Successful free flap salvage upon venous congestion in bilateral breast reconstruction using a venous cross-over bypass: A case report

Improving the Safety of DIEP Flap Transplantation: Detailed Perforator Anatomy Study Using Preoperative CTA

Background: Deep inferior epigastric perforator and muscle sparing transverse rectus abdominis muscle flaps are commonly used flaps for autologous breast reconstruction. CT-angiography allows to analyse the perforator course preoperatively. Our aim was to compare the different aspects of perforator anatomy in the most detailed study. Methods: CT-angiographies of 300 female patients with autologous breast reconstruction of 10 years were analysed regarding the anatomy of the deep inferior epigastric artery and every perforator. Results: Overall, 2260 perforators were included. We identified correlations regarding the DIEA branching point and number of perforators and their intramuscular course. The largest perforator emerged more often from the medial branch of the DIEA than the smaller perforators (70% (416/595) vs. 54% (878/1634), p < 0.001) and more often had a direct connection to the SIEV (large 67% (401/595) vs. small 39% (634/1634), p < 0.01). Medial row perforators were larger than the laterals (lateral 1.44 mm ± 0.43 (n = 941) vs. medial 1.58 mm ± 0.52 (n = 1304) (p < 0.001)). The larger and more medial the perforator, the more likely it was connected to the SIEV: perforators with direct connection to the SIEV had a diameter of 1.65 mm ± 0.53 (n = 1050), perforators with indirect connection had a diameter of 1.43 ± 0.43 (n = 1028), perforators without connection had a diameter of 1.31 mm ± 0.37 (n = 169) (p < 0.001). Medial perforators were more often directly connected to the SIEV than lateral perforators (medial 56% (723/1302) vs. lateral 35% (327/941), p < 0.001). A lateral perforator more often had a short intramuscular course than medial perforators (69% (554/800) vs. 45% (474/1055), p < 0.001), which was also more often observed in the case of a small perforator and a caudal exit of the rectus sheath. Conclusion: The largest perforator emerges more often from the medial branch of the DIEA and frequently has a direct connection to the SIEV, making medial row perforators ideal for DIEP flap transplantation.

Bilateral free flap breast reconstruction using venous cross-over bypass to contralateral internal mammary artery for salvaging thrombosed arterial anastomosis in unilateral repeated irradiation of the breast: A case report

Adjuvant radiotherapy in breast cancer patients might enhance complications after autologous breast reconstruction, including thrombosis of the internal mammary artery (IMA) precluding its use as recipient vessel. This case report shows a salvage procedure for thrombosis of the IMA during bilateral autologous breast reconstruction in a 51-year-old patient who had undergone repeated irradiation of the chest wall after Hodgkin's disease and recurrent breast carcinoma of the right side. After mastectomy of the right breast and prophylactic mastectomy of the left breast, the patient desired breast reconstruction with autologous tissue. During simultaneous bilateral breast reconstruction using two deep inferior epigastric perforator (DIEP) flaps anastomosed to the left and right inframammary vessels, arterial anastomosis to the right IMA was not feasible due to arterial thrombosis. A salvage procedure using an interpositional cephalic vein graft as a crossover bypass and a subcutaneous presternal tunnel was used. The inferior epigastric artery of the right DIEP flap was anastomosed to the venous bypass, which was anastomosed to the contralateral IMA. Both flaps healed without any complications during the postoperative course and follow up of 6 months. The presented case shows the feasibility of a cross-over venous bypass procedure during bilateral breast reconstruction as salvage maneuver for the arterial anastomosis after repeated radiation of the unilateral breast.

Less is more - retrospective comparison of shoulder strength and range of motion between conventional and muscle-sparing harvesting technique of a latissimus dorsi flap

BACKGROUND

The muscle-sparing latissimus dorsi flap poses an alternative to the conventional latissimus dorsi flap when a defect requires a smaller flap volume with a long vascular pedicle. The aim of the study was to analyze the functional outcome following muscle-sparing versus conventional harvest of a latissimus dorsi flap.

MATERIAL AND METHODS

Patients who received a muscle-sparing latissimus dorsi muscle flap transplantation (group 1) and patients with a complete latissimus dorsi muscle flap harvest (group 2) for defect reconstruction at the University Hospital of Erlangen between 2007 and 2016 were examined. The evaluation included a physical examination with the measurement of strength and range of motion of the shoulder of both the donor side as well as the nonoperated side. Furthermore, the DASH score was evaluated. Additionally, patients in group 1 received a neurophysiological examination.

