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Tanna N, Sultan DL, Minasian RA, Clappier M, Haddock NT, Chrysopoulo MT, Nahabedian MY, Serletti JM, Allen RJ. Contemporary Microsurgical Breast Reconstruction: Abdominally Based Flaps. Plast Reconstr Surg 2024; 154:199e-214e. [PMID: 38923931 DOI: 10.1097/prs.0000000000011373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand the types of abdominally based flaps, their anatomy, and their drawbacks. 2. Understand important aspects of the history and physical examination of patients wishing to undergo these procedures. 3. Understand the benefits of preoperative planning and its role in avoiding complication. 4. Understand the operative steps of the procedures and tips to increase efficiency. 5. Understand the postoperative care of these patients and the role of enhanced recovery pathways. SUMMARY In this article, the authors review the history, current state, and future directions related to abdominally based microsurgical breast reconstruction. This article covers preoperative, intraoperative, and postoperative considerations intended to improve patient outcomes and prevent complications. Evidence-based findings are reported when available to comprehensively review important aspects of these procedures.
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Affiliation(s)
- Neil Tanna
- From the Division of Plastic and Reconstructive Surgery, Northwell Health, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
| | - Darren L Sultan
- From the Division of Plastic and Reconstructive Surgery, Northwell Health, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
| | - Raquel A Minasian
- From the Division of Plastic and Reconstructive Surgery, Northwell Health, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
| | - Mona Clappier
- From the Division of Plastic and Reconstructive Surgery, Northwell Health, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
| | | | | | | | - Joseph M Serletti
- Division of Plastic and Reconstructive Surgery, University of Pennsylvania
| | - Robert J Allen
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health
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Sinik LM, Collins MS. Challenges in Autologous Breast Reconstruction: A Review of Recommendations. J Clin Med 2024; 13:971. [PMID: 38398283 PMCID: PMC10889312 DOI: 10.3390/jcm13040971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/04/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Breast reconstruction is an integral part of breast cancer treatment and offers significant psychosocial benefits for patients undergoing mastectomy as a part of their treatment plan. Autologous breast reconstruction (ABR) utilizes a patient's own tissue to reconstruct the mastectomy defect, obviating the need for the implantation of a foreign object. As the field of plastic surgery progresses, ABR has become an excellent option for the recreation of a native breast mount. With that said, there are patient populations who present unique challenges when optimizing an aesthetic ABR result. We aim to discuss these challenging groups, including patients with both high and low body mass index (BMI), patients with a history of massive weight loss, patients who require post-mastectomy radiation therapy (PMRT), and patients electing for unilateral procedures where the surgeon attempts to match the reconstructed breast with the native breast. In our discussion, we review the literature recommendations for management as well as our experiences with our own patient cases. Ultimately, we believe this procedure can be performed in a wide variety of patient types and can be offered to those who may not be considered the "ideal" candidate.
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Affiliation(s)
| | - Meredith S. Collins
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, KS 66160, USA;
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Tanna N, Barnett SL, Robinson EL, Smith ML. Hybrid Microsurgical Breast Reconstruction:: HyFIL® & HyPAD™ Techniques. Clin Plast Surg 2023; 50:337-346. [PMID: 36813411 DOI: 10.1016/j.cps.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
There are numerous indications for hybrid breast reconstruction, with the most common being patients who have inadequate donor site volume to achieve the desired breast volume. This article reviews all aspects of hybrid breast reconstruction, including preoperative and assessment, operative technique and considerations, and postoperative management.
