Superiority of the microvascularly augmented flap: analysis of 50 transverse rectus abdominis myocutaneous flaps for breast reconstruction

A Comprehensive Flap Classification: Beyond the Reconstructive Ladder

ABSTRACT

Perforator flaps have progressed massively in the last years. The improved vascular imaging techniques and the use of supermicrosurgery have shifted the practice from the traditional predefined angiosomal flaps to the endless variations of custom-made flaps. In this article, we propose a broadened classification of free-style flaps in 3 categories, the angiosomal, including all traditional perforator flaps and their variations, the extra-angiosomal, including flaps that are manufactured to include tissue from a different angiosome, such as turbocharging or supercharging a flap, and neoangiosomal flaps, which are based on the process of neoangiogenesis on autologous or allogenous tissue, such as the venous flow-through flap and integra flap. With this classification, we hope to help unify the classifications and, by doing so, facilitate the exchange of ideas, techniques and knowledge.MeSH terms: surgical flap / classification, terminology as topic.

Venous superdrainage using superficial circumflex iliac vein in deep circumflex iliac artery perforator flap with iliac crest for oromandibular reconstruction

The deep circumflex iliac artery perforator flap with iliac crest (DCIAPF) is considered a favourable single-flap option for oromandibular reconstruction. The aim of this study was to evaluate the effectiveness of venous superdrainage using the superficial circumflex iliac vein (SCIV) in the DCIAPF for oromandibular reconstruction. The data of 22 patients (12 female, 10 male) aged 10-76 years (median 53 years) who underwent simultaneous oromandibular reconstruction with a DCIAPF were reviewed retrospectively. Eleven patients received the DCIAPF with SCIV for superdrainage (group A) and another 11 patients received the conventional single-pedicled DCIAPF flap (group B). No flap loss occurred in either group. Venous congestion due to relative venous insufficiency was significantly more frequent in group B (P=0.045). There was no significant difference in the incidence of partial flap necrosis and wound dehiscence, or in the total operation time between the two groups. Superdrainage using the SCIV has the potential to reduce the incidence of venous congestion due to relative venous insufficiency in DCIAPF used for oromandibular reconstruction.

Muscle sparing-2 transverse rectus abdominis musculocutaneous flap for breast reconstruction: a comparison with deep inferior epigastric perforator flap

Breast reconstruction using free transverse rectus abdominis musculocutaneous (TRAM) flap can be divided into 4 muscle-sparing (MS) types: conventional TRAM flap containing full width muscle as MS-0, while deep inferior epigastric perforator (DIEP) flap containing absolutely no muscle as MS-3. We include only the muscle portion between the medial row and lateral row perforator vessels in TRAM flap, which is designated as MS-2. Between October 1999 and April 2006, the same surgeon performed 82 breast constructions using MS-2 free TRAM flaps in 79 patients. All the flaps survived. Postoperative complications included partial fat necrosis in 8 cases, all corresponding to zone IV or zone II. Bulging of donor site occurred in 5 patients, 4 of whom were obese and 1 had bilateral flap harvest. Compared with our own reconstructions using DIEP flap (30 cases), there were no significant differences in operative time and blood loss between the two techniques. In conclusion, MS-2 free TRAM flap is a useful technique for breast construction considering the easy surgical techniques, length of the vascular pedicle that can be harvested, and the degree of freedom of the flap.

Delay of transverse rectus abdominis myocutaneous flap reconstruction improves flap reliability in the obese patient

BACKGROUND

Since its introduction in 1982, the transverse rectus abdominis musculocutaneous (TRAM) flap has been a mainstay of breast reconstruction. However, in certain high-risk individuals, such as the obese, smokers, and irradiated patients, flap reliability is decreased, which leads to a higher rate of flap complications. The authors hypothesized that although the nonflap complication rate is increased in the obese patient, flap complications are not increased in those who undergo a delayed TRAM procedure.

METHODS

From 1995 to 2003, 107 consecutive patients who underwent a delayed TRAM procedure were examined in a retrospective study. The delayed TRAM procedures were all performed by the senior author (Georgiade) at a single institution. Patients were classified by their body mass index (weight in kilograms and height in square meters).

