Abstract
BackgroundMastectomies are one of the most common surgical procedures in women of the developed world. The gracilis myocutaneous flap is favoured by many reconstructive surgeons due to the donor site profile and speed of dissection. The distal component of the longitudinal skin paddle of the gracilis myocutaneous flap is unreliable. This study quantifies the fasciocutaneous vascular territories of the gracilis flap and offers the potential to reconstruct breasts of all sizes.MethodsTwenty-seven human cadaver dissections were performed and injected using lead oxide into the gracilis vascular pedicles, followed by radiographic studies to identify the muscular and fasciocutaneous perforator patterns. The vascular territories and choke zones were characterized quantitatively using the ‘Lymphatic Vessel Analysis Protocol’ (LVAP) plug-in for Image J® software.ResultsWe found a step-wise decrease in the average vessel density from the upper to middle and lower thirds of both the gracilis muscle and the overlying skin paddle with a significantly higher average vessel density in the skin compared to the muscle. The average vessel width was greater in the muscle. Distal to the main pedicle, there were either one (7/27 cases), two (14/27 cases) or three (6/27 cases) minor pedicles. The gracilis angiosome was T-shaped and the maximum cutaneous vascular territory for the main and first minor pedicle was 35×19 cm and 34×10 cm, respectively.ConclusionOur findings support the concept that small volume breast reconstructions can be performed on suitable patients, based on septocutaneous perforators from the minor pedicle without the need to harvest any muscle, further reducing donor site morbidity. For large reconstructions, if a ‘T’ or tri-lobed flap with an extended vertical component is needed, it is important to establish if three territories are present. Flap reliability and size may be optimized following computed tomographic angiography and surgical delay.
Highlights
Breast cancer is the leading cause of cancer death in females worldwide [1,2,3], accounting for 23% (1.38 million) of the total new cancer cases and 14% (458,400) of the total cancer deaths in 2008 [4]
Musculocutaneous perforators were more numerous than their septocutaneous counterpart (85 vs. 27), in the proximal third of the muscle in close proximity to the area where the main pedicle entered the gracilis
The majority (20/27) septocutaneous perforators were measured at 1 mm in diameter, whereas all musculocutaneous perforators were found to be less than this diameter (Table 3). 17 of these vessels branched directly from the first minor pedicle
Summary
Breast cancer is the leading cause of cancer death in females worldwide [1,2,3], accounting for 23% (1.38 million) of the total new cancer cases and 14% (458,400) of the total cancer deaths in 2008 [4]. In 2010, 61?5 mastectomies were performed per 100,000 people in the developed world (OECD), making it one of the most common contemporary surgical procedures [2]. In 2009, over 86,000 breast reconstructions were performed in the United States alone, a statistic which is increasing [7]. The American Society of Plastic Surgeons (ASPS) procedural statistics in 2010 show that implant based breast reconstruction remains the most practiced form of breast reconstruction in the United States (77%), this statistic is felt to be changing [8,9], as the relative increase in cost is worthwhile when considering reported superior outcomes and patient satisfaction [9,10]. Mastectomies are one of the most common surgical procedures in women of the developed world. This study quantifies the fasciocutaneous vascular territories of the gracilis flap and offers the potential to reconstruct breasts of all sizes
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