Inferior Epigastric Research Articles

Microsurgical phalloplasty: Anatomical study evaluating the use of the external pudendal vessels as recipients.

The inferior epigastric artery (IEA) is commonly used as a recipient vessel in microsurgical phalloplasty but its use can be associated with abdominal parietal complications (hernia, bulging). To preclude such complications and avoid involvement of the femoral artery, we assessed an external pudendal artery (EPA) as a recipient vessel. We studied the disposition of the external pudendal system and its general anatomy. Then we compared the external diameter of the EPA to that of the first branches of the femoral artery. The most important point was to determine the location of the EPA through a reference line to facilitate a surgical approach. We then illustrated this preliminary study with a clinical case to check the reliability of the identified landmarks. Ten adult cadavers were dissected. The arteries of interest were part of a system consisting of either a common trunk or a duplicated system. The branches of the pudendal system arose from either the femoral artery or the deep femoral artery. On a horizontal reference line passing through the two pubic tubercles, we observed that 83% of EPAs arose between the reference line and 3cm below it, at the level of a vertical axis centered on the femoral artery. The EPA could be suitable as recipient vessel in phalloplasty owing to its location, size, and ease of dissection. Using it instead of the IEA precludes abdominal parietal complications and reduces scarring in the recipient area.

Umbilical cord vessels other than the umbilical arteries and vein: a histological study of midterm human fetuses.

At birth, the umbilical cord contains various types of thin vessels that are near and outside the umbilicus and separate from the umbilical arteries and vein. These vessels are regarded as the remnant "vitelline vessels" and are often called "umbilical vessels", although this terminology could lead to confusion with the true umbilical arteries and vein. No study has yet comprehensively examined these vessels using histological sections. Our examination of these vessels in 25 midterm fetuses (gestational age: 10-16 weeks) led to five major findings: (i) all specimens had umbilical branches of the inferior epigastric artery; (ii) 5 specimens had vitelline vein remnants; (iii) 4 specimens had a thin artery originating from the left hepatic artery that ran along the umbilical vein; (iv) 2 specimens had a so-called "para-umbilical vein" that was along the umbilical vein and reached the umbilicus; and (v) all specimens had lymphatic vessels originating from the umbilicus that ran caudally along the umbilical artery. The pelvic vein tributaries were well developed along the intra-abdominal umbilical artery, but did not reach the umbilicus. The lymphatic vessel was distinguished from the veins by an intraluminar cluster of lymphocytes attaching to the endothelium. The arterial branch in the umbilical cord did not accompany veins and lymphatic vessels, in contrast to the mother artery in the rectus abdominis. All these thin vessels seemed to be obliterated when the fibrous umbilical ring grew during late-term. The para-umbilical collateral vein in adults might develop outside the fibrous umbilical ring after birth.

Surgeon-conducted color Doppler ultrasound deep inferior epigastric artery perforator mapping: A cohort study and learning curve assessment

Perforator mapping using diagnostic methods facilitates deep inferior epigastric perforator (DIEP) flap planning. Computed tomographic angiography (CTA) is a well-proven tool for perforator mapping. However, the benefits of color Doppler ultrasonography (CDU) are as follows: 1) CDU involves dynamic real-time examination and 2) does not use radiation. Comparing the accuracies of both methods in a cohort of patients, this study aimed to evaluate the learning curve of surgeon-conducted CDU perforator mapping. Twenty patients undergoing DIEP flap breast reconstruction were enrolled in a cohort study. All patients underwent CTA perforator mapping preoperatively. XY coordinates of significant perforators were subtracted by a radiologist. A single surgeon (sonographer) with minimal experience with CDU performed CDU perforator mapping, including XY coordinates subtraction. The sonographer was blinded to the CTA data. The reference coordinates of dissected perforators were measured during surgery. Deviations from reference coordinates for both methods were compared, and CDU mapping learning curve was assessed using Joinpoint Regression. We included 20 women (32 DIEP flaps and 59 dissected perforators). The mean deviation between mapped and reference coordinates was 1.00 (0.50-1.12) cm for CDU and 0.71 (0.50-1.12) cm for CTA. The learning curve of CDU mapping showed the breaking point after the seventh patient (≈ 21 localized perforators). After the breaking point, no significant differences between the deviations of both methods were found (p=0.980). A limited number of examinations were needed for the surgeon to learn CDU DIEA perforator mapping with accuracy similar to that of CTA mapping.