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Affiliation(s)
- Neil Tanna
- Division of Plastic and Reconstructive Surgery, Northwell Health, Great Neck, NY, USA; Divsion of Plastic & Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| | - Sarah L Barnett
- Division of Plastic and Reconstructive Surgery, Northwell Health, Great Neck, NY, USA
| | - Emma L Robinson
- Divsion of Plastic & Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Mark L Smith
- Division of Plastic and Reconstructive Surgery, Northwell Health, Great Neck, NY, USA; Divsion of Plastic & Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Tiziana R, M PN, Mary M, Venkat R. Stacked TUG and DIEP flaps to reconstruct a single breast: expanding the scope of autologous breast reconstruction. J Plast Reconstr Aesthet Surg 2022; 75:2974-2981. [DOI: 10.1016/j.bjps.2022.06.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 05/24/2022] [Accepted: 06/07/2022] [Indexed: 11/30/2022]
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Bilateral Outpatient Breast Reconstruction with Stacked DIEP and Vertical PAP Flaps. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3878. [PMID: 34671545 PMCID: PMC8522876 DOI: 10.1097/gox.0000000000003878] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/24/2021] [Indexed: 12/15/2022]
Abstract
Background: Stacking free flaps for breast reconstruction is far from novel, even in the case of a deep inferior epigastric perforator (DIEP) plus profunda artery perforator (PAP) configuration, where the latter is always described in the traditional transverse configuration. We present a series of consecutive patients undergoing bilateral breast reconstruction with stacked DIEP and vertical PAP flaps. Methods: Patients with inadequate abdominal donor tissue were offered the possibility of a stacking breast reconstruction. The DIEP flap was harvested via microfascial incisions, whereas the vertical PAP flap was harvested in the lithotomy position, following the course of the gracilis muscle. Results: In total, 28 consecutive patients with a mean BMI of 24.9 underwent bilateral breast reconstruction with stacked DIEP and vertical PAP flaps. The internal mammary artery and vein were used as recipient vessels in all 56 stacked flaps. Fifty-three PAP flaps were anastomosed to the distal portion of the (primary) DIEP flaps utilizing a sequential flap anastomosis technique, and one DIEP flap was anastomosed to the distal portion of the (primary) PAP flap. Hospitalization for the initial eight patients averaged 35 hours, whereas the following 20 patients were discharged within 23 hours. There were no postoperative takebacks or vascular complications. Conclusions: Stacked DIEP/PAP flaps offer an excellent option for patients who require more volume than available from DIEP flaps alone. When compared with transverse PAP flaps, the vertical PAP offers excellent variability of volume and ease of shaping to allow for excellent results, while minimizing donor site tension in the seated position and preserving the gluteal fold.
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Hamdi M, Al Harami S, Chahine F, Giunta G, De Baerdemaeker R, Zeltzer A. The "Hug Flap": Surgical Technique to Enhance the Aesthetic Breast Projection in Autologous Breast Reconstruction. Aesthet Surg J 2021; 41:NP1462-NP1470. [PMID: 33480982 DOI: 10.1093/asj/sjab030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Obtaining a natural breast mound shape contributes profoundly to a symmetrical and successful outcome in breast reconstruction. OBJECTIVES The authors sought to describe a new and efficient technique that enhances breast projection in delayed breast reconstruction employing abdominal free flaps and compare it with the current standard methods utilized. METHODS The charts of 490 consecutive patients who underwent delayed breast reconstruction employing free abdominal perforator flaps were reviewed between 2007 and 2017. Three methods of breast reconstruction were compared: undermining, de-epithelialization, and the "hug flap" (HF). In the newly described technique, the caudal mastectomy skin was de-epithelialized, and then the medial and lateral thirds were undermined and folded over to cover the central part. The rates of complications and secondary corrections were analyzed between the 3 groups. RESULTS There were 570 free abdominal flaps performed. The de-epithelization technique was the most commonly utilized (328 cases) followed by the undermining technique (153 cases). The HF technique was employed in 89 cases. The majority of HFs were performed in unilateral breast reconstruction. Bilateral cases were conducted in only 12 patients. The need for additional fat grafting was significantly (P = 0.003) less required in the HF group compared with the undermining and de-epithelializing groups (12% vs 28% and 21%, respectively). CONCLUSIONS Although all breast-enhancing options can be mixed and matched based on the surgeon's preference and experience as well as each patient's needs, the HF can be considered as an adjunct tool to provide adequate flap projection and enhance breast symmetry. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Moustapha Hamdi
- Department of Plastic and Reconstructive Surgery, Brussels University Hospital – Vrij Universiteit Brussel (VUB), Brussels, Belgium
| | - Sara Al Harami
- Department of Plastic and Reconstructive Surgery, Brussels University Hospital – Vrij Universiteit Brussel (VUB), Brussels, Belgium
| | - Fadel Chahine
- Department of Plastic and Reconstructive Surgery, Brussels University Hospital – Vrij Universiteit Brussel (VUB), Brussels, Belgium
| | - Gabriel Giunta
- Department of Plastic and Reconstructive Surgery, Brussels University Hospital – Vrij Universiteit Brussel (VUB), Brussels, Belgium
| | - Randy De Baerdemaeker
- Department of Plastic and Reconstructive Surgery, Brussels University Hospital – Vrij Universiteit Brussel (VUB), Brussels, Belgium
| | - Assaf Zeltzer
- Department of Plastic and Reconstructive Surgery, Brussels University Hospital – Vrij Universiteit Brussel (VUB), Brussels, Belgium
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Liu Q, Li W, Wu X, Xu L, Hu P, Cao Y. Immediate breast reconstruction using latissimus dorsi muscular flap: A retrospective study of Chinese patients with breast cancer. Medicine (Baltimore) 2021; 100:e26175. [PMID: 34128848 PMCID: PMC8213275 DOI: 10.1097/md.0000000000026175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 05/11/2021] [Indexed: 12/02/2022] Open
