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Lohasammakul S, Tonaree W, Suppasilp C, Numwong T, Ratanalekha R, Han HH. Superficial Inferior Epigastric Artery Flap: Vascular Pattern and Territory Across the Midline. J Reconstr Microsurg 2024; 40:435-442. [PMID: 37884058 DOI: 10.1055/a-2199-3960] [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: 10/28/2023]
Abstract
BACKGROUND Superficial inferior epigastric artery (SIEA) flap offers a significant advantage of lower donor site morbidity over other abdominal-based flaps for breast reconstruction. However, the inconsistent anatomy and territory across the midline remains a major issue. This study aimed to investigate the SIEA and determine its pattern and territory across the midline. METHODS Twenty cadavers were studied. Ipsilateral dye was injected to the dominant SIEA. Dissection was performed to evaluate the SIEA origin, artery and vein pattern, vessel diameter, and dye diffusion territory. RESULTS Overall, three SIEA patterns were identified: bilateral presence (45%), ipsilateral presence (30%), and bilateral absence (25%). The territory depended on the vessel course and dominant SIEA diameter, not on its common origin from the femoral artery, at the pubic tubercle level. Regarding the midline territory (pubic tubercle level to umbilicus), SIEA (type 1a) with a diameter of ≥1.4 mm on either side supplied at least half the distance, whereas SIEA with a diameter of <1 mm was limited to the suprapubic area. CONCLUSION Designing a SIEA flap island across the midline is feasible when contralateral SIEA is present to augment the contralateral territory (e.g., type 1a SIEA) or in SIEA with a common/superficial external pudendal artery origin. Preoperative imaging studies are important for confirming the SIEA system. When the diameter at the origin of the SIEA flap is larger than 1.4 mm, the blood supply to the ipsilateral and contralateral sides is sufficient to enable safe flap elevation.
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Affiliation(s)
- Suphalerk Lohasammakul
- Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Ulsan, Republic of Korea
| | - Warangkana Tonaree
- Division of Plastic and Reconstructive Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chaiyawat Suppasilp
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Terasut Numwong
- Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rosarin Ratanalekha
- Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Hyun Ho Han
- Division of Plastic and Reconstructive Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Franchi A, Patanè L, Hummel CH, Jung F. Confusion Regarding the Anatomy of the Superficial Inferior Epigastric Artery and the Superficial Circumflex Iliac Artery Superficial Branch. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5714. [PMID: 38596577 PMCID: PMC11003499 DOI: 10.1097/gox.0000000000005714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/08/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Alberto Franchi
- From the Department of Hand and Plastic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
| | - Luca Patanè
- Department of Surgery, Plastic Surgery Unit, Sapienza University of Rome, Rome, Italy
| | - Carmen H. Hummel
- From the Department of Hand and Plastic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
| | - Florian Jung
- From the Department of Hand and Plastic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
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Lam CM, Keim SA, Sayed D, Abd-Elsayed A, Gulati A, Schatman ME, Deer T, Latif U. Novel Implantation Technique for Thoracoabdominal Peripheral Nerve Stimulation via a Transversus Abdominal Plane Approach for Treatment of Chronic Abdominal Pain. J Pain Res 2024; 17:981-987. [PMID: 38500814 PMCID: PMC10946280 DOI: 10.2147/jpr.s451955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/07/2024] [Indexed: 03/20/2024] Open
Abstract
Background Chronic abdominal pain (CAP) is a common and challenging to treat condition with a global prevalence of up to 25%. Despite extensive evaluation, approximately 40% of patients with CAP have an unknown diagnosis. Medications may be ineffective, and surgery is rarely indicated. Interventional treatment including sympathetic blocks, sympathetic neurolysis, and transversus abdominal plane (TAP) blocks may be an option, but their efficacy can wane over time. Neuromodulation has emerged as an option for these patients, as there is evidence of success with dorsal column spinal cord and dorsal root ganglion (DRG) stimulation. Peripheral nerve stimulation (PNS) may be an alternative option, particularly in higher risk patients or in patients for whom neuraxial access may be unsafe or too technically challenging. Thoracoabdominal nerve peripheral nerve stimulation via a TAP approach may be more specifically targeted in comparison to dorsal column or DRG stimulation. In this short report, we detail a technique that the authors have successfully used for thoracoabdominal nerve PNS via a TAP approach for management of CAP. Methods This article describes a novel medial to lateral ultrasound guided thoracoabdominal nerve PNS via a TAP approach technique for lead placement and implantation. Results A medial to lateral ultrasound guided TAP approach as described to successfully implant percutaneous thoracoabdominal nerve PNS leads for management of CAP. Conclusion The thoracoabdominal nerve PNS via a TAP approach lead placement technique noted in this report has been used as a means for management of CAP utilizing peripheral neuromodulation. Here, we present a short report detailing a potential technique for PNS utilization for management of CAP. Further studies are needed to validate the safety and efficacy of this therapy modality, although the authors have found it to be a viable management option for patients with medically refractory neuropathic CAP.
