurement Information System surveys. Mixed-effects regression models were used to assess the effects of procedure type on outcomes. RESULTS Seven hundred twenty patients had 1-year follow-up and 587 had 2-year follow-up. Two years after reconstruction, SIEA compared with DIEP flaps were associated with a higher rate of donor-site complications (OR, 2.7; p = 0.001); however, SIEA flaps were associated with higher BREAST-Q abdominal physical well-being scores compared with DIEP flaps at 1 year (mean difference, 4.72, on a scale from 0 to 100; p = 0.053). This difference was not significant at 2 years. Abdominal physical well-being scores at 2 years postoperatively were lower in the pedicled TRAM flap group by 7.2 points (p = 0.006) compared with DIEP flaps and by 7.8 points (p = 0.03) compared with SIEA flaps, and in the free TRAM flap group, scores were lower by 4.9 points (p = 0.04) compared with DIEP flaps. Bilateral reconstruction had significantly lower abdominal physical well-being scores compared with unilateral reconstruction. CONCLUSIONS Although all abdominally based flaps are viable breast reconstruction options, DIEP and SIEA flaps are associated with higher abdominal physical well-being than pedicled and free TRAM flaps. Although SIEA flaps offer the advantage of not violating the fascia, higher rates of donor-site complications may diminish patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Jeong W, Lee S, Kim J. Meta-analysis of flap perfusion and donor site complications for breast reconstruction using pedicled versus free TRAM and DIEP flaps. Breast 2017; 38:45-51. [PMID: 29227815 DOI: 10.1016/j.breast.2017.12.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/27/2017] [Accepted: 12/04/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The transverse rectus abdominis musculocutaneous (TRAM) flap is an important option for breast reconstruction. Several studies have recently evaluated whether a greater number of complications result from the use of pedicled TRAM (pTRAM) flaps versus either free TRAM (fTRAM) flaps or deep inferior epigastric artery perforator (DIEP) flaps. To clarify the evidence regarding this issue, we performed an objective meta-analysis of published studies. MATERIALS AND METHODS A literature search of articles published between January 1, 1990, to January 1, 2017 was performed using the PubMed, EMBASE, Scopus, and Cochrane databases. Heterogeneity was statistically analyzed, and fixed effects and random effects models were used as appropriate. RESULTS Eleven articles comparing pedicled TRAM (pTRAM) flaps with either free TRAM (fTRAM) or DIEP flaps were included. The articles evaluated a total of 3968 flaps, including 1891 pTRAM flaps, 866 fTRAM flaps, and 1211 DIEP flaps. Patients with fTRAM flaps had a significantly lower risk of fat necrosis and partial flap necrosis than those with pTRAM flaps. No difference was observed in total flap necrosis and hernia or bulge between fTRAM and pTRAM flaps. No difference was noted in flap complications between DIEP and pTRAM flaps except for hernia or bulge.. CONCLUSION Although pTRAM flaps are being replaced by fTRAM and DIEP flaps, which exhibit fewer complications related to flap ischemia and donor site morbidity, it was unclear from the literature which flap type was most beneficial regarding flap vascularity and donor site morbidity. Hence, surgeons should choose the appropriate option based on their preferences and on patient factors..
