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Kueckelhaus M. Minimally Invasive Robotic-assisted Perforator-to-Perforator DIEP Flap Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5800. [PMID: 38741600 PMCID: PMC11090619 DOI: 10.1097/gox.0000000000005800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/18/2024] [Indexed: 05/16/2024]
Abstract
Reducing morbidity has been the goal of many reconstructive microsurgery efforts. Several techniques have been described for deep inferior epigastric perforator flap breast reconstruction to minimize abdominal donor-site morbidity. Although these techniques have certain tradeoffs, we designed a minimally invasive robot-assisted perforator-to-perforator approach to achieve minimal donor- and recipient-site morbidity. Simultaneous identification of the deep inferior epigastric artery (DIEA) and internal mammary artery (IMA) perforator was performed, followed by a small fascial incision around the dominant DIEA perforator. The IMA perforator was prepared for a prepectoral anastomosis. The short DIEA pedicle was dissected without further longitudinal fascial incision until an adequate diameter compared with the IMA perforator was reached, and a robot-assisted perforator-to-perforator anastomosis was performed prepectorally. All patients underwent reconstruction performed by a single surgeon. The smallest abdominal incision was 2.5 cm with a DIEP pedicle length of 6 cm. The average IMA perforator diameter was 1.14 mm (1.0 mm-1.2 mm). The average vein diameter was 2.0 mm (1.5-3.0 mm). The incision to closure lasted 330 minutes (313-348 minutes). Flap ischemia was 105 minutes (82-118 minutes), whereas the time for robot-assisted anastomosis was 25 minutes (22-30 minutes). All anastomoses were performed successfully. Our initial experience with robot-assisted perforator-to-perforator anastomosis for DIEP flap breast reconstruction demonstrates promise in achieving minimal patient morbidity. Raising only a very short pedicle can be compensated by adding the prepectoral IMA perforator length and enabling a good size match for small-caliber anastomosis. This technique combines important aspects of most minimally invasive DIEP flap harvests and insets.
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Affiliation(s)
- Maximilian Kueckelhaus
- From the Department of Plastic Surgery, University Hospital Muenster, Muenster, Germany
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, Muenster University, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany
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2
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Vourvachis M, Goodarzi MR, Scaglioni MF, Tartanus J, Jones A, Cheng HT, Abdelrahman M. Utilization of the internal mammary perforators as the recipient vessels for microsurgical breast reconstruction: A systematic review and meta-analysis of the literature. Microsurgery 2024; 44:e31105. [PMID: 37675648 DOI: 10.1002/micr.31105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 07/05/2023] [Accepted: 08/17/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND The selection of reliable recipient vessels is essential for successful free tissue transfer. The use of internal mammary intercostal perforators (IMAPs), instead of the internal mammary vessels as the recipient vessels, has been described in breast reconstruction. Debates exist regarding the reliability of these perforators as recipient vessels because of their variability in location and caliber. The aim of this paper was to conduct a systematic literature review and meta-analysis to determine the reliability of the IMAPs as recipient vessels. METHODS A systematic literature review was performed on the "PubMed," "Medline," "Ovid," and "Cochrane library" databases for articles published from January 1990 to March 2021. Exclusion criteria were non-English studies, reports with case number less than 5, cadaveric or animal studies, and studies with incomplete postoperative outcomes. The reliability of using IMAPs for breast reconstruction was determined by assessing the reported rates of partial or complete flap failure and other complications (fat necrosis, skin necrosis, and requirement for revision surgery). RESULTS Three hundred and sixteen cases in 13 studies were included for further analysis with more than 85% of the IMAPs suitable for anastomosis being located in the second and third intercostal spaces. Partial or total flap failure was reported in three of 316 patients (0.95%). The rate of other complications such as fat necrosis, skin necrosis, and requirement for revision surgery were all less than 5%. CONCLUSION With deliberate preoperative planning, delicate perioperative manipulation, and meticulous microvascular anastomosis, the internal mammary perforators can be used as reliable recipient vessels in microvascular breast reconstruction.