Abstract
Reconstruction of breast defects of patients who underwent mastectomy can be challenging. This study was designed to review a series of 43 breast cancer patients who underwent immediate breast reconstruction (IBR) using the latissimus dorsi myocutaneous flap with/without implants. The demographic characteristics, clinical application feasibility, and the satisfaction rates of the patients were retrospectively collected and evaluated.A total of 43 breast cancer patients who underwent mastectomy between August 2015 and February 2020 were included in the retrospective study. The included patients were subjected to IBR using latissimus dorsi muscular flap (LDMF) with/without implants. The clinical application feasibility and the satisfaction rates of the patients were evaluated.Among these patients, 35 patients underwent nipple-sparing mastectomy and 8 patients underwent skin-sparing mastectomy. Twenty-nine patients underwent IBR using LDMF with implants, and 14 patients underwent IBR using LDMF without implants. Among these patients, 2 patients had partial LDMF necrosis and atrophy, and showed significant shrink of the reconstructed breast. One patient developed seromas, and seromas were improved by active dressing change and sucking out the fluid via the skin using a syringe. Two patients had local skin flap necrosis on the chest, 1 patient had preserved areola and local necrosis of the nipple, and this was healed after dressing change. Based on the Harris method, 27, 9, 5, and 2 cases were evaluated as "excellent," "good," "fair," and "poor," respectively.In the present study, the reconstructed breast has natural shape, good symmetry, and hidden postoperative scars. The aesthetic effect is relatively good, and the use of LDMF may represent an acceptable and valid option for IBR. The success of this procedure depends on the design of the incision, the skill and proficiency of the operation, as well as the correct treatment after surgery.
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Safety of Routine Pedicle Division during Delayed Breast Augmentation following Free Flap Breast Reconstruction. Plast Reconstr Surg 2021; 147:1271-1277. [PMID: 33973947 DOI: 10.1097/prs.0000000000007956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Autologous free flap breast reconstruction is a common reconstructive procedure, with the ability to produce a natural breast shape and a long history of success. Despite its benefits, there are special situations in which patients lack sufficient donor-site tissue to achieve adequate breast size and projection. With this study, the authors describe their institutional experience of delayed implant augmentation after autologous breast reconstruction with a particular focus on pedicle division as a technique to improve aesthetic results. METHODS A retrospective chart review of patients that underwent free flap autologous breast reconstruction with delayed implant augmentation was conducted over a 13-year period. Flaps were divided into a control group without pedicle division and a divided pedicle group. Groups were compared in terms of demographics, clinical and surgical characteristics, implant details, and postoperative implant and flap complications. RESULTS No significant differences in terms of age, body mass index, comorbidities, radiation therapy, or surgical indications were noted. The most common reason for delayed implant augmentation after autologous breast reconstruction was change in breast size and breast asymmetry. In terms of implant and flap complications, we found no significant differences between the control and divided pedicle groups after delayed implant augmentation. CONCLUSIONS From the authors' institutional experience, pedicle division in delayed breast augmentation with implants after free flap breast reconstruction can be safety performed in selected cases. This technique can be a powerful tool for plastic surgeons to improve the final aesthetic appearance of the reconstructed breast. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Secondary Implant Augmentation in the Subpectoral Plane following Abdominal-based Perforator Flaps for Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3180. [PMID: 33173692 PMCID: PMC7647491 DOI: 10.1097/gox.0000000000003180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 08/20/2020] [Indexed: 11/26/2022]
Abstract
Background Abdominal-based perforator flaps are the gold standard for autologous breast reconstruction. However, among patients with a small-to-medium amount of redundant abdominal tissue, this may result in an inadequate breast mound. Secondary implant augmentation has been reported as one method to augment volume, address breast mound asymmetry, and enhance overall aesthetic outcome. We aim to analyze postoperative complications associated with the secondary implant augmentation following a primary breast reconstruction with abdominal perforator flaps. Methods This retrospective study included patients who underwent secondary implant augmentation following abdominal-based perforator flap breast reconstruction. Patient characteristics, immediate versus delayed reconstruction, type of flap used, indication for secondary augmentation as well as perioperative and postoperative complication including flap or implant loss were reviewed and analyzed. Results Twenty-four patients met inclusion criteria. Forty flaps were performed (16 bilateral and 8 unilateral). A total of 36 implants were placed in subpectoral plane in a secondary revision procedure. The mean time between secondary augmentation and index procedure was 22 months. Average implant volume was 270 g. No intraoperative complication or flap loss was recorded. Postoperative surgical site infection occurred in a total of 4 patients (17%) with 3 patients requiring explantation of a total of 4 implants. Conclusions Secondary augmentation of abdominal-based perforator flap using a permanent implant is an effective method to address volume and asymmetry and to enhance aesthetic outcome. In our study, however, we observed a higher than expected rate of postoperative infection.