RESULTS

No patient had complete loss of her flap regardless of body mass index. Patients with an index of 30 kg/m2 and under had a partial fat necrosis rate of 11.4 percent (10 of 88 patients), whereas two of 19 patients (10.5 percent) with an index of greater than 30 kg/m2 had partial fat necrosis of their flap (not significant). The average body mass index of the group with flap complications was 27.8 +/- 4.3 kg/m2, whereas that of the group with no flap complications was 26.5 +/- 4.3 kg/m2 (not significant). The rate of non-flap-related complications, such as deep venous thrombosis and pulmonary embolism, was 8 percent (seven of 88 patients) for those with a body mass index of less than 30 kg/m2 and 31.6 percent (six of 19 patients) for those with an index greater than 30 kg/m2 (p = 0.0112). The average body mass index of the group with nonflap complications was 29.9 +/- 4.9 kg/m2, compared with 26.3 +/- 4.0 kg/m2 for the group with no non-flap-related complications (p = 0.031). Of note, patients with a history of smoking and those who had received radiation therapy did not show a statistically significant increase in flap complications.

CONCLUSIONS

Despite a progressively increasing overall complication rate for patients with a higher body mass index, there was not a similar trend for flap-related complications. The authors' data support the idea that the delayed TRAM procedure is a safe and reliable technique for obese and morbidly obese patients.

Analyzing the Vascular Architecture of the Free TRAM Flap Using Intraoperative Ex Vivo Angiography

BACKGROUND

Using ex vivo intraoperative angiography to analyze 14 flaps from 12 breast reconstruction patients, the authors investigated the vascular architecture of free transverse rectus abdominis musculocutaneous (TRAM) flaps nourished by the deep inferior epigastric artery.

METHODS

Contrast medium was injected through the deep inferior epigastric artery and flaps were radiographed to observe their vascular patterns.

RESULTS

TRAM flaps showed one or two segmental arteries stained on their ipsilateral side (zones 1 and 3) and serving as the flap's axial artery. These segmental arteries directly connect to the large perforators (axial perforators) and emerge not only from the paraumbilical perforators but also from the caudal branches of the deep inferior epigastric artery. Arterial density is always lower in the contralateral area (zones 2 and 4) than in the ipsilateral area (zones 1 and 3).

CONCLUSIONS

Because the cephalic half of zone 2 and all of zone 4 remain unstained, these areas are prone to skin or fat necrosis, especially in high-risk patients. Ex vivo angiography, by providing specific information about the individual flap and by reflecting its flow physiology, enables one to observe and to chart the vascular architecture of free TRAM flaps nourished by the deep inferior epigastric artery.

Postmastectomy Radiation Therapy After TRAM Flap Breast Reconstruction

Postmastectomy chest wall and nodal radiation therapy decreases local recurrence and improves disease-free and overall survival. Immediate transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction after mastectomy has become more common. We report on our experience of irradiating the chest wall and regional lymph nodes after a TRAM flap reconstruction and describe the acute side effects, flap viability, and cosmetic outcome. Between 1995 and 2000, 22 patients with a median age of 47 years (range 27-61 years) received chest wall radiotherapy following mastectomy and immediate pedicled TRAM flap reconstruction. The indication for radiotherapy included tumor size, involved lymph nodes, or positive margins. All patients received chemotherapy before radiotherapy and three patients also received concurrent chemotherapy. The median dose to the chest wall was 50.4 Gy in 28 fractions of 1.8 Gy using a 6 or 4 MV linear accelerator. The patients were all computed tomography (CT) planned in the treatment position. The patients were immobilized using an alpha cradle. Two tangent fields were used to deliver the dose. On alternating days, a customized bolus was applied to the chest wall that spared the central region where the subsequent nipple reconstruction would be performed. All 22 patients completed 90% of the prescribed chest wall radiotherapy dose. Sixty-six percent of the patients received treatment without any treatment breaks. Only 10% of the patients developed desquamation of the TRAM flap skin. Thirty percent developed grade II erythema of the TRAM flap. With median follow-up of 18 months, no TRAM flaps have been lost or required revision. This technique for delivery of radiotherapy to the chest wall in patients who have undergone a mastectomy and immediate TRAM flap reconstruction is well tolerated. The acute toxicity was manageable. There were no TRAM flap losses or revisions performed secondary to the radiotherapy.