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Affiliation(s)
- Michail Vourvachis
- Department of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Mohammad R Goodarzi
- Department of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Mario F Scaglioni
- Department of Hand and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Justyna Tartanus
- Department of General Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Alex Jones
- Department of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Hsu-Tang Cheng
- Department of Plastic and Reconstructive Surgery, Asia University Hospital, Taichung City, Taiwan
| | - Mohamed Abdelrahman
- Department of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough, UK
- Department of Surgery, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
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3
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Vollbach FH, Neuss C, Siegwart LC, Bigdeli AK, Kneser U, Fansa H, Kotsougiani-Fischer D. The transverse myocutaneous gracilis flap (TMG) for breast reconstruction: ipsi vs. contralateral harvest-aesthetic outcome and refinement procedures. Breast Cancer 2023; 30:845-855. [PMID: 37392247 DOI: 10.1007/s12282-023-01478-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/19/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND The TMG flap is a popular choice for breast reconstruction. However, it remains unclear whether the side of flap harvest, subsequent flap shaping and inset impacts breast appearance and volume dispersion. This study compares the aesthetic outcome of the reconstructed breast following TMG flap harvest from the ipsilateral or contralateral thigh. PATIENT AND METHODS A retrospective matched-pair multi-center study was conducted. Patients were grouped according to the side of flap harvest (ipsilateral vs. contralateral) and matched for age, BMI and mastectomy type. Between 01/2013 and 03/2020, 384 TMG breast reconstructions were performed, of which 86 were included (43 ipsilateral vs. 43 contralateral). Standardized pre- and postoperative photographs were evaluated using a modified assessment scale comprising of a symmetry score (SymS, max. 20 points), a volume discrepancy score (VDS, max. 8 points) and an aesthetic appearance score (AS, max. 10 points). Autologous fat grafting (AFG) procedures for breast refinement were compared. RESULTS Pleasing breast symmetry (SymS Ipsi: 14.5/20; Contra: 14.9/20), volume (VDS Ipsi: 3.3/8; Contra: 2.4/8) and aesthetic appearance (AS Ipsi: 6.7/10; Contra: 6.7/10) were achieved with both surgical methods. No significant changes were present regarding the VDS (F(1.82) = 2.848, p = 0.095) or the SymS (F(1.82) = 1.031, p = 0.313) pre- to postoperatively. Significantly more autologous fat grafting was done in the contralateral group (p < 0.001). CONCLUSION The side of the TMG flap harvest, different shaping and inset techniques do not impact the aesthetic breast outcome. Both surgical methods result in pleasing breast symmetry and volume. Secondary procedures are common and should be entailed in the reconstructive strategy.
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Affiliation(s)
- Felix H Vollbach
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany.
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, University of Heidelberg, Im Neuenheimer Feld 672, 69120, Heidelberg, Germany.