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Affiliation(s)
- Christopher M Lam
- Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sarah A Keim
- Department of Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Dawood Sayed
- Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology and Perioperative Medicine, University of Wisconsin, Madison, WI, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
- Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Usman Latif
- Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center, Kansas City, KS, USA
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He J, Lu Y, Chen Y, Peng Y, Zhu Q, Li Z. Deep Circumflex Iliac Artery-vascularized Iliac Bone Graft for Femoral Head Osteonecrosis: Computed Tomography Anatomical Study. J Reconstr Microsurg 2024. [PMID: 38176431 DOI: 10.1055/a-2238-7798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
BACKGROUND Deep circumflex iliac artery (DCIA)-vascularized iliac graft transposition is a method for treating femoral head osteonecrosis but with inconsistent efficacy. We aim to improve the method of this surgery by recommending the optimal location of the iliac pedicle to satisfy the vascular length for transposition and the blood supply of the vascularized iliac graft. METHODS The DCIA and its surrounding tissues were assessed on computed tomography angiography images for 100 sides (left and right) of 50 patients. The length of the vascular pedicle required for transposition and the length of the pedicle at different iliac spine positions were compared. The diameter and cross-sectional area of the DCIA and the distance between the DCIA and iliac spine were measured at different points to assess blood supply. We also compared differences in sex and left-right position. RESULTS The diameter and cross-sectional area of the DCIA gradually decreased after crossing the anterior superior iliac spine (ASIS), and it approached the iliac bone. However, when the DCIA was 4 cm behind the ASIS (54 sides, 54%), it coursed posteriorly and superiorly away from the iliac spine. The vascular length of the pedicle was insufficient to transpose the vascularized iliac graft to the desired position when it was within 1 cm of the ASIS. The vascular length requirement was satisfied, and the blood supply was sufficient when the pedicle was positioned at 2 or 3 cm. CONCLUSION To obtain a satisfactory pedicle length and sufficient blood supply, the DCIA pedicle of the vascularized iliac graft should be placed 2 to 3 cm behind the ASIS. The dissection of DCIA has slight differences in sex and left-right position due to anatomical differences.
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Affiliation(s)
- Jiale He
- Department of Orthopaedic Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
- Department of Orthopaedic Surgery, Affiliated Hospital of Xizang Minzu University, Xianyang, Shaanxi, People's Republic of China
| | - Yunxiang Lu
- Department of Orthopaedic Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Yuxian Chen
- Department of Orthopaedic Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - You Peng
- Department of Orthopaedic Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Qi Zhu
- Department of Orthopaedic Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Zhiyong Li
- Department of Orthopaedic Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
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Zhang Y, Zeng A. An Easy Way to Harvest a Superthin SCIP Flap with Long Pedicle: Reappraisal of the Inferolateral Branches of the SCIA. Plast Reconstr Surg 2023; 152:1100-1104. [PMID: 36862953 DOI: 10.1097/prs.0000000000010338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
SUMMARY Despite being the first free flap used in reconstructive surgery, the groin flap slowly fell out of fashion because of its short pedicle length, small vessel diameter, variable vascular anatomy, and bulkiness. Over the years, the authors have found that perforators consistently exist inferolateral to the deep branch of the superficial circumflex iliac artery (SCIA), forming an F configuration with the main branch. The authors propose a new type of superficial circumflex iliac artery perforator (SCIP) flap design based on the perforators derived from these inferolateral branches of the SCIA. These perforators have the advantage of anatomic consistency and can be easily found by making an exploratory incision 2 cm caudal to the inguinal ligament. The perforators of the inferolateral branches extend directly into the dermal plexus, and thus can yield superthin flaps without microdissection defatting. Retrograde dissection allows the surgeon to elongate the pedicle to include a section or full length of the SCIA as needed and involving minimal muscle dissection. SCIP flaps harvested based on the perforators of the inferolateral branches of the SCIA were used successfully for six head and neck reconstructions and two trunk reconstructions with no major complications, including flap loss or lymphedema. The best indications for SCIP flaps based on the inferolateral branches of the SCIA are superficial soft-tissue defects that do not require much volume replacement.
