1
|
Kerai A, Modi P, Shackcloth M, Schache AG, Shaw RJ. Head and neck reconstruction in the vessel depleted neck using robot-assisted harvesting of the internal mammary vessels. Br J Oral Maxillofac Surg 2023; 61:368-372. [PMID: 37246020 DOI: 10.1016/j.bjoms.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 04/13/2023] [Accepted: 04/20/2023] [Indexed: 05/30/2023]
Abstract
We report a novel technique of robot-assisted harvesting of the internal mammary vessels to provide effective recipient vessels in a patient with bilateral vessel depleted neck (VDN). A 44-year-old with a Notani grade III osteoradionecrosis (ORN) of the anterior mandible underwent robot-assisted (Da Vinci® Surgical System, Intuitive Surgical) harvesting of the left internal mammary vessels (LIMA, LIMV). Reconstruction of the mandibular defect was done with a virtually planned composite fibular free flap and microvascular anastomosis of the peroneal vessels to the LIMA and LIMV. Successful reconstruction of the anterior mandible was achieved with excellent recipient arterial diameter and length, devoid of any significant thoracic morbidities resulting from robot-assisted harvesting of the internal mammary vessels. Robot-assisted harvesting of internal mammary vessels is a viable alternative to an open approach. The advantages in tissue handling, vessel length, and favourable profile of complications may extend the indications for this otherwise 'niche' solution in the VDN.
Collapse
Affiliation(s)
- Ashwin Kerai
- Liverpool Head & Neck Centre, Aintree University Hospital, Liverpool, UK
| | - Paul Modi
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | | | - Andrew G Schache
- Liverpool Head & Neck Centre, Aintree University Hospital, Liverpool, UK; Department of Molecular & Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Richard J Shaw
- Liverpool Head & Neck Centre, Aintree University Hospital, Liverpool, UK; Department of Molecular & Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| |
Collapse
|
2
|
Moon J, Lee KT, Park JW. Lower Leg Reconstruction With Free Tissue Transfer Using Reverse Flow Recipient Vein: A Case Report. INT J LOW EXTR WOUND 2023; 22:122-125. [PMID: 32975137 DOI: 10.1177/1534734620959184] [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: 02/04/2023]
Abstract
Since the introduction of distally based flap, the concept of reverse flow flap was expanded to free tissue transfers. For recipient vessels, retrograde arterial inflow is considered a safe option for anastomosis. However, the reliability of a retrograde recipient vein remains controversial. This report presents a case of successful lower leg reconstruction with free flap using a retrograde recipient vein. A 43-year-old woman had a mass lesion in the lateral side of the right calf, which was diagnosed as a malignant granular cell tumor. During wide excision of the tumor, the anterior tibial artery (ATA) and veins were ligated and resected at the bifurcation point from the popliteal artery and veins because the tumor abutted on the ATA near the bifurcation. The skin defect measured 17 × 7 cm with the proximal part of the tibia and lateral condyle exposed. A 19 × 7.5 cm anterolateral thigh flap was elevated, and anastomoses were performed using the distal end of the ATA and anterior tibial vein as retrograde recipient vessels. The flap was well perfused, and no signs of venous insufficiency were observed. Complete survival with no postoperative complications was achieved. In free tissue transfers of the lower leg, retrograde venous flow can be considered as a recipient vein when an antegrade vein is not available or has risks of venous insufficiency.
Collapse
Affiliation(s)
- Jeehyun Moon
- Samsung Medical Center, Sungkyunkwan University, Seoul, Republic of Korea
| | - Kyeong-Tae Lee
- Samsung Medical Center, Sungkyunkwan University, Seoul, Republic of Korea
| | - Jin-Woo Park
- Ewha Womans University Mokdong Hospital, Ewha Womans University, Seoul, Republic of Korea
| |
Collapse
|
3
|
Tokumoto H, Akita S, Kosaka K, Kubota Y, Mitsukawa N. Utilization of a partial rib-sparing procedure in microvascular breast reconstruction for preserving intercostal nerve and nipple reconstruction. J Plast Reconstr Aesthet Surg 2022; 75:4354-4360. [PMID: 36253301 DOI: 10.1016/j.bjps.2022.08.041] [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: 10/12/2021] [Revised: 05/19/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND In microvascular breast reconstruction, internal mammary vessel (IMV) exposure has been performed. The preservation of intercostal nerve (ICN) is effective for preserving sensibility and decreasing postoperative pain. In nipple reconstruction, cartilage grafting is performed to provide additional support and projection. We considered that ICN preservation and costal cartilage banking could be performed simultaneously. This method was described as the "partial rib-sparing procedure." The purpose of this study was to introduce this procedure. METHODS Surgical technique of this procedure was as follows. The second intercostal space was used. The width of the trimmed cartilage was kept within the superior half of the third costal cartilage. Soft tissue within 5 mm of the inferior border of the second rib edge was preserved to save the second ICN. The length of IMVs in the partial rib-sparing procedure and that in the total rib-sparing procedure was compared. RESULTS The number of patients in the partial rib-sparing and total rib-sparing groups was 137 procedures and 57 procedures, respectively. The length of IMVs was significantly longer in the partial rib-sparing procedure (median 20.5 mm vs. 17.6 mm, P < 0.001). In the partial rib-sparing group, no patient complained of prolonged local pain, and chest wall contour abnormalities were absent in all cases. CONCLUSIONS The partial rib-sparing procedure is superior, especially for patients with narrow intercostal spaces and/or patients who decide to undergo nipple reconstruction with costal cartilage. This procedure could be performed to preserve the soft tissues around the ICN and decrease the postoperative pain.
Collapse
Affiliation(s)
- Hideki Tokumoto
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, Japan.
| | - Shinsuke Akita
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, 66-2 Nitona, Chuo-ku, Chiba City, Chiba 260-8717, Japan
| | - Kentaro Kosaka
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, 66-2 Nitona, Chuo-ku, Chiba City, Chiba 260-8717, Japan
| | - Yoshitaka Kubota
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, 66-2 Nitona, Chuo-ku, Chiba City, Chiba 260-8717, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, 66-2 Nitona, Chuo-ku, Chiba City, Chiba 260-8717, Japan
| |
Collapse
|
4
|
Buffoli B, Verzeletti V, Gabusi V, Giugno L, Hirtler L, Faini G. Anatomical basis of retrograde thoracic veins flow and its implications in complex thoracic wall reconstructive surgery. SURGICAL AND RADIOLOGIC ANATOMY : SRA 2022; 44:1319-1328. [PMID: 36129523 PMCID: PMC9649502 DOI: 10.1007/s00276-022-03015-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 08/29/2022] [Indexed: 12/03/2022]
Abstract
Purpose Internal thoracic veins are increasingly used as recipient’s vessels in chest wall reconstructive surgery due to their predictable anatomy and to the possibility to make a double venous anastomosis, exploiting the retrograde flow within them. Over the years, retrograde flow had been explained by the absence of valves in internal thoracic veins, which have been found recently instead. Therefore, our aim is to analyze the retrograde flow and its relationship with valves in the internal thoracic veins. Methods We evaluated 32 internal thoracic veins of 16 fresh-frozen specimens with undamaged thoracic cages by dynamic analysis focused on retrograde flow assessment through a partial external circulation system obtained cannulating the subclavian veins. Gross anatomical and morphological evaluations about the presence of valves and their pattern were then made. Results Efficient, partial, and absent retrograde flow was, respectively, found in 17/30, 8/30 and ITVs and 5/30 internal thoracic veins. Following Arnez’s classification, 20/32 Type I and 12/32 Type II internal thoracic veins were identified. Valves were observed in 10/16 specimens (62.50%) corresponding to 36.67% of examined veins (11/30). Three valves were found between the 2nd intercostal space and 12 valves in the 3rd intercostal space. 13/15 valves were bicuspid, 2/15 tricuspid. A significant correlation (p < 0.001) between the retrograde flow and the presence of valves in internal thoracic veins was observed. Conclusion Our study suggests a possible influence of the presence and the number of valves in the efficient retrograde flow of the internal thoracic veins, suggesting that, especially for more complex cases, a preoperative or intraoperative evaluation of the chest wall drainage should be recommended.