| | - Clara Neuss
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, University of Heidelberg, Im Neuenheimer Feld 672, 69120, Heidelberg, Germany
| | - Laura C Siegwart
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, University of Heidelberg, Im Neuenheimer Feld 672, 69120, Heidelberg, Germany
| | - Amir K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, University of Heidelberg, Im Neuenheimer Feld 672, 69120, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, University of Heidelberg, Im Neuenheimer Feld 672, 69120, Heidelberg, Germany
| | - Hisham Fansa
- Department of Plastic Surgery and Breast Center, Spital Zollikerberg, Zollikerberg, 8125, Zurich, Switzerland
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Klinikum Bielefeld, OWL-University, 33604, Bielefeld, Germany
| | - Dimitra Kotsougiani-Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, University of Heidelberg, Im Neuenheimer Feld 672, 69120, Heidelberg, Germany
- Private Practice for Plastic and Aesthetic Surgery, AESTHETIKON Heidelberg and Mannheim, L9, 8, 68161, Mannheim, Germany
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4
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Fernandez-Diaz OF, Christopoulos G, Griffiths M. A Systematic Review and Meta-analysis of Clinical Outcomes in Autologous Breast Reconstruction Using Internal Mammary Artery Perforators as Recipient Vessels. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4969. [PMID: 37207242 PMCID: PMC10191480 DOI: 10.1097/gox.0000000000004969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 03/13/2023] [Indexed: 05/21/2023]
Abstract
Recipient vessel selection is vital for successful autologous free-flap breast reconstruction. Internal mammary artery perforators have gained interest as a recipient vessel option. However, previous studies on their microsurgical safety and efficacy are limited and inconsistent. Thus, we conducted a systematic review and meta-analysis to assess the safety and effectiveness of using internal mammary artery perforators as recipient vessels in breast reconstruction. Methods The protocol has been previously published in PROSPERO (CRD42020190020). The PubMed, Scopus, Web of Science, and PROSPERO databases were searched. Two independent reviewers evaluated the articles for inclusion in the study. Study quality was assessed using the Newcastle-Ottawa Scale and the MINORS instrument (Methodological Index for Non-Randomized Studies). Results Of the 361 articles screened, 13 studies were included (313 patients with 318 flaps; 223 unilateral, 31 bilateral, mean average age 51.2 and mean BMI 27.8 ± 1.9). The mean overall success rate was 99.8%, the pooled surgical success rate was 100% [95% confidence interval (CI): 97%-100%], and the overall rate of complications was 11% (95% CI: 7%-18%). The most common complication was vascular-related to microanastomoses, with an incidence of 5% (95% CI: 2%-10%). The fat necrosis rate was 3% (95% CI: 2%-6%). Conclusions This study verified that internal mammary artery perforator vessels are reliable in breast reconstruction, with a high success rate and a relatively low complication rate. Moreover, in selected microsurgical breast reconstruction patients, internal mammary artery perforators may be the primary recipient vessel choice over the internal mammary artery or thoracodorsal vessels.
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Affiliation(s)
- Oscar F. Fernandez-Diaz
- From the St. Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, UK
- Group for Academic Plastic Surgery, Blizard Institute, Queen Mary University of London, London, UK
| | - Georgios Christopoulos
- Group for Academic Plastic Surgery, Blizard Institute, Queen Mary University of London, London, UK
- Department of Plastic Surgery, Queen Victoria Hospital, East Grinstead, West Sussex, UK
| | - Matthew Griffiths
- From the St. Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, UK
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5
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Bigdeli AK, Momeni A, Kneser U. [Increasing Safety in Microsurgical Breast Reconstruction - Technique and Technology]. HANDCHIR MIKROCHIR P 2022; 54:314-325. [PMID: 35785806 DOI: 10.1055/a-1858-5214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Microsurgical reconstruction has established itself as a standard procedure in breast reconstruction as it permits creation of a natural and aesthetically appealing breast mound, even after modified radical mastectomy and radiation. In the past few decades numerous new free flap donor-sites have been described that permit an individualized approach to reconstruction, thus, resulting in a high level of patient satisfaction. Paralleling these technical innovations, the focus of microsurgical breast reconstruction has shifted from mere "flap success" to "aesthetic outcome", while also taking into account the respective donor-site morbidity. Here, the authors discuss contemporary developments in the field with a particular focus on surgical techniques and technologies that contribute to increasing the safety of microsurgical breast reconstruction.