Anatomical study of the origin of obturator artery in Indian cadavers

Obturator artery (OA) originates from the anterior division of the internal iliac artery (IIA) and gives various branches to the pelvic cavity, medial compartment of the thigh, and hip joint. Studies in literature illustrate variable origin from the posterior division of the IIA, external iliac artery (EIA), or the branches of both the IIA and EIA. Understanding the pelvic vascular anatomy pertaining to the OA is crucial in averting the risk of its injury in pelvic surgeries. Present study reports on the variant anatomy of the origin of the OA in the Indian population. The study included 61 specimens from 25 formalin-embalmed cadavers (male-19, female-6) and 11 hemipelvis (male-9, female-2) utilized for undergraduate teaching in the Department of Anatomy. After dissecting the peritoneum and mobilizing the pelvic organs, the origin of OA was examined for variations. The OA originated from the IIA in 83.61%. It was a branch from the anterior division of the IIA in 65.58% and the posterior division in 18.03%. OA was also given off at the site of the bifurcation of IIA into anterior and posterior divisions in 3.28%, from EIA in 4.92%, from an inferior epigastric artery (IEA) in 8.2%, and from the inferior gluteal artery and umbilical artery in 1.64% each. This study recognizes the variant anatomy of the origin of the OA. Anticipating these variations will be valuable in pelvic surgeries and laparoscopic procedures such as herniorrhaphy to avoid any untoward traumatic haemorrhage.

Implementation of closed incision negative pressure therapy in Enhanced Recovery After Surgery for immediate breast reconstruction with deep inferior epigastric artery perforator flap

Objectives: To compare the number of abdominal dehiscences in patients undergoing immediate breast reconstruction with Deep Inferior Epigastric artery Perforator flap (DIEP) before and after implementation of the Enhanced Recovery After Surgery (ERAS) protocol that adds postoperative Closed Incision Negative Pressure Therapy (ciNPT) to conventional abdominal binder compression therapy.

An Algorithmic Approach to Umbilical Inset during DIEP Flap Reconstruction.

An aesthetically pleasing umbilicus is a critical component to the overall cosmesis and resultant patient satisfaction after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Because of variables in body habitus, comorbidities, and technical aspects of the procedure, patients undergoing DIEP flap breast reconstruction are at a higher risk of umbilical complications and poor aesthetic appearance of the neoumbilicus compared with those undergoing cosmetic abdominoplasty. To minimize these potential problems and maximize the overall aesthetic appearance of the abdomen, the authors propose an algorithmic approach to umbilical inset after DIEP flap harvest that takes into account several critical factors: the thickness of the subcutaneous tissue of the abdominal flap, the length of the umbilical stalk, and the depth of the umbilical bowl. This simple algorithmic approach is a useful tool that will assist surgeons in minimizing umbilical complications and delivering a superior cosmetic appearance to the abdominal donor site in DIEP flap reconstruction.

Strategies for selecting perforator vessels for transverse and oblique DIEP flap in male pediatric patients: Anatomical study and clinical applications.

BackgroundTransverse and oblique deep inferior epigastric artery perforator (DIEP) flaps are widely used in breast, lower extremity, urogenital, head and neck reconstruction. In this report, we present our experience with selecting perforator vessels for transverse and oblique DIEP flaps based on an anatomical study and clinical cases.Materials and methodsA detailed anatomical study of the DIEP flap was carried out using a standardized injection of lead oxide in 10 fresh cadavers. Additionally, 35 male pediatric patients (age 5–12 years) underwent lower extremity reconstruction with a DIEP flap. A transverse DIEP flap was used when the defect template did not exceed zone IV, while an oblique DIEP flap was used when the defect template exceeded zone IV.ResultsPerforators located below the umbilicus in zones I and II were rich in transverse anastomoses across the midline of the abdominal wall, which is the basis for the transverse DIEP flap. Perforators lateral to the umbilicus in zone I had true anastomoses with the musculophrenic artery, the morphological basis for the oblique DIEP flap. The DIEP flap design was transverse in 20 patients and oblique in 15. Flap sizes ranged from 8 × 4.5 cm2 to 24 × 9 cm2. One oblique DIEP flap was necrosed totally, and it was repaired by a latissimus dorsi musculocutaneous flap.ConclusionThe transverse DIEP flap design based on the perforator located below the umbilicus in zone I is recommended for small skin and soft tissue defects. We recommend the use of the oblique DIEP flap design based on the perforator lateral to the umbilicus in zone I as an extended flap to reconstruct large tissue defects.