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Pompei B, Farhadi J. Diep Flap Volume Augmentation: Literature Review and "Calzone" Flap Shaping Technique. J Plast Reconstr Aesthet Surg 2020; 73:1933-1939. [PMID: 32571688 DOI: 10.1016/j.bjps.2020.05.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/07/2020] [Accepted: 05/16/2020] [Indexed: 11/18/2022]
Abstract
Breast reconstruction with DIEP flap is a well-accepted and well-established technique for autologous breast reconstruction. In the past, this reconstructive option was typically offered to a limited group of patients as previous surgeries or low BMI were considered to be an obstacle to the success of the procedure or for the achievement of a satisfactory cosmetic outcome due to the lack of available tissue. Nowadays, this does not correspond to truth anymore and DIEP flaps are performed routinely on slender patients and on women who have undergone previous liposuction or abdominal surgeries. This paper analyzes current surgical options for volume recruitment in patients with scanty abdominal tissue or with abdominal scars and presents our standardized approach for DIEP volume augmentation with the "Calzone style" bipedicled DIEP flap.
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Affiliation(s)
- Barbara Pompei
- Department of Plastic Reconstructive and Aesthetic Surgery, University of Modena and Reggio Emilia, Modena, Italy.
| | - Jian Farhadi
- Plastic Surgery Group, Zuerich, Switzerland; University of Basel, Basel, Switzerland
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Bach AD, Morgenstern IH, Horch RE. Secondary "Hybrid Reconstruction" Concept with Silicone Implants After Autologous Breast Reconstruction - Is It Safe and Reasonable? Med Sci Monit 2020; 26:e921329. [PMID: 32388530 PMCID: PMC7238811 DOI: 10.12659/msm.921329] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The use of autologous tissue for breast reconstructive surgery following mastectomy has become routine and allows for excellent symmetry and aesthetic results. However, in some cases, the amount of tissue available from the utilized flaps is not enough to achieve the desired outcome. The use of autologous fat grafting, as well as other techniques, has been described to deal with such problems. However, though well-established, these techniques may also fail to achieve the desired results. The aim of this study was to highlight the opportunity to improve aesthetic results using a secondary prosthesis underneath the previously used free flap and to examine whether this is a safe and reasonable procedure. Material/Methods In our study we included patients with unsatisfied aesthetic results after free flap procedures (DIEP, S-GAP, TMG, and FCI) between 2011 and 2018. In each case described, a secondary prosthesis was placed underneath the original flap in order to improve symmetry, shape and projection. Patient age, indication for surgery, adjuvant therapy, complications and outcomes have been registered. A 12-point scale was established to analyze patient satisfaction and aesthetic outcome. Results Overall “operative success” was achieved in all 13 patients (14 flaps) evaluated. At 12 months after reconstruction, all aesthetic scores collected were between good and excellent. In contrast to other studies, we chose a secondary approach for the flap augmentation and we used the epipectoral pocket for the placement of the implant. In our series, low rates of early and late post-operative complications were observed, with a high overall rate of satisfaction. Conclusions The demonstrated “Hybrid Breast Reconstruction” approach, using an implant underneath a free flap autologous breast reconstruction, provided a safe and reliable option to optimize breast reconstruction outcomes.