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Affiliation(s)
- Amir Khosrow Bigdeli
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie - Schwerbrandverletztenzentrum BG Klinik Ludwigshafen, Ludwigshafen, Germany.,Klinik für Hand- und Plastische Chirurgie der Ruprecht-Karls-Universität Heidelberg Heidelberg, Heidelberg, Germany
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Ulrich Kneser
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie - Schwerbrandverletztenzentrum BG Klinik Ludwigshafen, Ludwigshafen, Germany.,Klinik für Hand- und Plastische Chirurgie der Ruprecht-Karls-Universität Heidelberg Heidelberg, Heidelberg, Germany
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6
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Linder S, Walle L, Loucas M, Loucas R, Frerichs O, Fansa H. Enhanced Recovery after Surgery (ERAS) in DIEP-Flap Breast Reconstructions-A Comparison of Two Reconstructive Centers with and without ERAS-Protocol. J Pers Med 2022; 12:jpm12030347. [PMID: 35330347 PMCID: PMC8954560 DOI: 10.3390/jpm12030347] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 12/04/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) is established for autologous breast reconstruction. ERAS leads to a shortened hospital stay and improved outcome after elective surgery. In this retrospective, two-center case−control study, we compared two different treatment regimens for patients undergoing a DIEP-flap breast reconstruction from two centers, one with an established ERAS protocol and one without. All patients with DIEP breast reconstructions over the period of 12 months were included. The primary outcome measure was the length of hospital stay (LOS) in days. A total of 79 patients with 95 DIEP-flaps were analyzed. In group A (ERAS) 42 patients were operated with DIEP flaps, in group B (non-ERAS) 37 patients. LOS was significantly reduced in the ERAS group (4.51 days) compared to the non-ERAS group (6.32; p < 0.001). Multivariate analysis showed that, in group A, LOS is significantly affected by surgery duration. BMI in the ERAS group had no effect on LOS. In group B a higher BMI resulted in a significantly higher LOS. In multivariate analysis, neither age nor type for surgery (primary/secondary/after neoadjuvant therapy, etc.) affected LOS. In both groups, no systemic or flap-related complications were observed. Comparing two reconstructive centers with and without implemented ERAS, ERAS led to a significantly decreased LOS for all patients. ERAS implementation does not result in an increased complication rate or flap loss. Postoperative pain can be well managed with basic analgesia using NSAID when intraoperative blocks are applied. The reduced use of opioids was well tolerated. With implementation of ERAS the recovery experience can be enhanced making autologous breast reconstructions more available and attractive for various patients.
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Affiliation(s)
- Sora Linder
- Department of Plastic Surgery and Breast Center, Spital Zollikerberg, 8125 Zollikerberg, Switzerland; (S.L.); (M.L.); (R.L.)
| | - Leonard Walle
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Hand Surgery, Klinikum Bielefeld, OWL-University, 33604 Bielefeld, Germany; (L.W.); (O.F.)
| | - Marios Loucas
- Department of Plastic Surgery and Breast Center, Spital Zollikerberg, 8125 Zollikerberg, Switzerland; (S.L.); (M.L.); (R.L.)
| | - Rafael Loucas
- Department of Plastic Surgery and Breast Center, Spital Zollikerberg, 8125 Zollikerberg, Switzerland; (S.L.); (M.L.); (R.L.)
| | - Onno Frerichs
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Hand Surgery, Klinikum Bielefeld, OWL-University, 33604 Bielefeld, Germany; (L.W.); (O.F.)
| | - Hisham Fansa
- Department of Plastic Surgery and Breast Center, Spital Zollikerberg, 8125 Zollikerberg, Switzerland; (S.L.); (M.L.); (R.L.)
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Hand Surgery, Klinikum Bielefeld, OWL-University, 33604 Bielefeld, Germany; (L.W.); (O.F.)