Patient Reported Outcome and Quality of Life After Delayed Breast Reconstruction - An RCT Comparing Different Reconstructive Methods in Radiated and Non-radiated Patients

BackgroundHealth-related quality of life (HRQoL) is one of the core outcomes for breast reconstruction. The aim of this study was to evaluate whether the method of delayed breast reconstruction affects long-term HRQoL. MethodsParticipants were divided into 2 arms depending on previous radiotherapy, and subsequently randomized between 2 methods of breast reconstruction: a latissimus dorsi flap or a deep inferior epigastric artery perforator flap in the radiated arm and a thoracodorsal flap and implant or an expander in the non-radiated arm. Validated HRQoL instruments were used: BREAST-Q to evaluate breast specific HRQoL and satisfaction, RAND-36 and EQ-5D to evaluate generic HRQoL, and BDI-21 to measure symptoms of depression and anxiety. ResultsDuring the recruitment period (2009-2015), 233 patients were randomized. After opt-outs and exclusions, the remaining 107 participants comprise the study sample. Postoperative HrQoL was measured on average 7to 8years post-operatively. Response rates varied between 60 and 82 per cent. The BREAST-Q scores were higher after the reconstruction than before for the great majority of domains in both arms; albeit statistically significant only between the 2 methods for physical well-being chest in the radiated arm. Most participants in both arms had minimal or mild depression both before and after the operation. ConclusionNo distinct differences in long-term HrQoL could be seen for different methods There was a clear improvement in HrQoL compared to pre-reconstruction in all groups, but the effect of specific reconstructive methods on scores could not be reliably demonstrated.

Component Separation Reduces Donor-Site Morbidity in High-Risk Patients Undergoing Abdominally Based Breast Reconstruction.

Donor-site morbidity has been a key driver in the evolution of abdominally based breast reconstruction, resulting in the now widespread use of the deep inferior epigastric artery perforator flap. At the donor site, plastic surgeons have applied principles of abdominal wall reconstruction, including underlay subfascial or submuscular mesh placement with primary fascial closure, due to fundamental similarities between donor site and laparotomy defects. One core technique of abdominal wall reconstruction that has not been previously described in abdominally based breast reconstruction is component separation. As with patients undergoing laparotomy, some patients undergoing abdominally based breast reconstruction are predisposed to develop a bulge or hernia as a result of both patient factors (e.g., obesity) and surgical factors (e.g., perforator anatomy), even when there is no fascial defect, making component separation a logical consideration in these patients.1 We hypothesized that component separation may reduce donor-site morbidity in abdominally based breast reconstruction, particularly in patients with risk factors for donor-site complications. In 2016, the senior author (A.H.C.) began performing anterior component separation in select patients with obesity (body mass index > 30.0) undergoing abdominally based breast reconstruction. The rationale for this application was the fact that obesity is one of the most well-established risk factors for the development of a ventral hernia in laparotomy patients, and its incidence continues to rise in the United States.2,3 In this institutionally approved study, we compared this cohort of patients (2016 to 2021) with a matched historical cohort of obese patients who underwent abdominally based breast reconstruction without component separation (2011 to 2016 control group) by a single surgeon, all with a minimum of 6 months of follow-up. A total of 226 patients met inclusion criteria, with 124 patients in the 2016 to 2021 group and 102 patients in the 2011 to 2016 control group. There were no significant differences in preoperative or surgical characteristics. The average body mass index of the 2016 to 2021 group was 39.8 ± 7.2, compared to 38.4 ± 6.5 in the 2011 to 2016 control group (p = 0.85). The overall donor-site complication rate was 21.2 percent. The rates of use of mesh for donor-site closure were similar (p = 0.10). Patients who underwent component separation, however, were more likely to be able to undergo primary fascial closure than those who did not (98.4 percent versus 83.3 percent, respectively; p = 0.0001). Patients who underwent component separation experienced a similar rate of overall donor-site complications than those who did not, but they experienced a lower incidence of abdominal bulge (0.8 percent versus 9.8 percent, respectively; p = 0.003) and wound dehiscence (8.1 percent versus 17.6 percent, respectively; p = 0.04). Our results suggest that the use of component separation can reduce donor-site morbidity in high-risk patients undergoing abdominally based breast reconstruction, possibly by facilitating the ability to achieve primary fascial closure. This finding is consistent with prior descriptions of component separation used for closure of vertical rectus abdominis myocutaneous flap donor sites in pelvic reconstruction.4 Borrowing from the principles of abdominal wall reconstruction, the select use of component separation may further optimize outcomes in patients undergoing abdominally based breast reconstruction and it is a technique that can be readily performed with the exposure provided in abdominally based breast reconstruction. Further study is needed to better define the use of component separation in this patient population.