Comparison of Three Different Supercharging Procedures in a Rat Skin Flap Model

A significant clinical problem in reconstructive surgery is partial loss of a pedicled flap. To resolve this problem, various methods of vascular augmentation have been developed; "supercharging" is one of those techniques. A new rat flap model was developed for investigation of the supercharging procedure, and the efficacy of the arterial supercharging method was examined. The purpose of this study was to investigate how an arterial supercharging procedure could generate large flap survival areas with different supercharging positions in rats. On the basis of the vascular anatomical features of rats, a circumferential skin flap from the lower abdomen to the back, measuring 4 x 12 cm, was marked. The flap was divided along the dorsal midline. Forty rats were divided into four experimental groups, as follows: group 1 (control), flaps based only on the deep circumflex iliac artery and vein; group 2, flaps supercharged with the ipsilateral superficial inferior epigastric artery; group 3, flaps supercharged with the contralateral superficial inferior epigastric artery; group 4, flaps supercharged with the contralateral deep circumflex iliac artery. On the fourth postoperative day, the flaps were evaluated with measurements of necrosis and survival areas. Microfil (Flow Tech, Inc., Carver, Mass.) was then injected manually throughout the body, and the vascular changes produced by supercharging were angiographically evaluated. Compared with group 1 (control), the flap survival areas were significantly greater in distally supercharged flaps in groups 3 and 4 (mean flap survival, 91.2 +/- 5.2 percent and 90.5 +/- 10.6 percent, respectively; p < 0.001) and in proximally supercharged flaps in group 2 (45.9 +/- 4.1 percent, p < 0.05). Angiographic assessment of the flaps that survived completely revealed marked dilation of the choke veins among the territories and reorientation of dilated veins along the axes of the flaps. This study suggests that distal arterial supercharging (contralateral superficial inferior epigastric artery or contralateral deep circumflex iliac artery) is more effective than proximal arterial supercharging (ipsilateral superficial inferior epigastric artery) in increasing flap survival. Although the rat skin flap may not be analogous to human flaps, distal arterial supercharging might have useful therapeutic potential in increasing flap survival in clinical practice.

Free perforator crossover TRAM flap for breast reconstruction

Breast reconstruction using a transverse rectus abdominis musculocutaneous (TRAM) flap has become the preferred method of autogenous reconstruction for most surgeons. The vascular basis of both the superior and inferior vascular pedicles of this flap has been well documented. When a pedicled TRAM flap is based superiorly, the perfusion across the midline to zone 4 and sometimes zone 3 is, at best, variable. Augmentation of the blood supply of the contralateral side with various methods has been reported. The methods include the delay procedure, bipedicled flaps, supercharging, and turbo-charging. The deep inferior epigastric artery is the dominant blood supply, and a microsurgical free TRAM flap based inferiorly provides reliable perfusion, even to zone 4, which obviates the need for many of these maneuvers. It has also been demonstrated that the circulation across the midline in a TRAM flap is primarily by means of a subdermal plexus and that with a previous vertical midline abdominal scar there is virtually no midline crossover at any anastomotic level. Therefore, even with a free TRAM flap based on the dominant inferior pedicle, perfusion across a vertical midline scar is unreliable. As a result, many patients with a vertical midline scar have been denied the best autogenous reconstructive option. The authors present their experience with a free perforator crossover TRAM flap using a constant premuscular branch of the deep inferior epigastric artery and vein that provides many patients who have a previous midline scar with a genuine option for autogenous tissue breast reconstruction.

Bimodal distribution of the blood supply to lower abdominal fat: histological study of the microcirculation of the lower abdominal wall

Fat necrosis is a common postoperative complication in transverse rectus abdominis muscle flap breast reconstruction. A histological quantification of the blood supply to the lower abdominal fat was undertaken to define this problem further. One hundred eighty sections, 1.5 cm(2) in size, were studied from one half of the lower abdomen in 10 fresh cadavers. These represent three different depths of fat (superficial, middle, deep) and six different anatomic areas (upper, middle, and lower sectors of the medial and lateral parts of the hemiabdomen). The average diameter, number of blood vessels, and the total vascular area were measured in each section. The average diameter of the blood vessels was greater in the superficial compared with the mid fat layer (p = 0.02). The total vascular area was greater in the deep compared with the mid fat layer (p = 0.01) and the superficial fat layer (p = 0.05). The number of blood vessels was also significantly higher in the deep fat layer compared with the mid fat layer (p = 0.001) and the superficial fat layer (p = 0.01). The lower medial area of the lower anterior abdominal wall contained the largest number and average diameter of blood vessels whereas the mid lateral area contained the smallest number and average diameter; however, this did not reach significance (p = 0.1 and 0.2). The results of this study are in keeping with the bimodal vascular supply to the subcutaneous fat of the anterior abdominal wall. The deep and the superficial fat layers are supplied more richly with vessels with a larger diameter whereas the intermediate fat layer is supplied from the terminal branches of these vessels.