Collapse
Affiliation(s)
- Barbara Buffoli
- Anatomy and Physiopathology Division, Department of Clinical and Experimental Sciences, University of Brescia, V.le Europa 11, 25123, Brescia, Italy.
- Interdipartimental University Center of Research "Adaptation and Regeneration of Tissues and Organs (ARTO)", University of Brescia, 25123, Brescia, Italy.
| | - Vincenzo Verzeletti
- Anatomy and Physiopathology Division, Department of Clinical and Experimental Sciences, University of Brescia, V.le Europa 11, 25123, Brescia, Italy
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Vittoria Gabusi
- Anatomy and Physiopathology Division, Department of Clinical and Experimental Sciences, University of Brescia, V.le Europa 11, 25123, Brescia, Italy
| | - Lorena Giugno
- Anatomy and Physiopathology Division, Department of Clinical and Experimental Sciences, University of Brescia, V.le Europa 11, 25123, Brescia, Italy
| | - Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Gianpaolo Faini
- Unit of Plastic and Reconstructive Surgery, "Ospedale di Esine", Esine, Italy
| |
Collapse
|
5
|
Tokumoto H, Akita S, Kosaka K, Kubota Y, Mitsukawa N. The correlation of flap blood glucose with fat necrosis of free abdominal flap for unilateral breast reconstruction. Microsurgery 2022; 42:677-684. [PMID: 35822602 DOI: 10.1002/micr.30938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 05/29/2022] [Accepted: 07/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Flap blood glucose (FBG) measurement is proposed as a monitoring technique. A cause of long-lasting fever could be derived from fat necrosis. If the findings of low FBG correlated with fat necrosis, it could predict the poor cosmetic result and a source of fever. However, this correlation remained unsolved. The purpose of this study was to clarify this correlation in breast reconstruction. METHODS In the 180 unilateral breast cancer patients (mean age = 49.8 years) performed free abdominal flap, we retrospectively compared the group where fat necrosis occurred with the group where it did not occur (45 patients with fat necrosis vs. 135 patients without). We compared the average of FBG in each postoperative day. RESULTS The average FBG was significantly lower in patients with fat necrosis in the second postoperative day (115.3 ± 27.3 vs. 126.3 ± 13.7 mg/dl, p = .026) and the third postoperative day (111.1 ± 22.1 vs. 118.8 ± 13.8 mg/dl, p = .036). Mean BMI and inserted total flap weight were significantly higher in patients with the fat necrosis group (24.8 vs. 22.9 kg/m2 , p = .005) (617 vs. 478 g, p = .006). The multivariate analysis revealed early FBG (OR = 0.96, p = .0002) and laterality (right side) (OR = 0.46, p = .043) were independently significant predictors. There were no significant between-group differences regarding other factors (age, systemic blood glucose, comorbidities and operative details). CONCLUSIONS The possibility of fat necrosis was high for patients with low FBG in the early postoperative day.
Collapse
Affiliation(s)
- Hideki Tokumoto
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, Chiba, Japan
| | - Shinsuke Akita
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Chiba University, Chiba, Japan
| | - Kentaro Kosaka
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Chiba University, Chiba, Japan
| | - Yoshitaka Kubota
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Chiba University, Chiba, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Chiba University, Chiba, Japan
| |
Collapse
|
6
|
Durhan G, Erdemir AG, Yuce Sari S, Gultekin M, Karakaya J, Akpınar MG, Özyiğit G, Yildiz F, Demirkazık F. Does Internal Mammary Node Irradiation for Breast Cancer Make a Significant Difference to the Diameter of the Internal Mammary Artery? Correlation with Computed Tomography. Breast Care (Basel) 2021; 15:635-641. [PMID: 33447238 DOI: 10.1159/000508244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/27/2020] [Indexed: 12/30/2022] Open
Abstract
Objective Lymphatic irradiation in breast cancer improves locoregional control and has been shown to decrease distant metastasis. However, irradiation also accelerates the formation of atherosclerosis and can cause stenosis, not only in the coronary arteries but also in the internal mammary artery (IMA). The aim of this study was to investigate the effects of radiation on IMAs via computed tomography (CT). Methods We reviewed the data of 3,612 patients with breast cancer treated with radiotherapy (RT) between January 2010 and December 2016. We included 239 patients with appropriate imaging and nodal irradiation in the study. All patients were treated with lymphatic irradiation of 46-50 Gy, and a boost dose (6-10 Gy) to the involved internal mammary nodes (IMNs) when imaging studies demonstrated pathological enlargement. Bilateral IMA diameter and the presence of calcification were assessed via thin contrast-enhanced CT and those of ipsilateral irradiated IMAs were compared with those of contralateral nonirradiated IMAs. Results The mean diameter of irradiated IMAs was significantly shorter than that of nonirradiated IMAs, regardless of laterality. All vascular calcifications were determined on the irradiated side. A boost dose of radiation to the IMNs and radiation technique did not significantly affect the IMA diameter or the presence of calcification. Conclusions The diameter of the IMA is decreased due to RT regardless of laterality, radiation technique, and administration of a boost dose. Evaluation of vessels on CT before coronary artery bypass graft or flap reconstruction can help the surgeon select the most appropriate vessel.
Collapse
Affiliation(s)
- Gamze Durhan
- Department of Radiology, Hacettepe University Medical School, Ankara, Turkey
| | | | - Sezin Yuce Sari
- Department of Radiation Oncology, Hacettepe University Medical School, Ankara, Turkey
| | - Melis Gultekin
- Department of Radiation Oncology, Hacettepe University Medical School, Ankara, Turkey
| | - Jale Karakaya
- Department of Biostatistics, Hacettepe University Medical School, Ankara, Turkey
| | | | - Gökhan Özyiğit
- Department of Radiation Oncology, Hacettepe University Medical School, Ankara, Turkey
| | - Ferah Yildiz
- Department of Radiation Oncology, Hacettepe University Medical School, Ankara, Turkey
| | - Figen Demirkazık
- Department of Radiology, Hacettepe University Medical School, Ankara, Turkey
| |
Collapse
|
7
|
Ismagilov A, Vanesyan A, Ovchinnikova I, Khamitov A, Basiashvili G, Zinchenko S. New technique of dissection of internal mammary vessels for breast reconstruction. Gland Surg 2020; 9:886-892. [PMID: 32953597 DOI: 10.21037/gs-20-104] [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: 11/06/2022]
Abstract
Background Although internal mammary vessels are considered the best recipients for free flap breast reconstruction, they present the notable drawback of limited accessibility. The aim of this study was to develop a minimally invasive surgical technique for the dissection of internal mammary vessels as recipients for breast reconstruction. Methods From 2008 to 2018, we performed 32 unilateral microsurgical breast reconstructions (mean patient age: 40.1±8.7 years; range, 23-58 years). As internal mammary vessels were exclusively used as recipients, they were dissected using a technique of minimally invasive video-assisted thoracoscopic surgery (VATS) developed in our hospital. Results The mean surgery time was 5.4±0.55 hours (range, 4.5-6.5 hours), and the mean duration of VATS dissection of internal mammary vessels was 20.6±2.9 minutes (range, 16-27 minutes). Of the specific complications associated with VATS, we only observed reductions in forced expiratory volume in the first second of >15% in 3 patients (9.4%), 10-15% in 8 patients (25%), and <10% in 21 patients (65.63%). We did not have any cases of significant bleeding or postoperative infection in this series of patients. With regard to aesthetic complications, we observed 1 and 2 cases of total necrosis and partial necrosis of the deep inferior epigastric perforator (DIEP) flap, respectively and 2 cases of partial necrosis of supercharged transverse rectus abdominis muscle flap. Conclusions Endoscopic dissection of internal mammary vessels is a simple and feasible technique. When performed by experienced surgeons, it is a fast procedure that is associated with low rate of complications.
