Mapping the vascular anatomy of free transplanted soft tissue flaps with computed tomographic angiography

The appearance of cartilage used in deep inferior epigastric perforator breast reconstruction surgery as a calcified mass on CT scan

This paper describes an unusual radiological appearance of implanted cartilage on CT scan in a patient who had recently undergone deep inferior epigastric perforator (DIEP) breast reconstruction surgery following a mastectomy for ductal carcinoma in situ. The purpose of this paper is to alert medical practitioners involved with DIEP breast reconstruction surgery, as well as general radiologists, to the possibility of surgically implanted costal cartilage undergoing calcification and then appearing on imaging studies as a malignant process. Information on the patient was gathered from clinical records, imaging reports and pathological samples. A literature search was performed to identify similar cases and the results showed that this occurrence has never before been described and therefore represents an advancement of knowledge about the imaging characteristics of reconstructed breast tissue.

Identification of perioperative risk factor by laser-doppler spectroscopy after free flap perfusion in the head and neck: a prospective clinical study

The aim of this study was to evaluate perioperative flap perfusion using noninvasive monitoring with a laser-Doppler flowmetry and spectrophotometry unit (O2C) and identify whether perioperative blood flow, velocity, hemoglobin level (Hb), and oxygen saturation (SO2 ) measured could be used as indicators of free flap success. Measurements of blood flow, velocity, Hb, and SO2 were performed in 196 microvascular flaps, which had been transferred into the oral cavity to reconstruct ablative defects after surgery for oral cancer. The values were calculated superficially on the skin surface and at a depth of 8 mm. The results showed that perioperative absolute values measured were not associated with an increased rate of microvascular revisions or free flap failure. Independent predictors of microvascular revisions at the first postoperative day were the development of a falling trend in superficial and deep blood flow, and velocity in comparison with baseline values of variables measured. On day 2, all superficial and deep values of Hb, flow, and velocity were independent prognostic factors (P < 0.01), demonstrated as a downward trend were associated with a need for revision. The superficial and deep values of SO2 (P = 0.59 and 0.43, respectively) were not associated with ultimate free flap failure. This is the first clinical study to demonstrate that during early free flap integration to the recipient site different parameters of perfusion and oxygenation play an important role at different points of time. Within the first two postoperative days, changes in these parameters can help influence the decision to revise microvascular anastomoses.

Secondary splitting of a free deep inferior epigastric perforator flap with pedicled transfer to the contralateral breast for staged reconstruction of two breasts: the split DIEP flap

Free tissue transfer has become popularized for post-mastectomy autologous breast reconstruction, particularly with the abdominal wall donor site. However, in the setting of previous autologous breast reconstruction, options for later contralateral reconstruction are limited. We present a case of breast reconstruction with a free deep inferior epigastric artery perforator (DIEP) flap, which was split from the initially reconstructed breast and shared to reconstruct the opposite breast after the occurrence of a metachronous contralateral second primary breast cancer. There were no operative complications, no flap-related complications, and at two years follow-up, the patient subjectively described bilateral soft and supple breasts, which were symmetrical in a bra, and with which she has reported high satisfaction. An account of the "split DIEP flap" is provided, highlighting the planning, technique, and vascular rationale. The technique comprises partition of a previously transferred DIEP flap breast reconstruction into two parts based on preoperative computed tomographic angiography, performed to guide surgical planning in avoiding pedicle damage and identifying the portion of the flap to island. The split DIEP flap for staged bilateral autologous breast reconstruction offers two soft-tissue flaps for the price of one donor site, offering new possibilities in breast reconstruction and the broader field of tissue transplantation.

Preoperative imaging in the planning of deep inferior epigastric artery perforator flap surgery

Breast reconstruction with adipocutaneous free flap from the abdominal wall combines the benefits of abdominoplasty to those of a prosthesis-free breast reconstruction. The deep inferior epigastric artery perforator (DIEP) flap is supplied by intramuscular perforators from the deep inferior epigastric artery (DIEA). It consists of the dissection of perforating branches of the DIEA within the rectus abdominis muscle, thus sparing both muscle and fascia. Preoperative imaging in the planning of DIEP flap surgery has been shown to facilitate faster and safer surgery. This review article aims to discuss advantages and drawbacks of current imaging modalities for mapping the course of perforating vessels in the planning of DIEP flap surgery, and to present state-of-the-art imaging techniques.