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Hernandez Rosa J, Sherif RD, Torina PJ, Harmaty MA. Use of both antegrade and retrograde internal mammary vessels in the bipedicled deep inferior epigastric perforator flap for unilateral breast reconstruction. J Plast Reconstr Aesthet Surg 2016; 70:47-53. [PMID: 28029602 DOI: 10.1016/j.bjps.2016.09.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/04/2016] [Accepted: 09/09/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Autologous abdominal tissue transfer is a well-established method of breast reconstruction. The deep inferior epigastric perforator (DIEP) flap has the additional benefit of minimal donor site morbidity as it spares the muscle and fascia. Conventional DIEP flaps may not provide adequate volume in cases where the patient is thin, has midline abdominal scars, and/or has a large volume of tissue to replace. One solution is to use a bipedicled DIEP flap, incorporating all the available abdominal tissue. Bipedicled DIEP flaps have been described in a number of different configurations. The literature appears to favor intra-flap anastomosis, with a minimal exposition of two recipient vessels. It has been demonstrated that both the antegrade internal mammary artery (aIMA) and retrograde internal mammary artery (rIMA) are adequate recipient vessels. Here, the authors present a single-center experience with bipedicled DIEP flaps to both the aIMA and rIMA, showing their feasibility and safety. METHODS A retrospective review of patients who underwent unilateral breast reconstruction using bipedicled DIEP flaps was performed to assess outcomes. RESULTS A total of 20 patients who underwent unilateral breast reconstruction using a bipedicled DIEP flap were selected for this study. All of them were previously diagnosed with cancer. There were zero flap failure and zero instance of abdominal hernia or issue with abdominal wall functionality following the surgeries. CONCLUSIONS The series of surgeries described in this study resulted in successful breast reconstruction in 20 women using a bipedicled DIEP flap. The results show that this approach allows for reconstruction in places where a conventional DIEP does not provide adequate volume, achieved safely, and does not increase morbidity. The bipedicled DIEP flap is a viable option for large-volume autologous breast reconstruction, providing ample tissue for successful reconstruction while also allowing for shorter recovery and limited donor site morbidity.
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Dražan L, Lombardo GAG. TRIDIMENSIONAL DOPPLER ASSESSMENT: A RELIABLE, NON-INVASIVE AND COST-EFFECTIVE METHOD FOR PREOPERATIVE PERFORATOR ASSESSMENT IN DIEP FLAP. ACTA CHIRURGIAE PLASTICAE 2016; 58:60-63. [PMID: 28079390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND The preoperative perforator mapping is an important step in autologous breast reconstruction, making the flap raising safer, more predictable and time-saving. Although the Doppler exam has proven to be less accurate in locating perforators compared with colour duplex sonography and CTA, it will probably remain of importance in clinical practice. The aim of this paper is to share some advices on how to perform a Doppler exam in preoperative evaluation of a DIEAp flap, increasing its reliability in location of the perforators. METHODS The study was carried-out preoperatively on 26 consecutive patients. For the evaluation of the matching between Doppler Dot and operative finding was used a Cartesian coordinate systemResults: We have marked preoperatively 145 perforators in 26 patients for a total of 52 semi-abdomens. An average of 5.6 vessels per patient were marked. Of these, 80 (55.17%) were found between 0-1 cm, 36 (24.82%) between 1-2 cm and 5 (3.4%) of these more than 2 cm from each other. We had 24 (16.55%) false positives in which there was no correspondence between the signal and the intraoperative finding. CONCLUSION Although the Doppler exam may not provide the same anatomic details as the other newer modalities, such as CTA and MRA, the HHD remains a very useful and important tool for autologous reconstruction. We recommend performing this exam in our standardized and reproducible method to improve the reliability..
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Borović MML, Kostić JT, Borović SD, Zaletel IV, Dzelebdzić SM, Puskas NS, Kostić JV, Trifunović ZZ. Structural features of arterial grafts important for surgical myocardial revascularization: Part II--Histology of the radial, inferior epigastric, and right gastroepiploic arteries. VOJNOSANIT PREGL 2015; 72:1111-1117. [PMID: 26898036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023] Open
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Juyu T, Liming Q, Panfeng W, Zhengbing Z, Jieyu L, Fang Y, Jinfei F. [Application of free chimeric perforator flap with deep epigastric inferior artery for the soft tissue defect on the lower extremity with deep dead space]. ZHONGHUA ZHENG XING WAI KE ZA ZHI = ZHONGHUA ZHENGXING WAIKE ZAZHI = CHINESE JOURNAL OF PLASTIC SURGERY 2015; 31:425-428. [PMID: 27055320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To explore the feasibility and the effect of free chimeric perforator flap with deep inferior epigastric artery for the soft tissue defect on the lower extremity with deep dead space. METHODS From Mar. 2010 to Aug. 2011, 8 patients with soft tissue defects on the lower extremities combined with dead space, bone or joint exposure were reconstructed with free hinged perforator flaps with deep inferior epigastric artery. The muscle flap was inserted into the deep dead space, with perforator flap for superficial defect. The defects on the donor sites were closed directly. RESULTS All the flaps survived with primary healing. Good color and texture was achieved. The patients were followed up for 12-24 months, with an average of 16 months. 2 over-thick flaps were treated by flap-thinning surgery. Only linear scar was left on the donor site on abdomen with no malfunction. CONCLUSIONS The free chimeric perforator flap with deep inferior epigastric artery can simultaneously construct the dead space and superficial defect with only anastomosis of one set of vascular pedicle. It is an ideal method with good results on recipientsites and less morbidity on donor sites.