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Affiliation(s)
- Alexander D Bach
- Department of Plastic and Aesthetic Surgery, Hand Surgery and Reconstructive Surgery, Euregio Breast Center, St.-Antonius-Hospital, Eschweiler, Germany
| | - Isabelle H Morgenstern
- Department of Plastic and Aesthetic Surgery, Hand Surgery and Reconstructive Surgery, Euregio Breast Center, St.-Antonius-Hospital, Eschweiler, Germany
| | - Raymund E Horch
- Department of Plastic and Hand Surgery, University of Erlangen, Erlangen, Germany
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A Critical Analysis of Prosthetic Augmentation of Autologous Microvascular Breast Reconstruction. Ann Plast Surg 2019; 84:717-721. [PMID: 31663940 DOI: 10.1097/sap.0000000000002085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The combined approach using both an implant and autologous tissue for breast reconstruction has become more common over the last 10 years. We sought to provide a systematic review and outcomes analysis of this technique. METHODS We searched PubMed and the Cochrane Library database to identify studies that described implant augmentation of autologous flaps for breast reconstruction. The references of selected articles were also reviewed to identify any additional pertinent articles. RESULTS We identified 11 articles, which included 230 patients and 378 flaps. Implants used ranged in size from 90 to 510 cc, with an average size of 198 cc. Implants were more frequently placed at the time of autologous reconstruction and in the subpectoral plane. There were no total flap losses, and partial flap loss occurred in 3 patients (1%). There were no cases of venous or arterial thrombosis and no early return to the operating room for flap compromise. Eight implants (2%) were lost because of infection or extrusion, and capsular contracture occurred in 9 breasts (3%). When stratified by the timing of implant placement (immediate vs delayed), there were no significant differences in any postoperative outcomes except the immediate group had a higher infection rate. CONCLUSIONS The criteria for women to be candidates for autologous tissue breast reconstruction can be expanded by adding an implant underneath the flap. We found the overall flap loss rate is comparable with standard autologous flap reconstruction, and the implant loss rate is lower than that in patients who undergo prosthetic reconstruction alone.
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Combining Abdominal Flaps and Implants in the Breast Reconstruction Patient. Plast Reconstr Surg 2019; 143:495e-503e. [DOI: 10.1097/prs.0000000000005373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ho OA, Lin YL, Pappalardo M, Cheng MH. Nipple-sparing mastectomy and breast reconstruction with a deep inferior epigastric perforator flap using thoracodorsal recipient vessels and a low lateral incision. J Surg Oncol 2018; 118:621-629. [PMID: 30212598 DOI: 10.1002/jso.25204] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 07/23/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy poses challenges in providing esthetically-pleasing immediate autologous breast reconstruction. This study was to investigate the outcomes of nipple-sparing mastectomy with breast reconstruction using free abdominal flaps between two different recipient sites. METHODS Between 2010 and 2016, 79 patients who underwent nipple-sparing mastectomy with autologous breast reconstruction using thoracodorsal (TD) vessels in 30 cases or internal mammary (IM) vessels in 49 cases were investigated. Demographics, intraoperative findings, complications, and quality of life using Breast-Q questionnaire were compared between two groups. RESULTS All flap survived. There was no statistical difference in age, BMI, ischemia time, and flap-used percentage. The TD artery had a statistically smaller diameter 1.8 ± 0.4 mm than the IM artery 2.7 ± 0.43 mm (p = 0.02). At a mean follow-up of 44.4 ± 35.2 months, there was no statistical difference in total complication rates between TD and IM groups (23.3% and 36.7%, respectively, p > 0.05). The "psychosocial well-being" of Breast-Q in TD group 83.9 ± 14.6 was statistically greater than IM group 72.8 ± 17.6 (p = 0.04). CONCLUSIONS Nipple-sparing mastectomy with immediate breast reconstruction using TD vessels with a low lateral scar is a safe procedure that provides an inconspicuous scar with better cosmesis and minimal complication rate.
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Affiliation(s)
- Olivia A Ho
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Yi-Ling Lin
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Marco Pappalardo
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
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Creation of a Central Under Flap Pocket Allows Secondary Implant Augmentation of Perforator Flap Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1734. [PMID: 29707469 PMCID: PMC5908497 DOI: 10.1097/gox.0000000000001734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 02/06/2018] [Indexed: 11/26/2022]
Abstract
Background: When a single perforator flap does not provide adequate volume or projection for satisfactory breast reconstruction, the addition of an implant may be considered at the time of second-stage revisions. Dissection of an implant pocket beneath the flap may lead to the inadvertent injury of the flap pedicle as the tissue planes have been obscured by tissue ingrowth. The authors present a technique in which the boundaries of the implant pocket are predetermined at the time of flap reconstruction allowing an implant to be inserted at the second stage in ideal position with greater ease of dissection and minimal risk to the flap pedicle. Methods: Forty patients (80 bilateral perforator flap breast reconstructions) treated with the creation of central under flap pocket technique in anticipation of subsequent sub flap implant augmentation within an 18-month period were assessed retrospectively. Results: Sixty-eight patients with flaps (85%) went on to receive secondary augmentation with silicone implants. The average percentage increase in volume contributed by the implant was 41%. The undersurface of the acellular dermal matrix was readily identified, and its medial most extent safely determined, allowing the expeditious recreation of the predelineated central under-flap implant pocket. No flap pedicles were injured during the process, and the implants were placed in a favorable position providing maximum projection to the reconstruction. No subsequent development of fat necrosis was identified after augmentation. Conclusion: The creation of central under flap pocket technique allows for safe, effective, and expedient delayed implant augmentation of perforator flap breast reconstruction.
