Inferior Epigastric Perforator Research Articles

Filling the Upper Pole with the Pectoralis Major Muscle Flap in Profunda Femoris Artery Perforator Flap Breast Reconstruction.

Background and Objectives: Among many donor site options for autologous breast reconstruction, the use of the profunda femoris artery perforator (PAP) flap has become common in patients who are not suitable for the gold standard procedure, the deep inferior epigastric artery perforator flap. However, its limited volume has precluded its wide use in breast reconstruction. The aim of this report was to demonstrate the effectiveness of a method in which the anatomical position of the pectoralis major muscle was adjusted to augment the volume of the superior pole of the breast during PAP flap transfer. A comparison was made with a conventional PAP flap breast reconstruction. Materials and Methods: Fifty-nine consecutive cases where unilateral autologous breast reconstruction was performed using the vertically designed PAP flap were retrospectively reviewed. Conventional PAP flap transfer was performed in 36 patients (Group 1), and PAP flap transfer with pectoralis major muscle augmentation was performed in 23 patients (Group 2). Results: The patient satisfaction at 12 months postoperatively was statistically greater in Group 2, with the pectoralis major muscle augmentation, than in Group 1 [23/36 (64%) vs. 22/23 (96%), p = 0.005]. There were no significant differences in postoperative complication rates at the reconstructed site [2/36 (5.6%) vs. 0/23 (0%), p = 0.52]. Conclusions: Higher patient satisfaction could be achieved with pectoralis major muscle augmentation in PAP flap breast reconstruction without increasing the postoperative complication rate at the reconstructed site.

A New CT Analysis of Abdominal Wall after DIEP Flap Harvesting.

The abdominal microsurgical flap based on the deep inferior epigastric artery perforator (DIEP) flap has become the most popular option worldwide for autologous breast reconstruction. Several authors have investigated the results of reconstructed breasts, but the literature lacks systematic reviews exploring the donor site of the abdominal wall. To fulfil our aims, a new diagnostic muscle imaging analysis was designed and implemented. This study focused on rectus abdominal muscle morphology and function in a single series of 12 consecutive patients analysed before and after breast reconstruction with a microsurgical DIEP flap. Patients were divided into two groups, namely, “ipsilateral reconstruction” and “contralateral reconstruction”, depending on the side of the flap harvest and breast reconstruction, then evaluated by computed tomography (CT) scans scheduled for tumor staging, and clinically examined by a physiatrist. Numerous alterations in muscle physiology were observed due to surgical dissection of perforator vessels, and rectus muscle distress without functional impairment was a common result. Postoperatively, patients undergoing “contralateral reconstruction” appeared to exhibit fewer rectus muscle alterations. Overall, only three patients were impacted by a long-term deterioration in their quality of life. On the basis of the newly developed and implemented diagnostic approach, we concluded that DIEP microsurgical breast reconstruction is a safe procedure without major complications at the donor site, even if long-term alterations of the rectus muscle are a common finding.

Per-operative indocyanine green angiography (ICG-A) on donor-site/abdominal region visualizing insufficient perfusion of the right side of the deep inferior epigastric artery perforator (DIEP)-flap.

Per-operative indocyanine green angiography (ICG-A) on donor-site/abdominal region visualizing insufficient perfusion of the right side of the deep inferior epigastric artery perforator (DIEP)-flap.

Indocyanine green angiography (ICG-A) showing insufficient intra-flap perfusion of a deep inferior epigastric artery perforator (DIEP)-flap after transposition to the breast region and microvascular anastomoses. Patient experienced partial flap loss of the medial 20% of the flap corresponding to the intraoperative angiography.

Indocyanine green angiography (ICG-A) showing insufficient intra-flap perfusion of a deep inferior epigastric artery perforator (DIEP)-flap after transposition to the breast region and microvascular anastomoses. Patient experienced partial flap loss of the medial 20% of the flap corresponding to the intraoperative angiography.

Simultaneous Lymphatic Superficial Circumflex Iliac Artery Perforator Flap Transfer from the Zone 4 Region in Autologous Breast Reconstruction Using the Deep Inferior Epigastric Artery Perforator Flap: A Proof-of-Concept Study.