Collapse
Affiliation(s)
- Arthur Ismagilov
- Department of Surgery, Kazan Federal University, Kazan, Russia.,Department of Plastic Surgery, Kazan State Medical Academy, Kazan, Russia.,Department of Breast Surgery, Regional Clinical Oncological Center of Tatarstan, Kazan, Russia
| | - Anna Vanesyan
- Department of Breast Surgery, Regional Clinical Oncological Center of Tatarstan, Kazan, Russia
| | - Irina Ovchinnikova
- Department of Breast Surgery, Regional Clinical Oncological Center of Tatarstan, Kazan, Russia
| | - Airat Khamitov
- Department of Plastic Surgery, Kazan State Medical Academy, Kazan, Russia.,Department of Breast Surgery, Regional Clinical Oncological Center of Tatarstan, Kazan, Russia
| | - George Basiashvili
- Department of Plastic Surgery, Kazan State Medical Academy, Kazan, Russia.,Department of Breast Surgery, Regional Clinical Oncological Center of Tatarstan, Kazan, Russia
| | - Sergei Zinchenko
- Department of Surgery, Kazan Federal University, Kazan, Russia.,Department of Plastic Surgery, Kazan State Medical Academy, Kazan, Russia.,Department of Breast Surgery, Regional Clinical Oncological Center of Tatarstan, Kazan, Russia
| |
Collapse
|
8
|
Comparison of the second and third intercostal spaces regarding the use of internal mammary vessels as recipient vessels in DIEP flap breast reconstruction: An anatomical and clinical study. Arch Plast Surg 2020; 47:333-339. [PMID: 32718112 PMCID: PMC7398814 DOI: 10.5999/aps.2019.01312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 05/25/2020] [Indexed: 11/25/2022] Open
Abstract
Background The purpose of this study was to compare the anatomical features of the internal mammary vessels (IMVs) at the second and third intercostal spaces (ICSs) with regard to their use as recipient vessels in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Methods A total of 38 consecutive DIEP breast reconstructions in 36 patients were performed using IMVs as recipient vessels between March 2017 and August 2018. The intraoperative findings and postoperative complications were analyzed. Anatomical analyses were performed using intraoperative measurements and computed tomography (CT) angiographic images. Results CT angiographic analysis revealed the mean diameter of the deep inferior epigastric artery to be 2.42±0.27 mm, while that of the deep inferior epigastric vein was 2.91±0.30 mm. A larger mean vessel diameter was observed at the second than at the third ICS for both the internal mammary artery (2.26±0.32 mm vs. 1.99±0.33 mm, respectively; P=0.001) and the internal mammary vein (IMv) (2.52±0.46 mm vs. 2.05±0.42 mm, respectively; P<0.001). Similarly, the second ICS was wider than the third (18.08±3.72 mm vs. 12.32±2.96 mm, respectively; P<0.001) and the distance from the medial sternal border to the medial IMv was greater (9.49±2.28 mm vs. 7.18±2.13 mm, respectively; P<0.001). Bifurcations of the IMv were found in 18.4% of cases at the second ICS and in 63.2% of cases at the third ICS. Conclusions The IMVs at the second ICS had more favorable anatomic features for use as recipient vessels in DIEP flap breast reconstruction than those at the third ICS.
Collapse
|
9
|
Diametric Comparison between the Thoracodorsal Vessel and Deep Inferior Epigastric Vessel in Breast Reconstruction. BIOMED RESEARCH INTERNATIONAL 2020; 2020:6352939. [PMID: 32724804 PMCID: PMC7381952 DOI: 10.1155/2020/6352939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/25/2020] [Accepted: 07/07/2020] [Indexed: 11/17/2022]
Abstract
Background In microvascular anastomosis, size discrepancy is common and can increase thrombotic complications. If size differences can be predicted, then vessels of the appropriate size can be selected. This study documented the difference in diameter between the thoracodorsal (TD) vessel and deep inferior epigastric perforator (DIEP) pedicle in each patient who underwent breast reconstruction using free tissue transfer. Patients and Methods. This retrospective study included 32 anastomoses (27 breasts including five cases of supercharged anastomosis) of breast reconstruction with the free DIEP flap and TD recipient between August 2018 and June 2019. In the microscopic view, the caliber of the TD vessel, the largest branch to the serratus anterior muscle, the descending branch, the largest and the second largest branches to the latissimus dorsi muscle, and the DIEP pedicle were measured. Results The diameter of the deep inferior epigastric artery was similar to that of the descending branch, and their anastomosing rate was 56.3%. The diameter of the deep inferior epigastric vein was similar to the branch to the serratus anterior muscle and the descending branch, and their anastomosing rates were 29.3% and 29.3%, respectively. All flaps were survived; however, in one case, a reoperation was needed to remove the hematoma, in which case fat necrosis occurred as the only complication. Conclusion TD branches of similar size to the DIEP pedicle were prioritized in anastomosis. The descending branch and the branch to the serratus anterior muscle are expected to be good candidates as recipients in breast reconstruction with DIEP free flap. Moreover, supercharged anastomosis of DIEP pedicles can be achieved within TD branches.
Collapse
|
10
|
Samaras S, McKelvie MA, Oni G, Malata CM. An unusual "venous circle" of the internal mammary vein encountered during microvascular anastomosis and implications for practice. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2020; 7:54-56. [PMID: 32373676 PMCID: PMC7191913 DOI: 10.1080/23320885.2020.1754129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 03/29/2020] [Indexed: 10/24/2022]
Abstract
The internal mammary vessels are commonly used for anastomosis in breast reconstruction. The anatomy when using the 2nd ICS has been shown to be predictable and hence preferentially used by the senior author. We present an unusual case of internal mammary vein bifurcation and immediate confluence forming a 'venous circle'.
Collapse
Affiliation(s)
- S Samaras
- Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Plastic & Reconstructive Surgery, 401 Military Hospital of Athens, Athens, Greece
| | - M A McKelvie
- Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - G Oni
- Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - C M Malata
- Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Anglia Ruskin School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, UK.,Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| |
Collapse
|
11
|
Muto M, Satake T, Masuda Y, Kobayashi S, Tamura S, Kobayashi S, Ohtake T, Maegawa J. Absent Internal Mammary Recipient Vein in Autologous Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2660. [PMID: 32309101 PMCID: PMC7159964 DOI: 10.1097/gox.0000000000002660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/17/2019] [Indexed: 11/25/2022]
Abstract
The internal mammary vessels (IMA/Vs) have been used as the first-choice recipient vessels for microsurgical anastomosis and flap inset in autologous breast reconstruction owing to their ease of access and use compared with the thoracodorsal vessels (TDA/Vs). Herein, we report two cases of deep inferior epigastric perforator flap breast reconstructions in which the recipient internal mammary vein (IMV) was lacking. In the first case, a 50-year-old patient underwent delayed two-stage reconstruction, and in the second, a 45-year-old patient underwent delayed reconstruction because of capsular contracture following breast implant reconstruction. Neither patient received preoperative radiation therapy. During IMA/V preparation, we could not find the internal mammary vein (IMV) around the internal mammary artery (IMA) despite careful dissection. No internal mammary lymph node adenopathy and vascular encasement from metastasis were noted. Intraoperative indocyanine green angiography revealed absence of IMV, which was presumed to be congenital. Therefore, microsurgical anastomosis was performed to connect the deep inferior epigastric vessels to the thoracodorsal vessel. The postoperative course was uneventful in both cases. Although many anatomical studies have revealed different locations, diameters, branching patterns, and perforators of the IMA/V, absent IMV has been reported very rarely. In autologous breast reconstruction, plastic surgeons should be prepared for the possibility of the absence of IMV.