242.12: The Outcome of the Inferior Epigastric Artery as a Donor Vessel for Managing Accessory Renal Arteries in Renal Transplantation: A Systematic Review and Meta-Analysis

Background: Utilisation of renal allografts with multiple renal arteries (MRA) has always been considered a technical challenge during implantation of renal allografts. There is sparse literature comparing the implantation technique of MRA and allograft outcomes. The aim of this study was to perform systematic review and meta-analysis of literature comparing inferior epigastric artery (IEA) to other surgical anastomosis techniques in renal allografts with MRA. Methodology: The database MEDLINE was searched via PubMed, EMBASE, The Cochrane Library. Grey literature search was utilised including GoogleScholar. We appraised the studies using Keywords and MeSH were utilised, including: “epigastric artery” AND “kidney transplant”. The studies were appraised using Newcastle-Ottawa scale and meta-analysed using random-effects model. Results: A total of eight studies met the inclusion and exclusion criteria for analysis. Five studies were included in the quantitative analysis. Majority of the studies were poor (n=4) or fair (n=4). There were a total of n=846 patients in the studies, with n=161(19.0%) undergoing inferior epigastric artery anastomosis. Other anastomosis techniques consisted of: side-to-side with single anastomosis, long or modified carrell patch, end to side to main renal artery with single anastomosis. Nearly all of the renal allografts in the study population consisted of living donation kidney allografts. In meta-analysis: there was no statistical difference in urological complication rate between IEA versus other techniques, O.R. 0.82 (CI 0.21, 3.24). There was a trend towards lower delayed graft function (DGF) in IEA versus other anastomosis techniques but it did not reach statistical significance (O.R. 0.45, CI 0.10, 2.02). In qualitative analysis, vascular complications were largely reported in one paper, with 3 in IEA vs 6 in other anastomosis group. Long-term graft function was only reported in one paper, with 2 (9.5%) in IEA vs 47(16.2%) in other anastomosis group. Overall follow-up ranged from 12 months to 10 years, with none reporting long-term patient survival. Conclusion: Utilisation of recipient inferior epigastric artery for accessory polar vessels is an acceptable technique in renal transplantation. Whilst no short-term differences were shown in peri-procedural vascular or urological complication, there was a trend towards reduced delayed graft function. Long-term impact on graft function remains to be determined.

Unconventional Obturator Artery Nutrient Branch: Image of an Anatomical Variation.

Variations in vascular anatomy are of great concern to surgeons, as proper identification of aberrant arteries can reduce the risk of iatrogenic injury and improve patient outcomes. Several studies have highlighted the irregular branching pattern of pelvic arteries, with a recent focus on the obturator artery (OA). The OA has an inconstant origin from the internal iliac artery, external iliac artery, or inferior epigastric artery. Within the pelvis, the OA can give off muscular branches and nutrient vessels to the ilium and pubis. Though occasionally described in text, few resources employ images of human donors that depict branches arising from the OAs. Out of the 34 hemisected pelves studied, we identified 1 individual with a substantial nutrient vessel branching unilaterally from the OA. Herein, we present the first image of this unconventional nutrient artery. This vessel should be highlighted given that its size and course make it particularly vulnerable during intrapelvic surgeries such as pelvic lymph node dissection or in procedures requiring arterial embolization of the OA.