The incidence of upper extremity lymphedema after breast cancer treatment is reported to be 14% after axillary lymph node dissection (ALND) and 33% after ALND and regional lymph node dissection. The present report describes a novel method in which the afferent lymphatic vessels are harvested with their lymph nodes from the Zone 4 region as a separate flap, the superficial circumflex iliac artery perforator (SCIP) flap, in the setting of autologous breast reconstruction using the deep inferior epigastric artery perforator (DIEP) flap. From September 2017 to September 2020, seven female patients with an average age of 46.9 years (range: 39 to 54 years) underwent autologous breast reconstruction using the DIEP flap and the lymphatic SCIP flap procured separately from the Zone 4 region. All patients had undergone ALND, four patients had undergone radiation therapy, and three patients had established lymphedema at the time of reconstruction. All lymphatic SCIP flaps survived completely. Lymphedema did not occur in any of the four patients to whom the lymphatic flap was transferred for a preventive purpose (average follow-up: 37.5 months). In three patients with established lymphedema at the time of reconstruction, the average rate of estimated volume decrease at the last follow-up (average: 29.0 months) was 12.6%. A lymphatic SCIP flap procured from the Zone 4 region in DIEP flap breast reconstruction can contribute to improvement or prevention of lymphedema with no additional donor site.

Prognosis of Subcutaneous Mastectomy for Special Types of Breast Cancer.

Background and objectives: In the treatment of the special type of breast cancer (STBC), the choice of chemotherapeutic agents is often based on the characteristic features of the histological type. On the other hand, the surgical strategy is usually determined by the tumor size and presence of lymph node metastasis, and the indication for immediate reconstruction is rarely discussed based on the histological type. The prognoses of STBC and invasive ductal carcinoma of the breast (IDC) patients who underwent subcutaneous mastectomy (SCM) with immediate reconstruction at our institution were compared. Materials and Methods: A total of 254 patients with SCM with immediate reconstruction from 1998 to 2018 were included; their tumor diameter or induration was less than 25 mm, and it was not in close proximity to the skin. Preoperative chemotherapy and non-invasive cancer cases were excluded. Results: The number of patients was 166 for skin-sparing mastectomy (SSM) and 88 for nipple-sparing mastectomy (NSM). The reconstructive techniques were deep inferior epigastric artery perforator flap (DIEP) reconstruction in 43 cases, latissimus dorsi flap reconstruction (LDflap) in 63 cases, tissue expander (TE) in 117 cases, and transverse rectus abdominis myocutaneous flap/vertical rectus abdominis myocutaneous flap (TRAM/VRAM) reconstruction in 31 cases. The histological types of breast cancer were 211 IDC and 43 STBC; 17 were mucinous carcinoma (MUC), 17 were invasive lobular carcinoma (ILC), 6 were apocrine carcinoma, 1 was tubular carcinoma, and 2 were invasive micropapillary carcinoma. There was no difference in local recurrence or disease-free survival (LRFS, DFS) between IDC and STBC, and overall survival (OS) was significantly longer in STBC. OS was better in the STBC group because SCM with immediate reconstruction was performed for STBC, which is a histological type with a relatively good prognosis. Highly malignant histological types, such as squamous cell carcinoma or metaplastic carcinoma, were totally absent in this study. Conclusions: The indications for SCM with immediate reconstruction for relatively common STBCs such as MUC and ILC can be the same as for IDC.

Teaching Microsurgical Breast Reconstruction-A Retrospective Cohort Study.

Microsurgical breast reconstruction demands the highest level of expertise in both reconstructive and aesthetic plastic surgery. Implementation of such a complex surgical procedure is generally associated with a learning curve defined by higher complication rates at the beginning. The aim of this study was to present an approach for teaching deep inferior epigastric artery perforator (DIEP) and transverse upper gracilis (TUG) flap breast reconstruction, which can diminish complications and provide satisfying outcomes from the beginning. DIEP and TUG flap procedures for breast reconstruction were either performed by a senior surgeon (>200 DIEP/TUG, ”no-training group”), or taught to one of five trainees (>80 breast surgeries; >50 free flaps) in a step-wise approach. The latter were either performed by the senior surgeon, and a trainee was assisting the surgery (“passive training”); by the trainee, and a senior surgeon was supervising (“active training”); or by the trainee without a senior surgeon (“after training”). Surgeries of each group were analyzed regarding OR-time, complications, and refinement procedures. A total of 95 DIEP and 93 TUG flaps were included into this study. Before the first DIEP/TUG flap without supervision, each trainee underwent a mean of 6.8 DIEP and 7.3 TUG training surgeries (p > 0.05). Outcome measures did not reveal any statistically significant differences (passive training/active training/after training/no-training: OR-time (min): DIEP: 331/351/338/304 (p > 0.05); TUG: 229/214/239/217 (p > 0.05); complications (n): DIEP: 6/13/16/11 (p > 0.05); TUG: 6/19/23/11 (p > 0.05); refinement procedures (n): DIEP:71/63/49/44 (p > 0.05); TUG: 65/41/36/56 (p > 0.05)), indicating safe and secure implementation of this step-wise training approach for microsurgical breast reconstruction in both aesthetic and reconstructive measures. Of note, despite being a perforator flap, DIEP flap required no more training than TUG flap, highlighting the importance of flap inset at the recipient site.