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Baskin B. Invited commentary for "preoperative magnetic resonance imaging-based breast volumetry for immediate breast reconstruction". Aesthetic Plast Surg 2015; 39:377-8. [PMID: 25917064 DOI: 10.1007/s00266-015-0492-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 04/14/2015] [Indexed: 12/01/2022]
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Hadad I, Ibrahim AMS, Lin SJ, Lee BT. Augmented SIEA flap for microvascular breast reconstruction after prior ligation of bilateral deep inferior epigastric arteries. J Plast Reconstr Aesthet Surg 2012; 66:845-7. [PMID: 23047181 DOI: 10.1016/j.bjps.2012.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 08/27/2012] [Accepted: 09/10/2012] [Indexed: 12/29/2022]
Abstract
The superficial inferior epigastric artery (SIEA) flap is an excellent option for free tissue transfer breast reconstruction. Similar to the free transverse rectus myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps, the SIEA pedicle supplies the fasciocutaneous tissues of the lower abdomen. The SIEA flap does not involve removal of or potential damage to the rectus muscles. Nonetheless, the vascular pedicle may be a challenge to dissect and variable in its presence and caliber. This article presents a case report and an extended delay technique to augment the SIEA system in a patient with prior bilateral deep inferior epigastric artery ligation.
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Nemes M, Grujic D, Crainiceanu Z, Jiga L, Prilipceanu G, Olariu D, Bodog F, Bratu T. Breast reconstruction with autologous tissue--our clinical experience. Chirurgia (Bucur) 2012; 107:199-205. [PMID: 22712349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
INTRODUCTION Breast reconstruction after mastectomy gained new grounds since the introduction of autologous tissue and oncoplastic surgery techniques. Nowadays large postoperative breast defects can be treated with high quality tissues obtained by autogenous flap surgery, to achieve the best functional and physical results. OBJECTIVES The purpose of this study is to analyze our results in breast reconstruction using autologous tissue and to emphasize the importance of a multidisciplinary team. MATERIAL AND METHODS During a five year period (2005-2009) we performed 28 breast reconstructions after cancer surgery, 15 in delayed and 13 in primary reconstruction, using three types of flaps: latissiumus dorsi flap, transverse rectus abdominis myocutaneous flap and deep inferior epigastric artery perforator flap. RESULTS Functional and cosmetic results were very good, only minor complications such as seroma and hematoma of the donor site and partial/marginal flap necrosis occurred after the surgical procedure. There were no major complications like total flap loss. CONCLUSIONS Breast reconstruction with autologous tissue is a safe, well proved, although not easy procedure that confers best functional and cosmetic results and is at the same time oncologically safe.
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Zeng A, Qiao Q, Zhu L, Fang BR, Bai M, Zhang HL, Pan B. [Vaginal reconstruction with pedicled deep inferior epigastric perforator flap]. ZHONGHUA ZHENG XING WAI KE ZA ZHI = ZHONGHUA ZHENGXING WAIKE ZAZHI = CHINESE JOURNAL OF PLASTIC SURGERY 2009; 25:8-10. [PMID: 19408715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To explore a new surgical procedure for vaginal reconstruction with pedicled deep inferior epigastric perforator (DIEP) flap. METHODS Since June 2007, 6 cases underwent vaginal reconstruction, including five congenital vaginal absence and one immediately after total vaginal resection due to carcinoma. Intensive CT scans were performed preoperatively for perforator selection. The DIEP flaps were designed vertically on the anterior abdominal wall and transferred for vaginal reconstruction. RESULTS All the patients recovered uneventfully with no flap loss and other complication. The patients were followed up for 1 to 8 months (mean, 4 months) with satisfactory results. CONCLUSION Vaginal reconstruction with vertical DIEP flaps is a safe and reliable method.