Effect of Incision Negative Pressure Wound Therapy on Donor Site Morbidity in Breast Reconstruction with Deep Inferior Epigastric Artery Perforator Flap

SummaryBackgroundThe usefulness of closed incision negative pressure wound therapy (ciNPWT) has been well documented in many surgical sites, except for the donor site of the deep inferior epigastric artery perforator (DIEP) flap. The aim of this study was to evaluate the effect of ciNPWT on microsurgical breast reconstruction using a DIEP flap.MethodsFifty-six cases of breast reconstruction with DIEP flap were included and divided into two groups based on post-surgical wound management: the ciNPWT group received ciNPWT at the donor site, while the conventional group received conventional wound management. The primary outcomes were the incidence of seroma, wound dehiscence, and surgical site infection, and secondary outcomes were the time to drain removal and amount of drainage. The breast reconstruction risk assessment (BRA) score was used to evaluate the comprehensive risk in each case.ResultsAmong the patient and surgical characteristics, only the BRA score (P=0.02) and the time to elevate the flap (P=0.02) were significantly higher and longer in the ciNPWT group, respectively. The incidence of seroma, dehiscence, and wound infection showed no significant difference between the two groups. In the subgroup analysis of patients with body mass index ≥ 25, the primary outcomes did not differ, while the secondary outcomes were significantly lower in the ciNPWT group (drainage volume, P = 0.04; time to drain removal, P = 0.04)ConclusionciNPWT can potentially reduce the incidence of donor site complications of DIEP flaps, especially if the comprehensive risk for post-surgical complications is considered.

Pseudoaneurysm after Radical Prostatectomy: A Case Report and Narrative Literature Review

(1) Background: We report a very unusual presentation of pseudoaneurysm developed following a robot-assisted radical prostatectomy (RARP) with bilateral pelvic lymph node dissection. The patient was a 66-year-old male, admitted at the Emergency Department 20 days after discharge from RARP due to chest pain, lipothymia and occult bleeding, necessitating a blood transfusion and a moderate increase of serum troponin. Angiography showed a pseudo-aneurysm involving the inferior-epigastric artery pubic branch. The patient underwent percutaneous embolization with complete resolution. The aim of this study is to offer an overview on pseudoaneurysms developed as radical prostatectomy complications; (2) Methods: A literature search was conducted on Scopus and PubMed for pseudoaneurysms after RARP to analyze all the previously published cases. The search terms used were “pseudoaneurysm” and “prostatectomy” using the Boolean Operator “AND”. We used the default search strategy “all fields”; (3) Results: Herein, a narrative review is proposed to facilitate the approach to this emerging clinical challenge, due to both an implementing in diagnosis imaging techniques and a spread of robotic surgery in prostate cancer; (4) Conclusions: The management of radical prostatectomy complications still remains barely uniformed and needs to be precisely calibrated as the initial cure approach itself.

An original method of analysis of the breast contour curve with 3-dimensional imaging: Case series.

Introduction:Postoperative assessment of breast reconstruction results has become increasingly important. In this paper, a unique analysis method with 3-dimensional surface images of patients who were treated with immediate breast reconstruction is presented.Patient concerns:Five Japanese women were suspected of having breast cancer and visited our hospital for treatment.Diagnosis:Breast cancer was diagnosed by biopsy, mammography, ultrasonography, computed tomography, and magnetic resonance imaging.Interventions:Five patients underwent nipple/skin-sparing mastectomy, concomitant sentinel lymph node biopsy, and immediate breast reconstruction in our hospital. Three cases were reconstructed by extended latissimus dorsi flaps, one was reconstructed by a pedicled transverse rectus abdominis myocutaneous flap, and one was reconstructed by a deep inferior epigastric artery perforator flap. Three-dimensional photographs were taken 1 year postoperatively. The similarity of the breast contours between the reconstructed breast and the nonaffected opposite breast obtained from 3-dimensional images was analyzed. The calculated value is called the breast contour score.Outcomes:No recurrence was observed during the follow-up period in any cases. All cases could be analyzed by breast contour score to evaluate the breast shapes.Conclusion:The scores become a relative value that ranges from 0 (completely different) to 100 (completely the same). By expressing the score as a relative value, the breast contour score could help us understand the degree of breast symmetry more intuitively.