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Perforator Flaps Covering Alloplastic Materials in Full-Thickness Chest Wall Defects Reconstruction: A Safe Option? PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1289. [PMID: 28607844 PMCID: PMC5459627 DOI: 10.1097/gox.0000000000001289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 02/15/2017] [Indexed: 11/25/2022]
Abstract
Large full-thickness chest wall reconstruction requires an alloplastic material to ensure chest wall stability, as well as a flap that provides good soft-tissue coverage. The choice not to use perforator flaps over any mesh or inert material is often based on the concern that the vascularization would be inadequate. However, perforator flaps have shown good results in several reconstructive fields, minimizing donor-site morbidity and offering versatility when local tissues are unavailable or affected by radiotherapy. In this study, we present 4 cases of patients with full-thickness chest wall defects that were repaired with a double Marlex mesh, acrylic cement (n = 2) or a double patch of Goretex (n = 2) in combination with perforator flaps (3 deep inferior epigastric artery perforators and 1 lumbar artery perforator flap). The results we obtained are encouraging, and we believe the use of perforator flaps in combination with alloplastic materials should be considered as a reliable option for full-thickness chest wall defect reconstruction.
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Mani M, Saour S, Ramsey K, Power K, Harris P, James S. Bilateral breast reconstruction with deep inferior epigastric perforator flaps in slim patients. Microsurgery 2017; 38:143-150. [DOI: 10.1002/micr.30173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 02/03/2017] [Accepted: 02/28/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Maria Mani
- Department of Plastic and Reconstructive Surgery; The Royal Marsden Hospital; London United Kingdom
- Department of Surgical Sciences; Section of Plastic and Reconstructive Surgery; Uppsala University, Uppsala Sweden
| | - Samer Saour
- Department of Plastic and Reconstructive Surgery; The Royal Marsden Hospital; London United Kingdom
| | - Kelvin Ramsey
- Department of Plastic and Reconstructive Surgery; The Royal Marsden Hospital; London United Kingdom
| | - Kieran Power
- Department of Plastic and Reconstructive Surgery; The Royal Marsden Hospital; London United Kingdom
| | - Paul Harris
- Department of Plastic and Reconstructive Surgery; The Royal Marsden Hospital; London United Kingdom
| | - Stuart James
- Department of Plastic and Reconstructive Surgery; The Royal Marsden Hospital; London United Kingdom
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Momeni A, Kanchwala SK. Improved pocket control in immediate microsurgical breast reconstruction with simultaneous implant placement through the use of mesh. Microsurgery 2016; 38:450-457. [PMID: 27770576 DOI: 10.1002/micr.30123] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 09/17/2016] [Accepted: 09/30/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND Autologous breast reconstruction is associated with long-term patient satisfaction that is superior to implant-based approaches. Occasionally, however, patients who desire autologous reconstruction present with inadequate donor-site volume. A hybrid approach, combining free flap reconstruction with simultaneous implant placement, is a solution. We present our experience with the use of mesh for improved pocket control using this reconstructive modality. METHODS A retrospective analysis of a prospectively maintained database of patients undergoing autologous breast reconstruction was performed. Patients who underwent bilateral immediate breast reconstruction with free microsurgical abdominal tissue transfer with simultaneous implant placement were included for analysis. RESULTS A total of 19 patients (38 breasts) with a mean age of 42.7 years (range, 31-57 years) and mean BMI of 26.3 (range, 23.6-30.8) were included in the study. No flap loss or implant-related complications were encountered during a mean follow-up of 14.2 months. The most common implant volume was 150 cc (N = 15; [78.9%]). No patient requested an implant change due to malposition or insufficient volume. Secondary fat grafting was performed in 5 patients (26.3%), 4 of which had undergone adjuvant radiotherapy. Three cases of red breast syndrome were observed following acellular dermal matrix placement. This prompted a transition to using polyglactin mesh thereafter without any untoward sequelae. CONCLUSIONS Abdominal flap transfer with simultaneous implant placement is a safe reconstructive option in select patients. Improved implant pocket control is achieved through the use of mesh, thus, minimizing problems related to implant malposition. Adjuvant radiotherapy does not appear to put the reconstruction at risk with the occasional flap volume loss being easily remedied by secondary fat grafting.