Laparoscopic Abdominal Surgery after Primary Breast Reconstruction Using an Abdominal Flap

Background and objectives: Our department has been performing primary breast reconstruction for breast cancer surgery, incorporating a transverse rectus abdominis myocutaneous flap (TRAM)/vertical rectus abdominis myocutaneous flap (VRAM) since 1998 and a deep inferior epigastric artery perforator flap (DIEP) since 2008. Currently, most gastrointestinal operations in abdominal surgery are performed laparoscopically or are robot-assisted. Cases in which abdominal surgery was performed after breast reconstruction using an abdominal flap were reviewed. Method: A total of 119 cases of primary breast reconstruction using an abdominal flap performed in our department were reviewed. Result: The reconstructive techniques were DIEP in 69 cases and TRAM/VRAM in 50 cases. After breast surgery, seven abdominal operations were performed in six cases. In DIEP cases, one robotic surgery was performed for uterine cancer, and one laparoscopic surgery was performed for ovarian tumor. In TRAM/VRAM cases, two laparoscopic cholecystectomies, one laparoscopic total gastrectomy, one laparoscopic ileus reduction, and one open total hysterectomy oophorectomy were performed. Six surgeries were completed by laparoscopy or robotic assistance. Conclusion: The survival rate after breast cancer surgery is improving, and the choice of breast reconstruction procedure should take into account the possibility of performing a prophylactic resection of the ovaries due to the genetic background and possibly postoperative abdominal surgery due to other diseases. However, in cases in which laparoscopic surgery was attempted after breast reconstruction using an abdominal flap, the laparoscopic surgery could be completed in all cases.

The influence of venous system patterns on DIEP flap viability for breast reconstruction

A deep inferior epigastric artery perforator (DIEP) flap has unique variations in the anatomy of the vascular supply, and this idea has been adapted to the venous system. Venous system patterns, including connections between the superficial and deep inferior epigastric vein (SDC) or connections of the superficial inferior epigastric vein across the midline-crossing linking veins (MCLV), have gradually become recognized as a cause of fat necrosis and induration due to venous congestion. Therefore, it is important to select patients who are appropriate for transplantation by evaluating blood flow in the flap based on these patterns. The subjects were 52 consecutive patients who underwent DIEP flap breast reconstruction. Relationships of fat necrosis and induration of a transplanted flap and venous system patterns (presence of SDC on the contralateral side: cSDC or MCLV, direction and diameter of perforator vein) in the flap were investigated. Logistic regression and univariate and multivariate analyses were used to identify predictors of fat necrosis and induration of the flap. Fat necrosis and induration were detected in 17.4 and 34.8% of cases, respectively. These incidences were significantly linked to the absence of cSDC and MCLV patterns in the flap. Patients without a cSDC or MCLV pattern had harder fat tissue in Zone II, especially in the distal portion. These results suggest that the absence of a cSDC or MCLV pattern causes complications such as fat necrosis and induration in a transplanted flap. If neither pattern is detected before surgery, improvement of venous drainage is recommended.

An alternative method in augmenting venous drainage to salvage deep inferior epigastric artery perforator reconstruction

An alternative method in augmenting venous drainage to salvage deep inferior epigastric artery perforator reconstruction

Tạo hình khuyết hổng trong phẫu thuật ung thư âm hộ: báo cáo 2 trường hợp tạo hình phức tạp và tổng quan y văn

Performing radical surgery for locally advanced vulvar cancer is usually associated with the occurrence of large perineal defects. These defects, especially in previously radiated cases, often require more advanced reconstructive techniques using locoregional flaps. We present two cases of vulvar reconstruction, one case using a split and thinned, transversely oriented, pedicled deep inferior epigastric artery perforator (DIEP) flap and another one with gracilis myocutaneous flap. These pedicled flap seems to be an effective and feasible method of perineal reconstruction after extended perineal resection for locally advanced vulvar cancers. especially in pre-irradiated patients.