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Fang BR, Zeng A, Huang WQ, Qiao Q, Gao P, Yan XQ. [Application of computed tomography angiography in preoperative design of deep inferior epigastric artery perforator flap]. ZHONGHUA ZHENG XING WAI KE ZA ZHI = ZHONGHUA ZHENGXING WAIKE ZAZHI = CHINESE JOURNAL OF PLASTIC SURGERY 2009; 25:3-7. [PMID: 19408714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To explore the application of computed tomography angiography (CTA) in preoperative design of deep inferior epigastric artery perforator (DIEAP) flap. METHODS From Jan, 2007 to Mar, 2008, preoperative CTA of deep inferior epigastric artery was performed in 13 patients, including 5 patients with congenital absence of the vagina, 4 patients with penile and scrotal Paget's disease and 4 patients after mastectomy. The images were analyzed, including multiple planar reformation (MPR), maximum intensity projection (MIP) and volume rendering (VR). Then the distributions, branches and locations of perforators of deep inferior epigastric artery were measured. The images from CTA were compared with intraoperative observation. RESULTS The images demonstrated the distributions of deep inferior epigastric artery and locations of its perforators, which were proved to be true by intraoperative observation. CONCLUSIONS The preoperative CTA of deep inferior epigastric artery is very useful for preoperative design of DIEAP flaps.
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Zeng A, Qiao Q, Fang B, Jia Y, Zhang H, Zhu L, Pan B. [Clinical application of intensive CT in pedicled deep inferior epigastric perforator flap design]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2008; 22:1426-1428. [PMID: 19137881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To explore the effect of the intensive CT on the deep inferior epigastric perforator (DIEP) flap design strategy. METHODS From June 2007 to March 2008, 7 patients received reconstructive operation of the vertical DIEP flap, among whom there were 5 females with congenital absence of vagina and 2 males with peno-scrotal Paget's disease, aged 18-62 years old. Before the operation, the intensive CT scans were applied to all the patients in search for DIEP. The flaps were designed according to the radiological findings. The scrotum and penis defects were reconstructed in 2 cases and vaginal reconstruction was performed in 5 cases. The flap dimension ranged from 15 cm x 7 cm to 22 cm x 5 cm. The donor site was closed directly. RESULTS A total of 10 ideal perforating branches of all the 7 DIEP flaps were found before the operation, with the diameter of over 1.5 mm. Of the 7 flaps, 4 had 1 perforating branch and the other 3 had 2 perforating branches. All 7 flaps survived completely. The incisions of 6 patients obtained healing by first intention. Only 1 patient with Paget's disease had erosion at the scrotum incision and partial necrosis 7 days after the operation, and then healed after discontinuous dressing change. The incisions at the donor site obtained healing by first intension. Two patients complained about draw-off at the lower abdomen on the operated side, which was basically relieved at 7 days after the operation. All patients were followed up for 1 to 10 months (4.5 months on average). No operation-related complication was observed after operation. Six patients were satisfied with the reconstructive results. Only 1 patient was dissatisfied with the buried pennies and requested a revision. CONCLUSION The intensive CT scans play an important role in the DIEP flap design. It can not only make the flap safer, but also decrease operation time and improve efficiency.
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Zheng M, Lin HD, Jiang ZC, Yang JQ. [Free deep inferior epigastric artery perforator flap techniques for the immediate post modified radial mastectomy reconstruction]. ZHONGHUA YI XUE ZA ZHI 2008; 88:1069-1070. [PMID: 18754444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To discuss the feasibility and method of immediate breast reconstruction right after modified radical mastectomy in early breast carcinoma patients. METHODS Deep inferior epigastric artery perforation flaps were immediately applied on patients to reconstruct the breast after the skin-sparing mastectomy. The breasts were shaped after the deep inferior epigastric artery and vein were anastomosed to the thoracodorsal artery and vein. RESULTS In 10 cases of breast reconstruction by DIEP flaps since 2005, there were completely survival in 8 flaps, distal skin necrosis in 1 flap, adiponecrosis in 1 flap. With the follow-up of 9-28 months, the reconstructed breasts were well-shaped and there were no abdominal complication in dnor sites. Ninety percent patients were satisfied with the results from the good to the best level. CONCLUSION Most patients were satisfied with the results of mastectomy reconstruction.