- Correspondence:
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7
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Vollbach FH, Thomas BF, Fansa H. Identification of Independent Risk Factors for Skin Complications in a Multifactorial Logistic Regression Analysis of Simultaneous Immediate Autologous Breast Reconstruction and Skin Reduction Mastectomy in Large and Ptotic Breasts Using an Inferiorly Based Deepithelialized Dermal Breast Flap. J Pers Med 2022; 12:jpm12030332. [PMID: 35330332 PMCID: PMC8951157 DOI: 10.3390/jpm12030332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 02/05/2023] Open
Abstract
Autologous immediate breast reconstruction in large and ptotic breasts remains challenging. We aimed to identify independent risk factors for impaired wound healing and nipple necrosis after skin reducing wise pattern mastectomy in autologous reconstruction with an auxiliary deepithelialized inferiorly based dermal flap (IBDF). Methods. This retrospective study examined patients with wise pattern mastectomy with autologous immediate breast reconstruction (IBR) between 2017 and 2019. All cases of large and ptotic breasts were included. Demographic, oncologic, reconstructive, and surgical data were compiled, and multifactorial binary logistic regression models identified independent predictors for skin complications and nipple areolar complex (NAC) necrosis. Results. Of 591 autologous breast reconstructions, 62 (11%) met the inclusion criteria. Overall wound complication rate was 32% (n = 20, DIEP 11, thigh 9, p = 0.99), including 26% minor (n = 16, non-surgically treated) and 7% major complications (n = 4, surgically treated). Complete NAC necrosis occurred in one case. Nipple sparing mastectomy (NSM) (p = 0.003), high BMI (p = 0.019), longer operation time (p = 0.044) and higher patient age (p = 0.045) were independent risk factors for skin complications. Using internal mammary artery perforators (IMAP) as recipient vessels did not result in increased complication rates (p = 0.59). Conclusion. Higher patient age, BMI, and operation time (OT) significantly increase the risk for skin complications in combined reduction wise pattern mastectomies with autologous IBR. In this context, IBDFs help preserve the inframammary fold, providing vasculature to the T-junction and the mastectomy skin flaps. Acceptable complication rates can be achieved in large and ptotic breasts, regardless of preoperative chemotherapy or radiation. Gentle tissue handling with minimal thermal trauma preserves internal mammary artery perforators (IMAPs) as recipient vessels. In cases of flap failure and alloplastic conversion, the IBDF can serve as an autoderm, protecting the implant from exposure
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Affiliation(s)
- Felix H. Vollbach
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany; (F.H.V.); (B.F.T.)
- Department of Hand and Plastic Surgery, University of Heidelberg, 69117 Heidelberg, Germany
| | - Benjamin F. Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany; (F.H.V.); (B.F.T.)
- Department of Hand and Plastic Surgery, University of Heidelberg, 69117 Heidelberg, Germany
| | - Hisham Fansa
- Department of Plastic Surgery and Breast Center, Spital Zollikerberg, 8125 Zollikerberg, Switzerland
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Hand Surgery, Klinikum Bielefeld, OWL-University, 33604 Bielefeld, Germany
- Correspondence:
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8
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Scaglioni MF, Meroni M, Fritsche E. Free tissue transfer with supermicrosurgical perforator-to-perforator (P-to-P) technique for tissue defect reconstruction around the body: Technical pearls and clinical experience. J Plast Reconstr Aesthet Surg 2020; 74:1791-1800. [PMID: 33388271 DOI: 10.1016/j.bjps.2020.12.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 11/06/2020] [Accepted: 12/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Resorting to perforators as recipient vessels is a valid alternative that might offer a series of advantages in many situations. They allow the use of a shorter pedicle, reduce the time of dissection, and are a good solution when deep vessels are difficult to reach. The aim of this study is to investigate the efficacy of P-to-P tissue transfer for reconstructing defects in different areas of the body. PATIENTS AND METHODS Between April 2018 and February 2020, 40 patients presenting soft tissue defects were reconstructed by using P-to-P-anastomosed free flap transfer. The cause of the defect was trauma in 16 cases and surgically excised tumor in 24. Five defects were located in the upper extremities, 1 in the neck, 1 in the thorax, and 21 in the lower limb, and 13 cases were breast reconstructions, 2 of which bilateral (43 total flaps). RESULTS Of all 43 flaps, 22 were abdominal flaps, 17 flaps were harvested from the upper thigh, and 4 were harvested from the lower leg. At the 9 month follow-up, 42 flaps were successfully healed, 36 without complications, 3 after wound dehiscence, and 3 after wound infection, and only 1 flap was lost requiring further surgery. Flap failure rate was 2.3%. CONCLUSIONS Free flaps anastomosed in perforator-to-perforator fashion can be safely used in different settings throughout the body. Even if they are technically more demanding, they may allow a quicker operation time and lower morbidity. With the developments in microsurgical instruments, we believe that this technique may become the gold standard for tissue-defect reconstruction.