Collapse
Affiliation(s)
- Mayu Muto
- Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Toshihiko Satake
- Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Yuma Masuda
- Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Saya Kobayashi
- Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Shihoko Tamura
- Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Shinji Kobayashi
- Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Tohru Ohtake
- Department of Breast Surgery, Fukushima Medical University Hospital, Fukushima, Fukushima, Japan
| | - Jiro Maegawa
- Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
| |
Collapse
|
12
|
Zhang Q, Xiao Q, Guo R, Xiu B, Li L, Chi W, Gu Y, Wu J. Applications of rib sparing technique in internal mammary vessels exposure of abdominal free flap breast reconstructions: a 12-year single-center experience of 215 cases. Gland Surg 2019; 8:477-485. [PMID: 31741878 DOI: 10.21037/gs.2019.08.08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Internal mammary vessels (IMVs) are widely used recipient vessels in abdominal free flap breast reconstructions. Rib sparing technique is an alternative method with less damage in IMVs exposure. This study aims to investigate the factors influencing the selection of IMVs, as well as analyze the applicability and related factors of rib sparing technique in abdominal breast reconstruction. Methods Medical records of 215 patients who underwent abdominal free flap reconstruction from November 2006 to December 2017 in Fudan University Shanghai Cancer Center (FUSCC) were analyzed. Intercostal space (ICS) was measured from preoperative chest computed tomography scan. Factors influencing the choice of recipient vessels and rib sparing were analyzed. Surgery time, hospitalization and complications were assessed. Results Among all 218 flaps, 172 flaps used IMVs as the recipient vessels while 46 used other vessels. patients with immediate reconstruction (P=0.005) and axillary lymph nodes dissection (ALND) (P<0.001) were less likely to use IMVs. Patients' body mass index (BMI) and radiotherapy history showed no statistically significant differences between the two groups (P=0.338 and 0.811). In IMVs group, 62% cases used rib sparing technique. Compared with rib resection group, patients with rib sparing were taller (P=0.047) and with a wider ICS (2.65±0.54 vs. 2.25±0.38 cm, P<0.001). Rib sparing group had a shorter surgery and postoperative hospitalization time, as well as a lower complication rate, but the differences were not statistically significant (P=0.120, 0.450 and 0.612). Conclusions IMVs were used more frequently as the recipient vessels in abdominal free flap breast reconstructions, especially when axillary operation was not performed at the same time. Rib sparing technique had the potential to decrease surgery time, hospitalization days and complications rate. It could be applied in most of the patients with IMVs exposure, particularly in taller patients and patients with a wider ICS. Preoperative chest computed tomography scan can be used to assess the ICS width to provide operational suggestions.
Collapse
Affiliation(s)
- Qi Zhang
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qin Xiao
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.,Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Rong Guo
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Bingqiu Xiu
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Lun Li
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Weiru Chi
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yajia Gu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.,Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Jiong Wu
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.,Collaborative Innovation Center for Cancer Medicine, Shanghai 200032, China
| |
Collapse
|
13
|
Tokumoto H, Akita S, Arai M, Kubota Y, Kuriyama M, Mitsukawa N. A method using the cephalic vein for superdrainage in breast reconstruction. Microsurgery 2019; 39:502-508. [PMID: 31328302 DOI: 10.1002/micr.30489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 05/31/2019] [Accepted: 06/21/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND In breast reconstruction, a superdrainage procedure using the superficial inferior epigastric vein has been described. The purpose of this study was to investigate whether the utility of cephalic vein (CV) was equivalent to that of serratus anterior muscle branch of the thoracodorsal vein (SA) and lateral thoracic vein (LTV) for recipient vein. METHODS Eighty-eight patients were enrolled in this study. The superdrainage was not performed if the internal mammary vein diameter was greater than, or equal to, that of the deep inferior epigastric vein diameter. In superdrainage cases, the SA or LTV was used as the recipient vein firstly, and the CV was used when both of them were unsuitable. RESULTS The superdrainage was performed in 45 (51.1%) patients. No significant differences were observed between with and without superdrainage. In superdrainage group, the CV was used in 7 (15.5%) patients. In two groups (CV vs. LTV and SA), because we added to perform superdrainage to the CV at the time of re-exploration and tried to use the SA or the LTV firstly, the re-exploration rate (28.6 vs. 0%) and operating time (652.1 vs. 591.1 min) of CV group were significantly high (p = .023 and .028). No complications were observed, due to CV harvesting. Other characteristics showed no significant differences. CONCLUSIONS At the point of superdrainage, the CV was equivalent to the SA and LTV. Using of the CV would only be essential in rare cases; nonetheless, the possibility of its use should be considered.
Collapse
Affiliation(s)
- Hideki Tokumoto
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, Chiba, Japan
| | - Shinsuke Akita
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, Chiba, Japan
| | - Minami Arai
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, Chiba, Japan
| | - Yoshitaka Kubota
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, Chiba, Japan
| | - Motone Kuriyama
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, Chiba, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, Chiba, Japan
| |
Collapse
|
14
|
Onoda S, Kinoshita M. Salvage Surgery for Jejunal Necrosis After a Free Jejunal Transfer. Ann Surg Oncol 2019; 26:2122-2126. [DOI: 10.1245/s10434-019-07348-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Indexed: 11/18/2022]
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Location of the Internal Mammary Vessels for Microvascular Autologous Breast Reconstruction. Plast Reconstr Surg 2018; 142:28-36. [DOI: 10.1097/prs.0000000000004519] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
17
|
Silhol T, Suffee T, Hivelin M, Lantieri L. Déroutage de la veine céphalique dans la reconstruction mammaire par lambeaux libres : note technique. ANN CHIR PLAST ESTH 2018; 63:75-80. [DOI: 10.1016/j.anplas.2017.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 10/12/2017] [Indexed: 11/29/2022]
|
18
|
Morel F, Crampon F, Adnot J, Litzler PY, Duparc F, Trost O. Rerouting the internal thoracic pedicle: a novel solution for maxillofacial reconstruction in vessel-depleted situations? A preliminary anatomic study. Surg Radiol Anat 2018; 40:911-916. [PMID: 29289988 DOI: 10.1007/s00276-017-1965-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 12/20/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Microsurgical reconstruction in a vessel-depleted neck is a challenge due to the lack of reliable vessels in or nearby the host site. The use of the internal thoracic pedicle (ITP) by rib section or sparring is a limited option due to the small length of the pedicle of some flaps. However, in cardiac surgery, the internal thoracic artery (ITA) is widely used for myocardial revascularization, providing a long and versatile pedicle. We aimed at determining precise anatomical bases for the use of the ITP, approached by sternotomy and rerouted in the neck, as recipient vessels for free-flap facial reconstructions. METHODS We performed a descriptive single centre anatomical study on 20 formalin-embalmed cadavers. The ITP was harvested on both sides from the emergence of the artery under the brachiocephalic vein to its terminal division. The level reached by the ITP in the cervicofacial area was described. Distal arterial and venous diameters, pedicle length and other parameters were measured. RESULTS In at least 85% of the cases, the ITP reached the mandibular angle. The mean diameter at the distal extremity for the ITA was 2.36 ± 0.15, and 2.48 ± 0.19 mm for the committing vein. The mean length of the ITP was 177.3 mm. CONCLUSION Rerouting the ITP towards the cervicofacial area could provide a reliable pedicle for free-flap reconstructions in patients with a vessel-depleted neck but it should be limited to selected patients. This novel solution for situations where current techniques are unfeasible warrants further clinical research.