Unilateral immediate deep inferior epigastric artery perforator flap breast reconstruction following skin sparing mastectomy: A comparative study on revision surgeries to improve breast symmetry.

The number of revision surgeries to improve breast asymmetry after deep inferior epigastric perforator (DIEP) flap breast reconstruction is still high worldwide with impact on both patients and healthcare systems. These procedures include fat grafting, contralateral breast symmetrization, scar revision, flap repositioning and remodeling. A previously published DIEP flap insetting algorithm has proven to be effective in selecting patient-tailored strategies to achieve excellent aesthetic outcomes. This study investigated whether this insetting algorithm was effective in reducing revision surgeries in patients undergoing SSM and immediate DIEP flap breast reconstruction to achieve the goal of a one-stage reconstruction. This retrospective case-control study included 60 patients (group A) treated without the DIEP flap standardized insetting algorithm and 60 patients (group B) treated with the standardized insetting algorithm, which considers among its variables the type of breast to be reconstructed, abdominal tissue thickness, rotation due to harvesting side. Demographic data, operative data, complications and number of revision surgeries were recorded. One hundred and twenty primary and 106 revision surgeries were performed. Groups were homogenous for age (p=.32), body mass index (p=.77), flap weight (p=.7), operative time (p=.87) and early complications (p=.78). When excluding isolated nipple reconstruction from the revision surgeries, one-stage reconstruction was successfully performed in 26 patients in group A (43.3%) and 39 patients (65.0%) in group B, with a statistically significant difference between the groups (p=.003). The introduction of a standardized insetting algorithm for immediate unilateral DIEP flap breast reconstruction can be effective in reducing the number of revision surgeries for breast asymmetry, making a one-stage reconstruction an achievable and reliable target.

Observational Study of Early Outcomes in Single-Vessel and Multiple-Vessel Renal Allograft.

IntroductionEnd-stage renal disease (ESRD) is a global problem with a similar worldwide need for renal replacement therapy. However, the availability of transplant organs remains a challenge. Therefore, we conducted this study to measure early outcomes (up to one month) of renal allograft functions after renal transplant by assessing graft vascularity. We also measured the changes in serum creatinine and hemoglobin levels in single- and multiple-vessel renal allograft recipients.MethodsWe conducted an observational study of 108 renal allograft patients for two years. The study included all renal allograft recipients during the study period. The study excluded patients with a history of renal transplant, patients on antithrombotic therapy, a donor with previous surgery of graft kidney, and patients with anatomic abnormalities. Eighty-five patients were in the single-vessel group, and 23 were in the multiple-vessel group. Donors and recipients received standard pretransplant workup, including donor CT angiography and human leukocyte antigen crossmatching. We performed laparoscopic donor nephrectomies for all participants and perfused all renal arteries separately with Renograph solution (Claris Lifesciences, North Brunswick, NJ). A renal transplant was done in the right or left iliac fossa, noting warm and cold ischemia times. In single-vessel recipients, we anastomosed the renal artery to the external iliac artery (EIA), the renal vein to the external iliac vein (EIV), and the ureter to the bladder via a modified Lich-Gregoir technique. In multiple-vessel recipients, we performed bench anastomosis to make a single vessel, or we anastomosed vessels separately to the EIA, EIV, or the inferior epigastric artery for patients with a second small renal artery. We measured postoperative serum creatinine and hemoglobin levels for one month. In addition, we assessed graft vascularity with ultrasound-guided (USG) Doppler in the first postoperative week. We used IBM SPSS Statistics for Windows, version 21.0. (IBM Corp., Armonk, NY) for all data analyses.ResultsWarm ischemia time (WIT) was longer in multiple-vessel patients than in single-vessel patients, but the difference was insignificant (p=0.054). Cold ischemia time (CIT) was significantly longer in the multiple-vessel group than in the single-vessel group (p=0.048). We found no significant difference in serum creatinine or hemoglobin levels between groups during the study period. Perigraft collection occurred in three single-vessel patients and decreased vascularity in two multiple-vessel patients, according to USG Doppler.ConclusionsWe conducted this study to measure early outcomes of renal allograft functions after renal transplant by assessing graft vascularity, serum creatinine, and hemoglobin levels in single- and multiple-vessel renal allograft patients. According to our results, renal transplantation is not inferior in multiple-vessel allograft patients. We found no significant difference in serum creatinine levels one month postoperatively. Using multiple-vessel donors helps increase the limited donor pool, which is ultimately better for managing ESRD patients.