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Affiliation(s)
- Yuwei Zhang
- From the Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences
| | - Ang Zeng
- From the Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences
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Aravind P, Colakoglu S, Bhoopalam M, Ibrahim A, Mathes D, Kaoutzanis C, Mureau M, Reddy S. Perforator Characteristics and Impact on Postoperative Outcomes in DIEP Flap Breast Reconstruction: A Systematic Review and Meta-Analysis. J Reconstr Microsurg 2023; 39:138-147. [PMID: 35714621 DOI: 10.1055/s-0042-1750124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND High-quality evidence on perforator selection in deep inferior epigastric perforator (DIEP) flap harvesting is lacking, making preoperative planning and choice of perforators "surgeon-specific." This lack of consensus is a subject of continuous debate among microsurgeons. We aimed to systematically review perforator characteristics and their impact on DIEP flap breast reconstruction outcomes. METHODS We conducted a systematic review and meta-analysis across six databases: ClinicalTrials.gov, Cochrane Library, Medline, Ovid Embase, PubMed, and Web of Science for all studies on DIEP flap breast reconstruction focused on perforator characteristics-caliber, number, and location. The primary goal was to analyze the impact of perforator characteristics on partial and/or total flap failure and fat necrosis. Data was analyzed using RevMan V5.3. RESULTS Initial search gave us 2,768 articles of which 17 were included in our review. Pooled analysis did not show any statistically significant correlations between partial and/or total flap failure and perforator number, or perforator location. Sensitivity analysis accounting for heterogeneity across studies showed that, the risk for fat necrosis was significantly higher if single perforators (relative risk [RR] = 2.0, 95% confidence interval [CI] = 1.5-2.6, I 2 = 39%) and medial row perforators (RR = 2.7, 95% CI = 1.8-3.9, I 2 = 0%) were used. CONCLUSION Our findings suggest that a single dominant perforator and medial row perforators may be associated with higher risk of fat necrosis after DIEP flap breast reconstruction. Adopting a standardized perforator selection algorithm may facilitate operative decision making, shorten the learning curve for novice surgeons, and optimize postoperative outcomes by minimizing the burden of major complications. This in turn would help improve patient satisfaction and quality of life.
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Affiliation(s)
- Pathik Aravind
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Salih Colakoglu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Myan Bhoopalam
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmed Ibrahim
- Private Practice at Clevens Face and Body Specialists, Melbourne, Florida
| | - David Mathes
- Division of Plastic and Reconstructive Surgery, University of Colorado - CU Anschutz Medical Campus, Aurora, Colorado
| | - Christodoulos Kaoutzanis
- Division of Plastic and Reconstructive Surgery, University of Colorado - CU Anschutz Medical Campus, Aurora, Colorado
| | - Marc Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sashank Reddy
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Fuse Y, Yoshimatsu H, Karakawa R, Yano T. Deep Fat Saving Elevation of the Superficial Circumflex Iliac Artery Perforator Flap. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:670. [PMID: 35630087 PMCID: PMC9145857 DOI: 10.3390/medicina58050670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/09/2022] [Accepted: 05/12/2022] [Indexed: 11/27/2022]
Abstract
Background and Objectives: Prolonged drain stay and lymphorrhea are often problems at the donor site of the superficial circumflex iliac artery perforator (SCIP) flap. This study aimed to introduce a novel technique of the SCIP flap elevation: Deep Fat Saving (DFS) technique. Materials and Methods: Thirty-two patients who underwent the SCIP flap transfer were divided based on the flap-elevated layer: above the deep fascia or the Camper fascia saving the deep fat. The duration of drain stay and the rates of flap survival and donor-site complications were compared between the groups. The inverse probability weighting (IPW) method was conducted to balance confounders. Results: By IPW, two balanced pseudo-populations were created: DFS = 33.9 and Conventional = 31.3. There were no significant differences in the rate of flap survival (DFS: 100% verses Conventional: 95.8%, p = 0.32) and donor site complications (DFS: 2.4% versus Conventional: 1.3%, p = 0.68, respectively). The duration of drain stay was shorter in the DFS group (weighted median: 6 versus 8 days; weighted difference: -1.6 days (95% confidence interval: -2.8 to -0.4), p = 0.01). Conclusions: An SCIP flap can be reliably harvested using the Deep Fat Saving technique.
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Affiliation(s)
- Yuma Fuse
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (H.Y.); (R.K.); (T.Y.)
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