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Affiliation(s)
- Mario F Scaglioni
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland.
| | - Matteo Meroni
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Elmar Fritsche
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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9
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Scaglioni MF, Meroni M, Fritsche E, Rajan G. Internal mammary artery perforators as recipient vessels for free tissue transfer in head and neck reconstruction: A case report and literature review. Microsurgery 2020; 41:355-360. [PMID: 33159486 DOI: 10.1002/micr.30680] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/29/2020] [Accepted: 10/23/2020] [Indexed: 11/12/2022]
Abstract
Head and neck defect reconstruction is a common challenge for plastic surgeons. Microsurgical free tissue transfer is a frequently used solution but its success strictly depends on the quality of recipient vessels. A particularly demanding situation occurs when there are no nearby available vessels because of previous extensive neck dissection and radiotherapy. In similar cases, it is necessary to resort to other and farther vessels. Common alternatives might be the thoraco-acromial vessels, the transverse cervical vessels, and the internal mammary vessel. Recently, the perforator vessels of the internal mammary artery and vein were shown to be safe alternatives as recipient vessels for autologous breast reconstruction, causing less morbidity and allowing adequate perfusion of rather large flaps. Here we present a floor of the mouth reconstruction after cancer relapse resection. In this case, we employed a chimeric anterolateral thigh (ALT) free flap anastomosed to the internal mammary perforator vessels in end-to-end fashion. A 46-years-old male patient presented a defect in the floor of the mouth and base of the tongue after cancer removal. No nearby vessels were available because of extensive fibrosis and damages due to previous surgeries and radiotherapy. Therefore, on the basis of our experience in autologous breast reconstruction, we chose the internal mammary perforator vessels in the recipient side and we harvested a chimeric ALT-based skin island then split into two parts for mouth reconstruction and monitoring. We performed the anastomosis resorting to internal mammary perforator vessels and we obtained a satisfactory result from both the functional and aesthetic point of view. Postoperative course was uneventful and at 6 months follow up the reconstructive result was good with no functional issue. We believe that this might be a valid and modern evolution of the use of internal mammary vessels as recipient vessels and that it is a worthy addition in the field of perforator-anastomosed flaps, extending its application also to head and neck reconstructions. Moreover, a brief literature review about alternative recipient vessels for depleted neck is also provided.
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Affiliation(s)
- Mario F Scaglioni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matteo Meroni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Elmar Fritsche
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Gunesh Rajan
- Department of Otolaryngology, Head & Neck Surgery, Luzerner Kantonsspital, Lucerne, Switzerland.,Otolaryngology, Head & Neck Surgery, Medical School, University of Western Australia, Perth, Australia
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10
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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.
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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
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11
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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.
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12
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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.