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Affiliation(s)
- Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Suhail K Kanchwala
- Division of Plastic Surgery, University of Pennsylvania Health Systems, Philadelphia, Pennsylvania
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Immediate Bilateral Breast Reconstruction with Unilateral Deep Superior Epigastric Artery and Superficial Circumflex Iliac Artery Flaps. Arch Plast Surg 2016; 43:457-60. [PMID: 27689054 PMCID: PMC5040849 DOI: 10.5999/aps.2016.43.5.457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/28/2016] [Accepted: 06/07/2016] [Indexed: 11/30/2022] Open
Abstract
Autologous breast reconstruction utilizing a perforator flap is an increasingly popular method for reducing donor site morbidity and implant-related complications. However, aberrant anatomy not readily visible on computed tomography angiography is a rare albeit real risk when undergoing perforator flap reconstruction. We present an operative case of a patient who successfully underwent a bilateral breast reconstruction sourced from a unilateral abdominal flap divided into deep superior epigastric artery and superficial circumflex iliac artery flap segments.
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Patel NG, Rozen WM, Chow WTH, Chowdhry M, Fitzgerald O'Connor E, Sharma H, Griffiths M, Ramakrishnan VV. Stacked and bipedicled abdominal free flaps for breast reconstruction: considerations for shaping. Gland Surg 2016; 5:115-21. [PMID: 27047780 DOI: 10.3978/j.issn.2227-684x.2016.02.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Stacked and bipedicled abdominal flaps are useful in women who require a large breast reconstruction but have relative paucity of abdominal tissue. A new classification system is described to assist the surgeon in achieving the best possible aesthetic outcome. METHODS A retrospective review of 25 consecutive stacked and/or bipedicled deep inferior epigastric perforator (DIEP) flap reconstructions was assessed from 2009 to 2014. Demographic data and key variables were prospectively collected in our breast reconstruction database and an aesthetic classification devised. There are four main subtypes, (I) folded; (II) divided; (III) coned; and (IV) divided and folded. Each of these subtypes can be moulded in a symmetrically or asymmetrically fashion depending on the contralateral breast shape together with distribution and consistency of fat within the abdominal flap. RESULTS Of the 25 patients, three-quarter were immediate reconstruction, with an average age of 48 years and a median follow-up of 2 years 10 months. Just over half the patients (57%) had bipedicle flaps with two recipient donor vessels with the remaining 43% had stacked flaps. The most common recipient sites are the thoracodorsal vessels (62%) and intercostal perforators (26%). The average abdominal pannus weight was 610 grams (SD: 320 grams), with a hemi-abdominal weight of 305 grams. Two patients had haematomas, of which one lost their reconstruction. Another patient had a venous congestion flap which was salvaged. CONCLUSIONS Bipedicled or stacked abdominal flaps allow the all four zones of the abdominal tissue to be used in unilateral breast reconstruction. The approach of tailoring the abdominal flaps to match the contralateral breast reconstruction is largely an art form. The paper aims to bring some meaningful system to aid the surgeon to achieve the best possible outcome with the components presented to them.
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Affiliation(s)
- Nakul Gamanlal Patel
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK
| | - Warren Matthew Rozen
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK
| | - Whitney T H Chow
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK
| | - Muhammad Chowdhry
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK
| | - Edmund Fitzgerald O'Connor
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK
| | - Hrsikesa Sharma
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK
| | - Matthew Griffiths
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK
| | - Venkat V Ramakrishnan
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK
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Delayed Mammoplasty with Silicone Gel Implants following DIEP Flap Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e540. [PMID: 26579346 PMCID: PMC4634177 DOI: 10.1097/gox.0000000000000527] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 09/01/2015] [Indexed: 11/26/2022]
Abstract
The deep inferior epigastric artery perforator (DIEP) flap is a state-of-the-art option for breast reconstruction. However, thin patients with medium- to large-size native breasts are not ideal candidates due to the limited amount of available tissue. We reviewed our experience utilizing the DIEP flap in combination with prosthetic implants.