Collapse
Affiliation(s)
- François Morel
- Department of Oral and Maxillofacial Surgery, Rouen University Hospital, Rouen, France
| | - Frédéric Crampon
- Laboratory of Anatomy, Rouen Faculty of Medicine, 22, Boulevard Léon-Gambetta, 76000, Rouen, France
| | - Jérôme Adnot
- Department of Oral and Maxillofacial Surgery, Rouen University Hospital, Rouen, France
| | - Pierre-Yves Litzler
- Department of Thoracic and Cardiovascular Surgery, Rouen University Hospital, Rouen, France.,French National Institute for Health (INSERM), U-1096, Rouen, France
| | - Fabrice Duparc
- Laboratory of Anatomy, Rouen Faculty of Medicine, 22, Boulevard Léon-Gambetta, 76000, Rouen, France
| | - Olivier Trost
- Department of Oral and Maxillofacial Surgery, Rouen University Hospital, Rouen, France. .,Laboratory of Anatomy, Rouen Faculty of Medicine, 22, Boulevard Léon-Gambetta, 76000, Rouen, France. .,French National Institute for Health (INSERM), LIMICS UMR-1142, Rouen, France.
| |
Collapse
|
19
|
Samargandi OA, Winter J, Corkum JP, Al Youha S, Frank S, Williams J. Comparing the thoracodorsal and internal mammary vessels as recipients for microsurgical autologous breast reconstruction: A systematic review and meta-analysis. Microsurgery 2017; 37:937-946. [PMID: 28949034 DOI: 10.1002/micr.30244] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 08/14/2017] [Accepted: 09/05/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND Our aim was to determine whether the thoracodorsal (Td) vessels have comparable clinical outcomes to the internal mammary (IM) vessels as recipients for autologous free tissue transfer for breast reconstruction. METHODS Systematic searches of MEDLINE, EMBASE, CENTRAL, and World of Science from inception to June 2016 were performed by two independent reviewers. Studies that included adult females undergoing autologous free tissue transfer for breast reconstruction were selected. The two comparison groups were the use of IM or Td as recipient vessels. Our primary outcome was rate of flap survival. We assessed the methodologic quality of included studies using the JADAD and MINOR scales. RESULTS A total of 1897 patients underwent 2644 free abdominal flap tissue transfer in the 10 articles that were included in our analysis. There was one randomized controlled study (Jadad score 2/5) and 9 nonrandomized controlled studies (MINORS scores 11-19/24). There was no difference between the uses of either vessel in terms of flap loss (1.18; 95% CI 0.71-1.95). Complication rate among the IM vessels ranged from 5 to 12%, compared with 3.4-12% among Td vessels. Hematoma and seroma rates were variable. Fat necrosis was higher with Td vessels in two studies. Performing Td vessels anastomosis was associated with shorter operative time and higher risk of encountering unusable vessel. CONCLUSION Both recipient vessels are safe, reliable and demonstrate equivocal results in the absence of contraindications. Utilizing either as a first-line vessel is reasonable, depending on surgeons' preference or certain clinical scenarios. QUESTION Therapeutic, Level of evidence: III.
Collapse
Affiliation(s)
- Osama A Samargandi
- Division of Plastic Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Division of Plastic and Reconstructive Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Jessica Winter
- Department of Surgery, Section of Plastic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joseph P Corkum
- Division of Plastic Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sarah Al Youha
- Division of Plastic Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Simon Frank
- Division of Plastic Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Division of Plastic Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Jason Williams
- Division of Plastic Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| |
Collapse
|
20
|
Cook JA, Tholpady SS, Momeni A, Chu MW. Predictors of internal mammary vessel diameter: A computed tomographic angiography-assisted anatomic analysis. J Plast Reconstr Aesthet Surg 2016; 69:1340-8. [DOI: 10.1016/j.bjps.2016.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/20/2016] [Accepted: 07/03/2016] [Indexed: 10/21/2022]
|
21
|
O'Neill AC, Hayward V, Zhong T, Hofer SO. Usability of the internal mammary recipient vessels in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 2016; 69:907-11. [DOI: 10.1016/j.bjps.2016.01.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/05/2016] [Accepted: 01/28/2016] [Indexed: 10/22/2022]
|
22
|
La Padula S, Hersant B, Noel W, Niddam J, Hermeziu O, Bouhassira J, Bosc R, Meningaud JP. Use of the retrograde limb of the internal mammary vein to avoid venous congestion in DIEP flap breast reconstruction: Further evidences of a reliable and time-sparing procedure. Microsurgery 2016; 36:447-52. [DOI: 10.1002/micr.30043] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 02/08/2016] [Accepted: 02/16/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Simone La Padula
- Plastic Surgery Department; Henri Mondor Hospital, UPEC; Creteil France
| | - Barbara Hersant
- Plastic Surgery Department; Henri Mondor Hospital, UPEC; Creteil France
| | - Warren Noel
- Plastic Surgery Department; Henri Mondor Hospital, UPEC; Creteil France
| | - Jeremy Niddam
- Plastic Surgery Department; Henri Mondor Hospital, UPEC; Creteil France
| | - Oana Hermeziu
- Plastic Surgery Department; Henri Mondor Hospital, UPEC; Creteil France
| | | | - Romain Bosc
- Plastic Surgery Department; Henri Mondor Hospital, UPEC; Creteil France
| | | |
Collapse
|
23
|
Using the Retrograde Internal Mammary System for Stacked Perforator Flap Breast Reconstruction. Plast Reconstr Surg 2016; 137:265e-277e. [DOI: 10.1097/01.prs.0000475743.08559.b6] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
24
|
Malata CM, Rabey NG. Decision Making in Double-Pedicled DIEP and SIEA Abdominal Free Flap Breast Reconstructions: An Algorithmic Approach and Comprehensive Classification. Front Surg 2015; 2:49. [PMID: 26579526 PMCID: PMC4620682 DOI: 10.3389/fsurg.2015.00049] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/10/2015] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The deep inferior epigastric artery perforator free flap is the gold standard for autologous breast reconstruction. However, using a single vascular pedicle may not yield sufficient tissue in patients with midline scars or insufficient lower abdominal pannus. Double-pedicled free flaps overcome this problem using different vascular arrangements to harvest the entire lower abdominal flap. The literature is, however, sparse regarding technique selection. We therefore reviewed our experience in order to formulate an algorithm and comprehensive classification for this purpose. METHODS All patients undergoing unilateral double-pedicled abdominal perforator free flap breast reconstruction (AFFBR) by a single surgeon (CMM) over 40 months were reviewed from a prospectively collected database. RESULTS Of the 112 consecutive breast free flaps performed, 25 (22%) utilised two vascular pedicles. The mean patient age was 45 years (range = 27-54). All flaps, but one (which used the thoracodorsal system), were anastomosed to the internal mammary vessels using the rib-preservation technique. The surgical duration was 656 min (range = 468-690 min). The median flap weight was 618 g (range = 432-1275 g) and the mastectomy weight was 445 g (range = 220-896 g). All flaps were successful and only three patients requested minor liposuction to reduce and reshape their reconstructed breasts. CONCLUSION Bipedicled free abdominal perforator flaps, employed in a fifth of all our AFFBRs, are a reliable and safe option for unilateral breast reconstruction. They, however, necessitate clear indications to justify the additional technical complexity and surgical duration. Our algorithm and comprehensive classification facilitate technique selection for the anastomotic permutations and successful execution of these operations. LEVELS OF EVIDENCE Therapeutic level IV.