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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
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13
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Yang L, Long J, Li Z, Zhou X, Peng X, Song D, Zhou B, Lv C, Wu P. The lateral thoracic vessels: A novel recipient site for breast reconstruction with DIEP flap. J Plast Reconstr Aesthet Surg 2019; 72:1530-1536. [DOI: 10.1016/j.bjps.2019.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 11/16/2022]
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14
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Internal Mammary Artery and Vein Perforator Vessels as Troubleshooter Recipient Vessels. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2148. [PMID: 31044119 PMCID: PMC6467637 DOI: 10.1097/gox.0000000000002148] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 12/18/2018] [Indexed: 12/03/2022]
Abstract
In autologous breast reconstruction, the internal mammary artery (IMA) and internal mammary vein (IMV) are the standard recipient vessels. Recently, the perforator vessels of the IMA and IMV were found to be a safe alternative as recipient vessels cause less morbidity and allow adequate flap. We describe 2 cases in which the IMA and IMV perforators were used as additional recipient vessels to overcome intraoperatively occurred complications. The IMA and IMV perforators have some advantages over the IMA/IMV: (1) the dissection is done superficially and directly from the mastectomy site. Flap positioning is facilitated. (2) There is no need to remove a rib, which reduces postoperative pain and possible contour deformities. (3) Possible injuries to the pleura are avoided. (4) The IMA is spared for possible cardiac revascularization. Disadvantages can be that (1) the IMA perforators are not always present with the required caliber, (2) the position of the perforators is not suitable to adequately position the flap, and (3) dissection of the IMA perforators and their anastomoses has a learning curve. In the presented cases, the IMA and IMV perforators have proven to offer a simple solution to avoid complications. The additional dissection is done from the same recipient site, and there is no further dissection or incision necessary at the axilla or to explore the cephalic vein. This keeps morbidity and operation time low. Therefore, we suggest keeping the IMA and IMV perforators in mind not only as primary recipient vessels but also as a possible solution for intraoperatively occurred complications.
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15
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Shin D, Sung KW, Fan KL, Park TH, Song SY, Roh TS, Lew DH, Lee DW. Expanding the use of internal mammary artery perforators as a recipient vessel in free tissue transfer: An anatomical analysis by computed tomography angiography in breast cancer patients. Microsurgery 2019; 39:509-514. [PMID: 30830973 DOI: 10.1002/micr.30446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 01/25/2019] [Accepted: 02/22/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND The internal mammary artery (IMA) perforator has assumed recent prominence as recipient vessels in free autologous breast reconstruction. However, anatomical understanding is unclear, due to limited cadaver and clinical studies. We evaluated the usability of these vessels by evaluating perforator size, dominance, laterality, interspace location, and relationship with breast volume. METHODS A retrospective review assessed 197 female patients with breast cancer who had undergone computed tomography angiography (CTA) of the chest wall. The average age and body mass index (BMI) of patients was 49.0 ± 6.5 years and 24.2 ± 5 .8 kg/m2 , respectively. The average volume of breasts was 437 ± 190 mL. Our analysis focused on the anatomy of IMA perforator and its relationship to volume and BMI. RESULTS A total of 377 hemi-chest evaluations were performed. Most patients (95.5%) had sizeable perforating artery identified on CTA. Among all sizeable perforators identified, the mean diameter of the most dominant arterial perforator was 1.8 ± 0 .8 mm. The right hemi-chest had significantly larger perforators than the left (1.9 ± 0 .9 mm vs. 1.7 ± 0 .7 mm, p = 0.002). The first intercostal space (ICS) had a slightly greater of perforators than second ICS (34.6% vs. 29.8%, p = 0.172). However, second ICS had a greater number of most dominant perforators compared to first ICS (38.9% vs. 34.7%, p = 0.357). Perforators from first ICS emerge medial to the sternal edge and breast footprint. When dividing groups with 0-1 versus 2-3 reliable perforators, breast volume was significantly higher in the later (422.0 mL vs. 461.2 mL, p = 0.019). CONCLUSION These results are expected to encourage microsurgeons to use the IMA perforator by providing a clear anatomical roadmap.
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Affiliation(s)
- Dongwoo Shin
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Ki Wook Sung
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Tae Hwan Park
- Department of Plastic and Reconstructive Surgery, Bundang CHA Medical Center, Seongnam, Gyeonggi-do, South Korea
| | - Seung Yong Song
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Tai Suk Roh
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Dae Hyun Lew
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Won Lee
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
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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.
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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
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