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Lee KT, Lee JE, Nam SJ, Han BK, Mun GH. Is Holm Zone III safe from fat necrosis in medial row perforator-based deep inferior epigastric perforator flaps? Microsurgery 2014; 35:272-8. [DOI: 10.1002/micr.22328] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 08/04/2014] [Accepted: 08/29/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center; Sungkyunkwan University School of Medicine; Gangnam-Gu Seoul South Korea
| | - Jeong-Eon Lee
- Department of Surgery, Samsung Medical Center; Sungkyunkwan University School of Medicine; Gangnam-Gu Seoul South Korea
| | - Seok-Jin Nam
- Department of Surgery, Samsung Medical Center; Sungkyunkwan University School of Medicine; Gangnam-Gu Seoul South Korea
| | - Boo-Kyung Han
- Department of Radiology, Samsung Medical Center; Sungkyunkwan University School of Medicine; Gangnam-Gu Seoul South Korea
| | - Goo-Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center; Sungkyunkwan University School of Medicine; Gangnam-Gu Seoul South Korea
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Lakhiani C, Hammoudeh ZS, Aho JM, Lee M, Rasko Y, Cheng A, Saint-Cyr M. Maximizing aesthetic outcome in autologous breast reconstruction with implants and lipofilling. EUROPEAN JOURNAL OF PLASTIC SURGERY 2014. [DOI: 10.1007/s00238-014-0993-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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A Classification System for Partial and Complete DIEP Flap Necrosis Based on a Review of 17,096 DIEP Flaps in 693 Articles Including Analysis of 152 Total Flap Failures. Plast Reconstr Surg 2013; 132:1401-1408. [DOI: 10.1097/01.prs.0000434402.06564.bd] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Trignano E, Fallico N, Dessy LA, Armenti AF, Scuderi N, Rubino C, Ramakrishnan V. Transverse Upper Gracilis Flap with Implant In Postmastectomy Breast Reconstruction: a Case Report. Microsurgery 2013; 34:149-52. [DOI: 10.1002/micr.22165] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 06/24/2013] [Accepted: 07/08/2013] [Indexed: 11/05/2022]
Affiliation(s)
- Emilio Trignano
- Chelmsford, Broomfield Hospital- St Andrew's Centre for Plastic Surgery & Burns, Mid Essex Hospital Services NHS Trust; Court Road Broomfield, Chelmsford Essex UK
- Department of Plastic and Reconstructive Surgery; “Sapienza” University of Rome; Viale del Policlinico 151 Rome Italy
- Department of Plastic and Reconstructive Surgery; University of Sassari; Viale San Pietro 43b Sassari 07100 Italy
| | - Nefer Fallico
- Department of Plastic and Reconstructive Surgery; “Sapienza” University of Rome; Viale del Policlinico 151 Rome Italy
| | - Luca A. Dessy
- Department of Plastic and Reconstructive Surgery; “Sapienza” University of Rome; Viale del Policlinico 151 Rome Italy
| | - Andrea F. Armenti
- Department of Plastic and Reconstructive Surgery; “Sapienza” University of Rome; Viale del Policlinico 151 Rome Italy
| | - NicolÒ Scuderi
- Department of Plastic and Reconstructive Surgery; “Sapienza” University of Rome; Viale del Policlinico 151 Rome Italy
| | - Corrado Rubino
- Department of Plastic and Reconstructive Surgery; University of Sassari; Viale San Pietro 43b Sassari 07100 Italy
| | - Venkat Ramakrishnan
- Chelmsford, Broomfield Hospital- St Andrew's Centre for Plastic Surgery & Burns, Mid Essex Hospital Services NHS Trust; Court Road Broomfield, Chelmsford Essex UK
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Shafighi M, Constantinescu MA, Huemer GM, Olariu R, Bonel HM, Banic A, Ramakrishnan V. The extended diep flap: Extending the possibilities for breast reconstruction with tissue from the lower abdomen. Microsurgery 2012; 33:24-31. [DOI: 10.1002/micr.21975] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 02/04/2012] [Accepted: 02/07/2012] [Indexed: 11/09/2022]
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Evaluation of Outcomes in Breast Reconstructions Combining Lower Abdominal Free Flaps and Permanent Implants. Plast Reconstr Surg 2010; 126:349-357. [DOI: 10.1097/prs.0b013e3181de1b67] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Chia HL, Breitenfeldt N, Canal ACE, Malata CM. Implant augmentation after perforator flap breast reconstruction. J Plast Reconstr Aesthet Surg 2010; 63:e172-3. [PMID: 19362527 DOI: 10.1016/j.bjps.2009.02.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2009] [Accepted: 02/23/2009] [Indexed: 11/19/2022]
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