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Rozen WM, Phillips TJ, Ashton MW, Stella DL, Gibson RN, Taylor GI. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and doppler ultrasound. Plast Reconstr Surg 2008; 121:1-8. [PMID: 18213740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND Abdominal donor-site flaps, including the transverse rectus abdominis musculocutaneous (TRAM) and deep inferior epigastric artery (DIEA) perforator flaps, are standard in autologous breast reconstruction. With significant variation in the vascular anatomy of the abdominal wall, preoperative imaging is essential for preoperative planning and reducing intraoperative error. Doppler and color duplex sonography have been used with varying results, and the quest continues for optimal preoperative assessment. Computed tomographic angiography has recently been proposed as a noninvasive modality for this purpose. This is the first study to formally compare preoperative Doppler ultrasound with computed tomographic angiography for imaging the DIEA. METHODS Eight consecutive patients undergoing DIEA perforator flap surgery for breast reconstruction underwent both computed tomographic angiography and Doppler ultrasound preoperatively. All investigations and procedures were performed at the same institution with the same primary and assisting surgeons and the same radiology team. RESULTS Computed tomographic angiography was superior to Doppler ultrasound at identifying the course of the DIEA and its branching pattern, and in visualizing its perforators. Preoperative computed tomographic angiography was highly specific (100 percent) and more sensitive in mapping and visualizing perforators (p = 0.0078). It was also proficient at identifying the superficial epigastric arterial system and for effectively displaying the results intraoperatively. It was substantially quicker and removed the interobserver error associated with Doppler ultrasonography. The study was ceased after eight patients because of the overwhelming benefit of computed tomographic angiography over Doppler ultrasonography. CONCLUSION Computed tomographic angiography is a valuable imaging modality for the preoperative assessment of the donor-site vascular supply for TRAM and DIEA perforator flaps.
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El-Sherbiny M, Abou-Elela A, Morsy A, Salah M, Foda A. The use of the inferior epigastric artery for accessory lower polar artery revascularization in live donor renal transplantation. Int Urol Nephrol 2007; 40:283-7. [PMID: 17721826 DOI: 10.1007/s11255-007-9257-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Accepted: 07/09/2007] [Indexed: 11/29/2022]
Abstract
PURPOSE This study describes the surgical technique and outcomes of live donor renal allografts with multiple arteries in which the lower polar artery was anastomosed to the inferior epigastric artery after declamping. MATERIALS AND METHODS Between 1988 and 2004, 477 consecutive live donor renal transplants were performed, including 429 with single and 48 with multiple arteries. Anastomosis of the lower polar artery to the inferior epigastric artery was used for 15 grafts with multiple arteries. RESULTS Successful revascularization of all areas of the transplanted graft was confirmed by Doppler ultrasonography in most patients and radionuclide renal scanning +/- MRA in some patients. CONCLUSIONS In live donor renal transplantation with multiple arteries, the anastomosis of the lower polar artery to the inferior epigastric artery after declamping avoids prolongation of the ischemia time that occurs with other surgical and microsurgical techniques of intracorporeal and ex vivo surgeries.