Collapse
Affiliation(s)
- Charles M Malata
- Postgraduate Medical Institute, Faculty of Health Sciences, Anglia Ruskin University , Cambridge and Chelmsford , UK ; Cambridge Breast Unit, Plastic and Reconstructive Surgery Department, Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| | - Nicholas G Rabey
- Cambridge Breast Unit, Plastic and Reconstructive Surgery Department, Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK ; Cambridge Breast Unit, Plastic and Reconstructive Surgery Department, Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| |
Collapse
|
25
|
Total 'rib'-preservation technique of internal mammary vessel exposure for free flap breast reconstruction: A 5-year prospective cohort study and instructional video. Ann Med Surg (Lond) 2015; 4:293-300. [PMID: 26468373 PMCID: PMC4556813 DOI: 10.1016/j.amsu.2015.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 08/20/2015] [Indexed: 11/20/2022] Open
Abstract
Introduction The total ‘rib’-preservation method of dissecting out the internal mammary vessels (IMV) during microvascular breast reconstruction aims to reduce free flap morbidity at the recipient site. We review our five-year experience with this technique. Patients & methods An analysis of a prospectively collected free flap data cohort was undertaken to determine the indications, operative details and reconstructive outcomes in all breast reconstruction patients undergoing IMV exposure using the total ‘rib’-preservation method by a single surgeon. Results 178 consecutive breast free flaps (156 unilateral, 11 bilateral) were performed from 1st June 2008 to 31st May 2013 in 167 patients with a median age of 50 years (range 28–71). There were 154 DIEP flaps, 14 SIEA flaps, 7 muscle-sparing free TRAMs, 2 IGAP flaps and one free latissimus dorsi flap. 75% of the reconstructions (133/178) were immediate, 25% (45/178) were delayed. The mean inter-costal space distance was 20.9 mm (range 9–29). The mean time taken to expose and prepare the recipient IMV's was 54 min (range 17–131). The mean flap ischaemia time was 95 min (range 38–190). Free flap survival was 100%, although 2.2% (4 flaps) required a return to theatre for exploration and flap salvage. No patients complained of localised chest pain or tenderness at the recipient site and no chest wall contour deformity has been observed. Discussion & conclusion The total ‘rib’-preservation technique of IMV exposure is a safe, reliable and versatile method for microvascular breast reconstruction and should be considered as a valid alternative to the ‘rib’-sacrificing techniques. We review the rib-preservation technique for internal mammary vessel exposure by a single surgeon. An instructional video is presented depicting how to perform the rib-preserving technique step by step. The ‘rib’-preservation technique to dissect the internal mammary vessels is safe, reliable and reproducible.
Collapse
|
26
|
The Retrograde Limb of Internal Mammary Vessels as Reliable Recipient Vessels in DIEP Flap Breast Reconstruction. Ann Plast Surg 2015; 74:447-53. [DOI: 10.1097/sap.0b013e31829fd2e3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
27
|
A decision-making algorithm for recipient vein selection in bipedicle deep inferior epigastric artery perforator flap autologous breast reconstruction. J Plast Reconstr Aesthet Surg 2014; 67:1089-93. [DOI: 10.1016/j.bjps.2014.04.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 02/13/2014] [Accepted: 04/29/2014] [Indexed: 11/23/2022]
|
28
|
Khoo A, Rosich-Medina A, Woodham A, Jessop ZM, Di Candia M, Malata CM. The relationship between the intercostal distance, patient height and outcome in microsurgical breast reconstruction using the second interspace rib-sparing internal mammary vessel exposure. Microsurgery 2014; 34:448-53. [DOI: 10.1002/micr.22238] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 02/11/2014] [Accepted: 02/14/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Anna Khoo
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Anais Rosich-Medina
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Amandine Woodham
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Zita M. Jessop
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Michele Di Candia
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Charles M. Malata
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
- Cambridge Breast Unit; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
- Professor of Academic Plastic Surgery; Postgraduate Medical Institute at Anglia Ruskin University, Cambridge and Chelmsford; UK
| |
Collapse
|
29
|
Kubota Y, Mitsukawa N, Akita S, Hasegawa M, Satoh K. Postoperative patency of the retrograde internal mammary vein anastomosis in free flap transfer. J Plast Reconstr Aesthet Surg 2014; 67:205-11. [DOI: 10.1016/j.bjps.2013.10.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 09/02/2013] [Accepted: 10/07/2013] [Indexed: 11/25/2022]
|
30
|
A clinical anatomic study of internal mammary perforators as recipient vessels for breast reconstruction. Arch Plast Surg 2013; 40:761-5. [PMID: 24286051 PMCID: PMC3840185 DOI: 10.5999/aps.2013.40.6.761] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 07/27/2013] [Accepted: 07/30/2013] [Indexed: 11/18/2022] Open
Abstract
Background Partially resecting ribs of the recipient site to facilitate easy anastomosis of the internal mammary vessels to free flaps during breast reconstruction can cause chest wall pain or deformities. To avoid this, the intercostal perforating branches of the internal mammary vessels can be used for anastomosis. The purpose of this study was to investigate the location and size of the internal mammary perforator vessels based on clinical intraoperative findings and to determine their reliability as recipient vessels for breast reconstruction with microsurgical free tissue transfer. Methods Twelve patients were preoperatively screened for the presence of internal mammary perforators using Doppler tracing. After modified radical mastectomy was performed by a general surgeon, the location and size of the internal mammary perforator vessels were microscopically investigated. The external diameter was examined using a vessel-measuring gauge from a mechanical coupling device, and the distance from the mid-sternal line to the perforator was also measured. Results The largest arterial perforator averaged 1.5 mm, and the largest venous perforator averaged 2.2 mm. Perforators emerging from the second intercostal space had the largest average external diameter; the second intercostal space also had the largest number of perforators arising from it. The average distance from the mid-sternal line to the perforator was 20.2 mm. Conclusions Internal mammary perforators presented consistent and reliable anatomy in this study. Based on these results, the internal mammary perforators appear to have a suitable diameter for microvascular anastomosis and should be considered as an alternative recipient vessel to the internal mammary vessel.
Collapse
|
31
|
Demystifying the Use of Internal Mammary Vessels as Recipient Vessels in Free Flap Breast Reconstruction. Plast Reconstr Surg 2013; 132:763-768. [DOI: 10.1097/prs.0b013e31829fe321] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
32
|
Shankhdhar VK, Yadav PS, Dushyant J, Seetharaman SS, Chinmay W. Cephalic vein: Saviour in the microsurgical reconstruction of breast and head and neck cancers. Indian J Plast Surg 2013; 45:485-93. [PMID: 23450746 PMCID: PMC3580347 DOI: 10.4103/0970-0358.105957] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Reconstruction with microvascular free flaps is considered the reconstructive option of choice in cancer of the head and neck regions and breast. Rarely, there is paucity of vessels, especially the veins, at the recipient site. The cephalic vein with its good caliber and constant anatomy is a reliable recipient vein available in such situations. Materials and Methods: It is a retrospective study from January 2010 to July 2012 and includes 26 patients in whom cephalic vein was used for free-flap reconstruction in head and neck (3 cases) and breast cancers (23 cases). Results: All flaps in which cephalic vein was used survived completely. Conclusion: Cephalic vein can be considered as a reliable source of venous drainage when there is a non-availability/unusable of veins during free-flap reconstruction in the head and neck region and breast and also when additional source of venous drainage is required in these cases.