Free Flap-Based Breast Reconstruction

Breast cancer is one of the most common cancers worldwide affecting one in eight women. Surgery continues to be the mainstay of treatment, and mastectomy is performed for treatment and prophylaxis of breast malignancies. Autologous microvascular tissue transfer is frequently an option for breast reconstruction. In appropriate patients, microsurgical breast reconstruction is a safe procedure with low donor site morbidities and excellent aesthetic results. The lower abdomen, thigh, and gluteal regions are the main source of free flaps frequently used in breast reconstruction. This review contains 10 figures, 2 tables, and 54 references Keywords: breast cancer, breast reconstruction, breast surgery, microsurgery, autologous tissue transfer, free flap, deep inferior epigastric artery perforator flap (DIEP free flap), gracilis myocutaneous flap, gluteal artery perforator flap

Thin superficial inferior epigastric artery perforator flap for reconstruction of the tongue.

The superficial inferior epigastric artery (SIEA) flap is widely used in the repair of large soft tissue defects of the extremities and in breast reconstruction. Because of the high fat content of the abdomen, it has been less used for glossectomy reconstruction. Here we present a series of seven patients who each underwent reconstruction with a thin SIEA flap after resection of the tongue. There were six men and one woman (mean age 48, range 24-66 years). All patients underwent preoperative computed tomographic (CT) angiography, and colour Doppler ultrasound (US) was used to select and map the most suitable SIEA. The flap was raised above the Scarpa's layer while adjusted the plane of dissection according to the specific needs for bulk in each case. All the flaps survived; one flap required a secondary anastomosis because of a venous anastomotic embolus. The size of flap used was 5.0cm×6.0cm - 7.0cm×9.0cm, and the flap was 0.8cm-1.4cm thick. The functional outcome was evaluated at 6 - 18 months follow up, when speech and swallowing were both good in all cases. The dissection above the pubic symphysis is an important refinement of the SIEA flap, and we conclude that the thin SIEA flap is a good choice for reconstruction after excision of cancer of the tongue.

Efficacy of perforator CTA of deep inferior epigastric artery perforator flap in preoperative planning of breast reconstruction: comparative study with CDUS

BackgroundThe aim of the study is to compare the efficacy of perforator computed tomographic angiography (P-CTA) and color Doppler ultrasonography (CDUS) in preoperative planning of breast reconstruction with deep inferior epigastric artery perforator (DIEAP) flaps. From October 2018 to August 2019, 42 patients performed breast reconstruction with DIEAP flap procedures. All cases performed CDUS and multidetector perforator CT angiography (P-CTA) within 1 week prior to reconstructive surgery. The CDUS and P-CTA images were interpreted by two experienced vascular radiologists with 8- and 10-year experience, respectively, and compared with the surgical results.ResultsThere were statistically significant differences (P = 0.0025) between CDUS and P-CTA in the detection of the number of perforators with P-CTA being more accurate than CDUS. There were significant differences between the P-CTA and surgical findings in measuring the caliber of dominant perforators (P = 0.002). CDUS was more accurate than P-CTA in this parameter showing sensitivity and specificity of 94 and 96%, respectively. There were significant differences between CDUS and surgical findings in the detection of the course of the intramuscular segment of the perforator (P = 0.0028). P-CTA was more accurate than CDUS in this parameter showing sensitivity and specificity of 96 and 97%, respectively.ConclusionThe pre-operative mapping of perforators by CDUS and P-CTA proved to be effective and complementary to each other in the localization and vascular mapping of deep inferior epigastric artery perforators, thus greatly helping vascular surgeons in performing this surgical procedure.

Thinned Pedicle Deep Inferior Epigastric Perforator (DIEP) Flap for Scrotal Reconstruction

The deep inferior epigastric artery perforator (DIEP) flap has been widely used for approximately 30 years as an effective method for breast reconstruction, defect repair, and perineal reconstruction. However, few literatures have reported on thinned pedicle DIEP flaps for scrotal reconstruction. The present study presents a series of reconstruction of the scrotum using thinned pedicle DIEP flaps. Five patients with large scrotal skin defects were admitted to our hospital from October 2010 to December 2015. Among these patients, three patients had testes and spermatic cord exposure after accidental injury, while two patients had testes exposure after machine extrusion. All of these patients were repaired using thinned pedicle DIEP flaps. During the 12–24-month follow up, one patient experienced a bulky flap, and a subsequent thinned flap was successfully made. The other four flaps were successfully transplanted with good esthetic and functional results. All donor sites were primarily closed; there was no functional disturbance, such as dysuria and abdominal hernia, and the sensation of these flaps partially recovered after 6 months. The thinned pedicle DIEP flap is robust, reliable, and resilient, and offers good-quality skin cover and cushion to the testes. This flap can be considered a good choice for scrotal reconstruction.