Does it Always have to be the Abdomen? Alternative Flaps in Autologous Breast Reconstruction

[English] Deep inferior epigastric artery perforator (DIEP) or muscle-sparing transverse rectus abdominis muscle (ms-TRAM) flaps remain the gold standard for autologous reconstruction in post-mastectomy patients, although many women may not be candidates for abdominally based free tissue transfer. In this scenario, there are several other donor site options based from the thigh (transverse and diagonal upper gracilis flaps, profunda artery perforator flap, lateral thigh flap), trunk (lumbar artery perforator flap), and buttock (superior and inferior gluteal artery perforator flaps). This article will provide insight into the history, relevant anatomy, surgical technique and novel applications (neurotization) for alternative flaps in autologous breast reconstruction.

Effect of Breast Reconstruction on Kinematics and Performance during Upper Limb-Focused Functional Tasks.

Breast reconstruction after curative breast cancer surgery is becoming increasingly common. There is evidence to suggest that these surgeries have negative effects on shoulder function, but to date there have been no investigations of shoulder biomechanics during functional tasks in this group. The purpose of this study was to define and compare upper limb motion of patients with breast cancer who underwent mastectomy only or mastectomy with reconstruction with a control group without cancer during a range of work-related functional tasks. Ninety-five women participated: 25 controls, 25 patients with breast cancer who received a mastectomy only, and 45 patients with breast cancer who received a mastectomy with reconstruction (implant, latissimus dorsi flap, or deep inferior epigastric artery perforator flap). Motion of the torso, humeri, and scapulae were tracked during arm-focused functional tasks, involving reaching, dexterity, and lifting overhead, and joint angles were calculated. Mean, maximum, and minimum angles were calculated and compared among groups using one-way analyses of variance ( p < 0.05). The reconstruction group had significantly different kinematics than the other two groups. Throughout task performance, patients who had reconstruction had increased scapular posterior tilt and increased humeral external rotation. These findings are consistent with reconstruction surgical procedures and may highlight muscle pattern alterations that interfere with co-contraction, stability, and functional task performance. The findings suggest that breast reconstruction surgery influences functional task performance. Scapular and humeral kinematics may indicate movement pattern differences that are important to address in rehabilitation. Risk, II.

The Superficial Vein-Only DIEP Flap.

The deep inferior epigastric artery perforator (DIEP) flap, often considered the standard in autologous breast reconstruction, is reliant on robust arterial inflow and venous outflow. Venous outflow issues remain a critical part in determining the success of the DIEP flap. Previously, the superficial inferior epigastric vein (SIEV) has been used to augment venous outflow, or as a salvage option when flow through the deep inferior epigastric vein is compromised or insufficient. The authors describe a variant of the DIEP flap, the superficial vein-only DIEP flap, using the deep inferior epigastric artery and the SIEV as a viable alternative when indicated. The authors conducted a retrospective review of all patients undergoing autologous breast reconstruction performed by the senior author (B.C.) from July of 2015 to March of 2020 to identify DIEP flaps whose only source of venous outflow was the SIEV, excluding those performed as salvage maneuvers. The authors identified 30 patients (35 flaps) and describe their characteristics, flap characteristics, complications, and details of the flap harvest. Notably, the authors experienced complications in 26.7 percent of flaps, of which 62.5 percent were minor, with no flap loss. This was comparable to the complication rate observed in the standard DIEP flap population. The authors believe the superficial vein-only DIEP flap is an excellent option for the appropriate patient. It is an added tool to make abdominally based breast reconstruction more reliable and successful. The use of the SIEV in a superficial vein-only flap should be considered as part of any routine DIEP flap reconstruction. Therapeutic, IV.

Surgical technique for preservation of extrathoracic collateral networks in thoracoabdominal aortic surgery.

Surgical technique for preservation of extrathoracic collateral networks in thoracoabdominal aortic surgery.