RESULTS

The DASH score did not show statistically significant differences between both groups. Both strength (p = 0.031) and range of motion (p<0.05) of the shoulder of the donor side were statistically significantly lower than the nonoperated side in group 2, while no difference was found in group 1. The neurophysiological examination in group 1 showed a reduced nerve conduction velocity of the donor side as compared to the nonoperated side in most patients (60% and n = 3).

CONCLUSION

Harvesting the muscle-sparing latissimus dorsi flap leads to less functional impairments of the shoulder than harvesting the complete latissimus dorsi flap.

Retrospective analysis of free temporoparietal fascial flap for defect reconstruction of the hand and the distal upper extremity

INTRODUCTION

Soft tissue reconstruction of the hand and distal upper extremity is challenging to preserve the function of the hand as good as possible. Therefore, a thin flap has been shown to be useful. In this retrospective study, we aimed to show the use of the free temporoparietal fascial flap in soft tissue reconstruction of the hand and distal upper extremity.

METHODS

We analysed the outcome of free temporoparietal fascial flaps that were used between the years 2007and 2016 at our institution. Major and minor complications, defect location and donor site morbidity were the main fields of interest.

RESULTS

14 patients received a free temporoparietal fascial flap for soft tissue reconstruction of the distal upper extremity. Minor complications were noted in three patients and major complications in two patients. Total flap necrosis occurred in one patient.

CONCLUSION

The free temporoparietal fascial flap is a useful tool in reconstructive surgery of the hand and the distal upper extremity with a low donor site morbidity and moderate rates of major and minor complications.

Interdisciplinary Treatment of Breast Cancer After Mastectomy With Autologous Breast Reconstruction Using Abdominal Free Flaps in a University Teaching Hospital-A Standardized and Safe Procedure

Background: Breast cancer is the most common malignancy in women. The interdisciplinary treatment is based on the histological tumor type, the TNM classification, and the patient's wishes. Following tumor resection and (neo-) adjuvant therapy strategies, breast reconstruction represents the final step in the individual interdisciplinary treatment plan. Although manifold flaps have been described, abdominal free flaps, such as the deep inferior epigastric artery perforator (DIEP) or the muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) flap, are the current gold standard for autologous breast reconstruction. This retrospective study focuses on the safety of autologous breast reconstruction upon mastectomy using abdominal free flaps. Methods: From April 2012 until December 2018, 193 women received 217 abdominal free flaps for autologous breast reconstruction at the University Hospital of Erlangen. For perforator mapping, we performed computed tomography angiography (CTA). Venous anastomosis was standardized using a ring pin coupler system, and flap perfusion was assessed with fluorescence angiography. A retrospective analysis was performed based on medical records, the surgery report, and follow-up of outpatient course. Results: In most cases, autologous breast reconstruction was performed as a secondary reconstructive procedure after mastectomy and radiotherapy. In total, 132 ms1-TRAM, 23 ms2-TRAM, and 62 DIEP flaps were performed with 21 major complications (10%) during hospital stay including five free flap losses (2.3%). In all cases of free flap loss, we found an arterial thrombosis as the main cause. In 24 patients a bilateral breast reconstruction was performed without free flap loss. The majority of free flaps (96.7%) did not need additional supercharging or turbocharging to improve venous outflow. Median venous coupler size was 2.5 mm (range, 1.5-3.5 mm). Conclusion: Using CTA, intraoperative fluorescence angiography, titanized hernia meshes for rectus sheath reconstruction, and venous coupler systems, autologous breast reconstruction with DIEP or ms-TRAM free flaps is a safe and standardized procedure in high-volume microsurgery centers.

Successful free flap salvage upon venous congestion in bilateral breast reconstruction using a venous cross-over bypass: A case report

Abdominal free flaps such as the muscle sparing transverse rectus abdominis myocutaneous (ms-TRAM) or deep inferior epigastric artery perforator (DIEP) flap represent the gold standard in autologous breast reconstruction. We describe a salvage procedure during bilateral free flap breast reconstruction due to insufficient venous drainage using a venous cross-over bypass. A 54-year-old woman with a thrombosis of the left subclavian port-system in the medical history was elected for simultaneous bilateral breast reconstruction with ms-TRAM and DIEP flaps. Intraoperatively, a venous congestion of the DIEP flap, which was connected to the left cranial internal mammary vessels, appeared. In the absence of sufficient ipsilateral venous recipient vessels, we performed a salvage procedure requiring a 15 cm small saphenous vein graft and presternal subcutaneous tunneling. The flap vein was anastomosed end-to-end with the contralateral caudal internal mammary vein using a coupler system. The postoperative course was uneventful and both flaps survived. We describe the cross-over venous emergency bypass as a useful tool in unexpected venous thrombosis during bilateral free flap breast reconstruction.