Collapse
Affiliation(s)
- Vinay K Shankhdhar
- Department of Plastic and Reconstructive Services, TATA Memorial Hospital, Parel, Mumbai, India
| | | | | | | | | |
Collapse
|
33
|
|
34
|
Is There a Need for Preoperative Imaging of the Internal Mammary Recipient Site for Autologous Breast Reconstruction? Ann Plast Surg 2013; 70:111-5. [DOI: 10.1097/sap.0b013e318210874f] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
35
|
Fortin AJ, Evans HB, Chu MWA. The cardiac implications of breast reconstruction using the internal mammary artery as the recipient vessel. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2012. [DOI: 10.1177/229255031202000114] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Microsurgical breast reconstruction is a popular choice in breast reconstruction. Recipient vessel use for these autologous tissue reconstructions has shifted from the thoracodorsal to the internal mammary vessels. Coronary artery bypass (CAB) surgery remains the optimal revascularization strategy in patients with significant, diffuse coronary artery disease. The conduits of choice for coronary revascularization are the internal mammary arteries (IMA) because of their superior long-term graft patency rate and improved patient survival. Objective To review the cardiac risk factors in the breast reconstruction population, and to report the incidence of postoperative cardiac events at the London Health Sciences Centre, London, Ontario. The authors present the index cases illustrating cardiac complications following the use of internal mammary vessels. Method A retrospective, single-centre, cumulative audit of breast reconstruction practice from 2005 to 2009 was conducted. A total of 81 patients undergoing autologous breast reconstruction were reviewed. Two women were noted to have experienced postoperative myocardial infarction requiring intervention. Both were noted to have triple-vessel disease, an indication for CAB; however, during the breast reconstruction, their IMAs had been utilized. As a result, both women subsequently underwent triple-vesssel percutaneous intervention, with one woman later requiring CAB without IMA because of recurrent ischemia. Conclusion While there is limited overlap with the breast reconstruction and cardiac disease population, there can be significant cardiac health implications in the postoperative status (both short and long term) of women undergoing autologous breast reconstruction using the IMAs as recipient vessels.
Collapse
Affiliation(s)
- Amanda J Fortin
- Division of Cardiac Surgery, University of Western Ontario, London, Ontario
| | - H Brian Evans
- Division of Cardiac Surgery, University of Western Ontario, London, Ontario
| | - Michael WA Chu
- Division of Cardiac Surgery, University of Western Ontario, London, Ontario
| |
Collapse
|
36
|
The anatomy and variations of the internal thoracic (internal mammary) artery and implications in autologous breast reconstruction: clinical anatomical study and literature review. Surg Radiol Anat 2011; 34:159-65. [DOI: 10.1007/s00276-011-0886-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Accepted: 09/28/2011] [Indexed: 11/26/2022]
|
37
|
Venturi ML, Poh MM, Chevray PM, Hanasono MM. Comparison of flow rates in the antegrade and retrograde internal mammary vein for free flap breast reconstruction. Microsurgery 2011; 31:596-602. [DOI: 10.1002/micr.20928] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 05/13/2011] [Indexed: 11/08/2022]
|
38
|
Mackey SP, Ramsey KW. Exploring the myth of the valveless internal mammary vein – a cadaveric study. J Plast Reconstr Aesthet Surg 2011; 64:1174-9. [DOI: 10.1016/j.bjps.2011.03.045] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2011] [Accepted: 03/27/2011] [Indexed: 10/18/2022]
|
39
|
Tips for Successful Microvascular Abdominal Flap Breast Reconstruction Utilizing the “Total Rib Preservation” Technique for Internal Mammary Vessel Exposure. Ann Plast Surg 2011; 66:36-42. [DOI: 10.1097/sap.0b013e3181e19daf] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
40
|
Kropf N, Macadam SA, McCarthy C, Disa JJ, Pusic AL, Lio AD, Crisera C, Mehrara BJ. Influence of the recipient vessel on fat necrosis after breast reconstruction with a free transverse rectus abdominis myocutaneous flap. J Plast Surg Hand Surg 2010; 44:96-101. [DOI: 10.3109/02844311003675354] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
41
|
Technique of Internal Mammary Dissection Using Pectoralis Major Flap to Prevent Contour Deformities. Plast Reconstr Surg 2009; 123:1674-1675. [DOI: 10.1097/prs.0b013e3181a403f5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
42
|
Rib-Sparing Internal Mammary Vessel Harvest for Microvascular Breast Reconstruction in 100 Consecutive Cases. Plast Reconstr Surg 2009; 123:1403-1407. [DOI: 10.1097/prs.0b013e3181a07249] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
43
|
Lasso JM, Sancho M, Campo V, Jiménez E, Pérez Cano R. Epiperitoneal vessels: more resources to perform DIEP flaps. J Plast Reconstr Aesthet Surg 2008; 61:826-9. [PMID: 17446150 DOI: 10.1016/j.bjps.2007.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2006] [Revised: 10/20/2006] [Accepted: 03/06/2007] [Indexed: 11/30/2022]
Abstract
The development of the DIEP flap established an accepted concept of reconstructive surgery, but in patients who demonstrate inadequate in vivo flap perfusion, alternative surgical options to improve vascularisation are limited. We present a 42-year-old patient, with a left mastectomy whose breast was reconstructed with a DIEP flap. After anastomosis to the internal mammary vessels there was insufficient arterial perfusion of the flap. The situation was resolved by using an independent medial perforator artery emerging from the peritoneal layer (epiperitoneal vessels). This new pedicle was anastomosed end-to-end to the distal portion of the inferior epigastric artery. We consider that epiperitoneal vessels can be an emergency pedicle when needed and a possible alternative to the main pedicle of the DIEP flap.
Collapse
Affiliation(s)
- J M Lasso
- Hospital General Universitario Gregorio Marañón, Servicio de Cirugía Plástica y Reparadora, Madrid, Spain.
| | | | | | | | | |
Collapse
|
44
|
Deiler S, Zulkowski R, Muensterer O, Widmann J, Kanz KG, Stock W. Pedicled superior epigastric perforator flap for reconstruction of a soft tissue defect at the ventral thoracic wall. EUROPEAN JOURNAL OF PLASTIC SURGERY 2007. [DOI: 10.1007/s00238-007-0155-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
45
|
|
46
|
Jaffers GJ, Reiter C, Buckley CJ. Use of the internal mammary vein for access outflow in a hemodialysis fistula. Vascular 2007; 15:172-5. [PMID: 17573025 DOI: 10.2310/6670.2007.00019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A patient with occlusion of multiple central veins from both dialysis and nondialysis catheters required permanent access for hemodialysis. Magnetic resonance imaging showed a patent left innominate vein. He underwent creation of a left axillary artery to internal mammary vein transposition fistula using the basilic vein from his right arm. The fistula has required one revision for outflow stenosis and one for aneurysmal degeneration. It continues to function well 3 years after placement. The internal mammary vein is an option for outflow when permanent hemodialysis access has failed in the presence of a patent innominate vein with occluded or severely stenotic ipsilateral subclavian and jugular veins.