Two innovations of the star-flap technique for nipple reconstruction

Two innovations of the star-flap technique for nipple reconstruction are described. A combination of the star-flap technique and a contralateral nipple graft is indicated in patients with a large nipple and small areola on the contralateral side. It provides sufficient volume for the new nipple and improves the shape of the donor nipple. A combination of the star-flap technique and a banked costal-cartilage graft offers better nipple contour and projection than the conventional star-flap technique. Preparation of the cartilage graft is easy and does not result in additional scarring; the nipple projection can be expected to be maintained over a long period.

Physiological studies using laser Doppler flowmetry to compare blood flow to the zones of the free TRAM flap

Physiological studies of in vivo blood flow within the various types of lower transverse rectus abdominis musculocutaneous (TRAM) flaps have been limited. Therefore, to supplement our knowledge, intraoperative measurements of flow to the cutaneous paddle as derived from laser Doppler flowmetry were recorded in 13 free TRAM flaps in 10 patients (3 bilateral). The relative contributions from both the deep inferior epigastric artery (DIEA) and the superior epigastric artery (SEA) to each zone were assessed jointly and then independently. Mean flow via the DIEA contribution alone was equal to or greater than twice that of the SEA in all zones, although this was not significant (p = 0.079). Flow from either the DIEA or the SEA diminished the farther the zone was from the source pedicle. Contralateral skin territories had significantly decreased flow when compared with all ipsilateral territories (p = 0.005), so that a relative ischemia exists even in free TRAM flaps, which could be the source of unexpected partial flap loss and/or fat necrosis in these zones. These findings were consistent with anatomic descriptions of the lower TRAM flap that imply that the DIEA is the dominant source vessel to the skin of this region.

[Breast reconstruction using gluteal inferior free flaps. 34 cases in 30 patients]

Recent evolution of breast reconstruction favorised autologous tissues, without prosthesis. 34 gluteal inferior free flaps have been performed in 30 patients aged from 33 to 72 years for immediate reconstruction (6) or secondary reconstruction (28), unilateral (26) or bilateral (8 flaps); after complete mastectomy (21 included a bilateral one), partial mastectomy (3), sub-cutaneous mastectomy with skin-sparing mastectomy (3 bilateral cases), radical mastectomy with radiolesion (2), non efficient reconstruction using prosthesis (2). The myocutaneous flap vascularized by gluteal inferior artery was anastomosed on thoracodorsal pedicle or on humeral vein. Added procedures have been symmetrizations (21), flap modifications (21), nipple reconstruction (20). Thirty three flaps presented good survey. Cosmetic results were excellent in five cases, good in 21 cases, middle in eight cases. Flap disadvantages were: possible failure of microsurgery with vessel thrombosis and flap necrosis, long operative time (average five hours), variable quality of the skin flap and hypoesthesia of the posterior area of buttock. Flap advantages were: the suffisant volume (300 to 500 g), the simple procedure to raise the flap (after specific training) and discrete scar of the donor site. This flap seems to be a excellent method for autologous mammary versus TRAM flap or latissimus dorsi added fat flap.

Delaying the skin for TRAM flaps

This study was undertaken to determine whether a less extensive delay procedure would be as efficacious as the standard delay procedure in breast reconstruction.Between July 1996 and February 1999, 15 patients underwent delay procedures prior to breast reconstruction. Six patients underwent the standard delay procedure. Nine patients underwent a less extensive skin delay procedure. Transverse rectus abdominis myocutaneous (TRAM) reconstruction was performed 1 week after delay procedures.Average operating time was 28.7 minutes for the standard delay and 19.7 minutes for the skin paddle delay. The incidences of fat necrosis were 17% in the standard delay group and 22% in the skin paddle delay group. The incidences of partial flap loss/slow healing were 17% in the standard delay group and 22% in the skin paddle delay group. The incidence of complications in each group was the same: approximately 1 per patient.Operating times were not statistically different between the two groups (p = 0.06). There was no increase in the incidence of slow healing/partial flap loss or fat necrosis in the skin delay group. The skin delay procedure for TRAM flaps seems to provide a concise delay procedure that does not increase the incidence of complications in those high-risk patients.