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Rockwell WB, Hurst CA, Morton DA, Kwok A, Foreman KB. The Deep Inferior Epigastric Artery: Anatomy and Applicability as a Source of Microvascular Arterial Grafts. Plast Reconstr Surg 2007; 120:209-214. [PMID: 17572565 DOI: 10.1097/01.prs.0000264068.41410.1e] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Arterial grafts are superior to venous grafts when used for microvascular grafting procedures. Advantages of arterial grafts include anatomical taper, improved size match, improved handling characteristics, and superior patency rates. The deep inferior epigastric artery may be used as a source of microvascular graft to replace damaged or diseased arterial segments. By studying cadaver dissections, it is possible to estimate the clinically usable length and caliber of the deep inferior epigastric artery. METHODS Thirty-four preserved cadavers were dissected and 63 deep inferior epigastric arterial systems were removed and measured. The deep inferior epigastric artery was used as an arterial conduit to bypass across nine wrists in eight patients. RESULTS The mean length from the external iliac artery to the point at which the vessel displayed an external diameter of 1 mm was 14.06 +/- 2.54 cm. The deep inferior epigastric artery has been used in nine clinical cases as an arterial conduit to bypass distal to the wrist. All nine bypasses were patent 1 year postoperatively, without donor-site complication. CONCLUSION The deep inferior epigastric artery is a morphologically reliable and clinically useful source of arterial grafts.
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Li P, Zeng ZC, Yu QP, Luo WJ. [Applied anatomy of inferior epigastric artery in coronary artery bypass grafting]. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2007; 32:515-9. [PMID: 17611337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To measure the inferior epigastric artery(IEA),coronary artery and arterial bridge to supply the anatomic and hemodynamic data of IEA in coronary artery bypass grafting for clinicians. METHODS Anatomic method was adopted to measure the length of IEA, arterial bridge, the outer diameter of IEA and coronary arteries. Colour doppler ultrasound instrument was adopted to measure the caliber and the blood flow rate of IEA and coronary artery. RESULTS In the anatomic method, the length of IEA was (13.00+/-2.58)cm and the caliber of original IEA was (2.95+/-0.21)mm, the caliber of IEA intersecting with abdomen rectus was (2.51+/-0.32)mm, and (1.60+/-0.26)mm at 1.0 cm below the umbilicus. In color doppler ultrasound method, the caliber of original IEA was (2.98+/-0.37)mm, and at 5 cm from the original spot was (2.60+/-0.27)mm. The blood flow rate was (57.00+/-6.78)cm/s. The main stem caliber of the left coronary artery was (4.90+/-0.76)mm, and that of the right coronary artery was (3.58+/-0.63)mm; the blood flow rate was (48.50+/-7.72)cm/s. The length of the arterial bridge was (10.95+/-1.35) approximately (15.30+/-2.82)cm. CONCLUSION IEA can bridge the aorta and the coronary artery branches including the left anterior descending branch, the left circumflex branch and the right main coronary artery in free grafting. Its caliber and blood flow rate can match with those of the coronary artery. Before the operation of applying color doppler ultrasound instrument, the safety of IEA in the coronary artery bypass grafting can be evaluated to provide a new safe method in clinical follow-up.
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Barry M, Touati G, Chardon K, Laude M, Libert JP, Sevestre H. Histologic study of coronary, radial, ulnar, epigastric and internal thoracic arteries: application to coronary artery bypass grafts. Surg Radiol Anat 2007; 29:297-302. [PMID: 17505775 DOI: 10.1007/s00276-007-0214-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Accepted: 04/19/2007] [Indexed: 11/26/2022]
Abstract
The biometry and the histology of coronary, radial, ulnar, epigastric and internal thoracic arteries were studied in order to investigate the cause of their occlusions in coronary bypass grafts and to improve the results of these bypass grafts. These various arteries were removed from 40 anatomical specimens (27 males and 13 females). We found a correlation between the internal calibers of the ulnar and coronary arteries in males. Intimal changes and the presence of atheromatous plaque were observed in coronary, radial and ulnar arteries, but never in the internal thoracic artery. Like coronary arteries and their branches, radial, ulnar and epigastric arteries are muscular arteries and ageing results in thickening of the intima, which becomes fibrotic with migration of myocytes from the media and duplication of the internal elastic lamina. The media becomes fibrous, hypertrophic or atrophic. In contrast, the internal thoracic artery is an elastic artery, like the aorta. Ageing is characterized by loss, over a variable extent, of one or several elastic laminae of the media and more marked intimal thickening. Although anatomically, the caliber of radial, ulnar, and epigastric arteries remains adapted to that of coronary arteries, the long-term patency of radial, ulnar and epigastric arteries used as grafts is related to their histological characteristics.
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