Collapse
Affiliation(s)
- Gregory J Jaffers
- Division of Transplantation Surgery, Scott and White Hospital, Temple, TX 76502, USA.
| | | | | |
Collapse
|
47
|
Saint-Cyr M, Youssef A, Bae HW, Robb GL, Chang DW. Changing Trends in Recipient Vessel Selection for Microvascular Autologous Breast Reconstruction: An Analysis of 1483 Consecutive Cases. Plast Reconstr Surg 2007; 119:1993-2000. [PMID: 17519690 DOI: 10.1097/01.prs.0000260636.43385.90] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Over the years, the authors' preferred recipient vessels for microvascular autologous breast reconstruction have changed from the thoracodorsal to the internal mammary vessels. METHODS From 1994 to 2004, 1483 microvascular autologous breast reconstructions were performed in 1168 patients at the authors' institution. Potential factors involved in the selection of the recipient vessels were evaluated and compared between the thoracodorsal and internal mammary groups. Rates of recipient vessel unusability and flap-related complications were also analyzed and compared between the two groups. RESULTS The mean patient age was 48 years, and the mean follow-up time was 1.5 years. The vessel conversion rate was 2.8 percent for the thoracodorsal group and 1.9 percent for the internal mammary group. Preoperative radiotherapy and previous axillary node dissection were significantly associated with thoracodorsal vessel conversion (odds ratios, 4.7 and 2.6, respectively). The overall flap-related complication rate (12.6 percent versus 8.6 percent) and specific flap-related complications, including flap loss (2.6 percent versus 3.8 percent), vessel thrombosis (3.7 percent versus 5.0 percent), fat necrosis (4.5 percent versus 2.6 percent), infection (0.7 percent versus 0.7 percent), and hematoma (1.6 percent versus 1.9 percent), were comparable between the two groups, but the flap seroma rate was significantly higher in the thoracodorsal group (4.0 percent versus 0.7 percent; odds ratio, 4.2). CONCLUSION In the authors' experience, use of internal mammary vessels is safe, with low rates of vessel conversion and flap-related complications.
Collapse
Affiliation(s)
- Michel Saint-Cyr
- Houston, Texas From the Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center
| | | | | | | | | |
Collapse
|
48
|
Yagi S, Kamei Y, Fujimoto Y, Torii S. Use of the Internal Mammary Vessels as Recipient Vessels for an Omental Flap in Head and Neck Reconstruction. Ann Plast Surg 2007; 58:531-5. [PMID: 17452838 DOI: 10.1097/01.sap.0000244928.29667.fd] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The availability of reliable recipient vessels for free flap transfer in head and neck reconstruction may be limited in cases of prior neck dissection or radiation therapy. One solution is to use the internal mammary vessels as recipients for a free omental flap. Five patients were treated with free omental flap transfer using the internal mammary vessels as recipient vessels during head and neck reconstruction. Two patients presented with a pharyngocutaneous fistula, 1 had mandibular osteomyelitis, 1 had primary esophageal cancer, and 1 had bilateral cervical radiation ulcers. All patients had received radiation therapy previously (average dose, 75.4 Gy), and 4 had undergone neck dissection (3 bilateral and 1 ipsilateral). All patients were reconstructed using a free omental flap. Four patients had a second free flap combined with the free omental flap (3 free jejunal flaps and 1 free fibular osteocutaneous flap). The mean follow-up was 26.4 months. All free flaps took entirely, the only complication ileus requiring reoperation in 1 patient. The internal mammary vessels are reliable recipient vessels for a free omental flap in head and neck reconstruction. This procedure is a good option for patients in whom previous surgery or radiation therapy has compromised local recipient vessels.
Collapse
Affiliation(s)
- Shunjiro Yagi
- Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | | | | | | |
Collapse
|
49
|
Hu H, Winters HAH, Paul RMA, Wuisman PIJM. Internal thoracic vessels used as pedicle graft for anastomosis with vascularized bone graft to reconstruct C7-T3 spinal defects: a new technique. Spine (Phila Pa 1976) 2007; 32:601-5. [PMID: 17334297 DOI: 10.1097/01.brs.0000256383.29014.42] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A report of 4 cases of primary bone tumors (3 cases) or infection (1 case) at the cervicothoracic junction treated with resection-reconstruction. OBJECTIVES To document a new technique using the internal thoracic vessels as recipient vessels for reconstruction of the cervicothoracic spine with free vascularized fibula grafts. SUMMARY OF BACKGROUND DATA The cervicothoracic junction is a difficult region in reconstructive spinal surgery. Although nonvascularized fibula grafts can be used to reconstruct the osseous defect, compared with free vascularized fibula grafts they are biomechanical weaker, incorporate less well, are less resistant to infection, and remodel incomplete in time. However, when using free vascularized bone grafts, the selection of suitable recipient vessels remains one of the most critical decisions. MATERIALS AND METHODS Four patients who had a primary tumor (3 cases) or a severe progressive kyphotic deformity and progressive neurologic symptoms due to tuberculosis (1 case) were treated by resection and vascularized reconstruction. In 3 patients, a staged anteroposterior en bloc resection of T1-T3 (2 cases) or T1-T2 (1 case) was performed; the ventral reconstruction of the osseous defect consisted of a vascularized fibula graft interposition between C7-T4 (2 cases) or C7-T3 (1 case). In another case, an axial slot was milled through the T1-T2 vertebral bodies to accept an osteotomized vascularized fibular graft. In all cases, a free vascularized fibula graft was used: the vascular anastomosis was performed between the peroneal and the dissected and rerouted internal thoracic vessels. The anterior construction was strengthened by a ventral plate-screw system. RESULTS The resection-reconstruction procedures, including the dissection, rerouting, and anastomosis between the internal thoracic vessels and the peroneal vessels, were successfully performed. At present, all patients are alive, and there is no evidence of recurrent disease, unchanged, or improved neurologic with a mean follow-up of 28 months. All grafts are well incorporated. CONCLUSIONS.: A combined low anterolateral cervical and midsternal approach or a midline sternotomy allows not only a safe and excellent exposure to the cervicothoracic junction but also to the internal thoracic vessels. The internal thoracic vessels are appropriate donor vessels: its longevity, diameter, length, and rerouting capacity allow vascularized graft reconstruction of vertebral column defects of the low cervical (C6-C7) and/or upper thoracic (T1-T3) region.
Collapse
Affiliation(s)
- Hai Hu
- Department of Orthopaedic Surgery, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | | | | | | |
Collapse
|
50
|
Casey WJ, Rebecca AM, Smith AA, Craft RO, Buchel EW. The cephalic and external jugular veins: Important alternative recipient vessels in left-sided microvascular breast reconstruction. Microsurgery 2007; 27:465-9. [PMID: 17596861 DOI: 10.1002/micr.20388] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The internal mammary and thoracodorsal vessels are the standard recipient sites in microsurgical breast reconstruction. We review our series of venous outflow alternatives when these vessels are inadequate or unusable. MATERIALS AND METHODS A retrospective review of all free breast reconstructions was performed from July 2003 through December 2005. Outcomes were measured with regard to re-exploration, flap failure, and fat necrosis, with attention to the timing and side of reconstruction, as well as the presence or absence of radiation therapy. RESULTS A total of 141 free breast reconstructions were performed during the study period. In seven cases (5%), alternative venous outflow vessels were selected (cephalic or external jugular vein). Nine anastamotic complications occurred, all of which involved the left internal mammary group (statistically significant for venous thrombosis, P = 0.0063) and three flaps failed. All cephalic and external jugular veins remained patent with no flap failures or fat necrosis within this group. CONCLUSION The cephalic vein and external jugular vein are excellent alternatives for venous outflow in free breast reconstruction if neither the internal mammary nor thoracodorsal veins are sufficient, especially in left-sided reconstruction.
Collapse
Affiliation(s)
- William J Casey
- Division of Plastic and Reconstructive Surgery, Mayo Clinic Scottsdale, Scottsdale, AZ 85054, USA.
| | | | | | | | | |
Collapse
|