Internal mammary artery and vein supercharge in TRAM flap breast reconstruction

To improve the blood supply of the pedicled flap we have performed an additional microvascular augmentation to this type of breast reconstruction procedure since 1991. The ipsilateral deep inferior epigastric pedicle is anastomosed to the internal mammary artery and vein (IMAV supercharge). In 19 of 20 patients this technique proved to be feasible. For the venous anastomoses the 3M microvascular anastomosis system facilitated the procedure. In one patient the venous anastomosis failed due to the small calibre of two internal mammary veins. In a majority of the cases rapid improvement of flap perfusion could be observed as the direct result of the supercharging. The IMAV supercharged flap is quite comparable with the free flap as regards to the operative procedure. Disadvantages are a slightly more extensive dissection and less freedom in positioning the flap due to the presence of the superior muscular pedicle. The main advantage is that the supercharge procedure minimises the risk of total flap loss. Further technical improvement may be obtained by the use of a contralateral vascular pedicle dissected with muscle-sparing techniques.

Prophylactic mastectomy and inherited predisposition to breast carcinoma

Relative to her risk of breast carcinoma, the woman with a BRCA1 or BRCA2 gene mutation can be managed either by intensive screening (with or without chemoprevention) or by prophylactic mastectomy. Although it would be preferable to avoid prophylactic surgery, the current level of screening technology and the rudimentary state of chemoprevention do not guarantee a good outcome with intensive surveillance. A review of the currently available data was undertaken to determine the efficacy of prophylactic surgery, intensive screening, and chemoprevention. An attempt then was made to extrapolate the efficacy of the various approaches to the management of women who carry BRCA1 or BRCA2 gene mutations. Intensive surveillance may not detect breast carcinoma at an early, curable stage in young women with BRCA1 or BRCA2 gene mutations because the growth rate of the tumors in these women most likely will be rapid and the density of the breast tissue may compromise detection. Chemoprevention is in its infancy, and its efficacy in this population is unknown. Conversely, prophylactic surgery may not be completely effective in preventing breast carcinoma. The authors are hopeful that sometime in the next decade advances in chemoprevention, screening technology, or breast carcinoma treatment will make mastectomy obsolete. However, for the time being prophylactic mastectomy has attributes that make it an alternative for this population that must be considered. Careful discussion of all options is essential in the management of these women.

An ipsilateral superdrainaged transverse rectus abdominis myocutaneous flap for breast reconstruction

A conventional single pedicled TRAM (transverse rectus abdominis myocutaneous) flap is a musculocutaneous flap widely used for breast reconstruction. However, complications such as partial flap necrosis, fat necrosis, and fatty induration may occur as a result of unstable blood flow circulation to the flap. One major factor is venous congestion in the flap. In an effort to obtain more stable TRAM flap blood circulation, we anastomosed the ipsilateral deep inferior epigastric vein of a pedicled TRAM flap to the thoracodorsal vein. This procedure provides superdrainage by means of enhanced venous perfusion. This flap with superdrainage augmentation is referred to as a superdrainaged TRAM flap (12 patients). Changes in cutaneous blood flow were also assessed by measurement of cutaneous blood flow in zone IV using a laser blood flow meter (8 patients). The patients who underwent breast reconstructive surgery using this technique showed no evidence of postoperative complications such as flap necrosis, fat necrosis, or fatty induration. Satisfactory results were obtained during breast reconstruction in patients who had previously undergone a radical mastectomy with resultant large areas of tissue defects. In addition, the two patient groups, 12 patients with superdrainaged TRAM flap and 20 patients with single pedicled TRAM flap, were compared to assess differences in complications. The incidence of partial flap necrosis, fat necrosis, and fatty induration was lower among patients with superdrainaged flap than those with single pedicled flap.

Radiation tolerance of transverse rectus abdominis myocutaneous-free flaps used in immediate breast reconstruction

The authors determine the effects of postoperative radiation therapy on flap and local control outcomes in patients who have undergone immediate transverse rectus abdominis myocutaneous (TRAM)-free flap reconstruction after modified radical mastectomy for locally advanced breast cancer. Details of surgery, chemotherapy, and radiation therapy for 21 patients who had undergone immediate TRAM-free flap reconstruction after modified radical mastectomy were gathered retrospectively. The outcomes examined were flap complications, overall cosmesis, and local recurrence rate. Radiation therapy was indicated for large primary tumors (T3-T4), close or positive margins, or extensive nodal disease. With a mean follow-up interval of 19 months, there have been no flap complications or losses. Cosmesis was rated as excellent by 60% of patients, good by 30%, and fair by the remaining 10%. Three patients thought that radiation had improved cosmesis, one noted worse cosmesis, and the remainder thought it had no effect on cosmesis. The local control rate was 86%. Postreconstruction irradiation of TRAM-free flaps used in immediate reconstruction for locally advanced breast cancer appears safe and cosmetically acceptable.