Interdisciplinary Treatment of Breast Cancer After Mastectomy With Autologous Breast Reconstruction Using Abdominal Free Flaps in a University Teaching Hospital-A Standardized and Safe Procedure.

Background: Breast cancer is the most common malignancy in women. The interdisciplinary treatment is based on the histological tumor type, the TNM classification, and the patient's wishes. Following tumor resection and (neo-) adjuvant therapy strategies, breast reconstruction represents the final step in the individual interdisciplinary treatment plan. Although manifold flaps have been described, abdominal free flaps, such as the deep inferior epigastric artery perforator (DIEP) or the muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) flap, are the current gold standard for autologous breast reconstruction. This retrospective study focuses on the safety of autologous breast reconstruction upon mastectomy using abdominal free flaps.Methods: From April 2012 until December 2018, 193 women received 217 abdominal free flaps for autologous breast reconstruction at the University Hospital of Erlangen. For perforator mapping, we performed computed tomography angiography (CTA). Venous anastomosis was standardized using a ring pin coupler system, and flap perfusion was assessed with fluorescence angiography. A retrospective analysis was performed based on medical records, the surgery report, and follow-up of outpatient course.Results: In most cases, autologous breast reconstruction was performed as a secondary reconstructive procedure after mastectomy and radiotherapy. In total, 132 ms1-TRAM, 23 ms2-TRAM, and 62 DIEP flaps were performed with 21 major complications (10%) during hospital stay including five free flap losses (2.3%). In all cases of free flap loss, we found an arterial thrombosis as the main cause. In 24 patients a bilateral breast reconstruction was performed without free flap loss. The majority of free flaps (96.7%) did not need additional supercharging or turbocharging to improve venous outflow. Median venous coupler size was 2.5 mm (range, 1.5–3.5 mm).Conclusion: Using CTA, intraoperative fluorescence angiography, titanized hernia meshes for rectus sheath reconstruction, and venous coupler systems, autologous breast reconstruction with DIEP or ms-TRAM free flaps is a safe and standardized procedure in high-volume microsurgery centers.

Extracorporeal Free Flap Perfusion Using Extracorporeal Membrane Oxygenation Device: An Experimental Model.

Extracorporeal perfusion of organs has a wide range of clinical applications like prolonged vital storage of organs, isolated applications of drugs, bridging time to transplant, and free composite tissue transfer without anastomosis, but there are a limited number of experimental models on this topic.This study aimed to develop and evaluate a human extracorporeal free flap perfusion model using an extracorporeal membrane oxygenation device. Five patients undergoing esthetic abdominoplasty participated in this study. Deep inferior epigastric artery perforator flaps were obtained abdominoplasty flaps, which are normally medical waste, used in this model. Deep inferior epigastric artery perforator flaps were extracorporeally perfused with a mean of 6 days. The biochemical and pathological evaluations of the perfusions were discussed in the article.

Video demonstrating ‘Our’ technique for utilizing computed tomographic angiography (CTA), highlighting the anatomy, methodology and approach to interpretation of CTA for deep inferior epigastric artery perforator (DIEP) flaps

Video demonstrating ‘Our’ technique for utilizing computed tomographic angiography (CTA), highlighting the anatomy, methodology and approach to interpretation of CTA for deep inferior epigastric artery perforator (DIEP) flaps

Staged immediate nipple reconstruction with tube flap in secondary autologous breast reconstruction

In the setting of secondary breast reconstruction by deep inferior epigastric artery perforator (DIEP) flap, the mastectomy skin is usually deepithelialized and buried under the reconstructed breast. In this study, by virtue of tube flap technique, we hypothesize that an amount of mastectomy skin could be transferred to the apex of reconstructed breast mound for nipple reconstruction. A total of 30 female postmastectomy patients were recruited between June 2012 and August 2015. A bipedicle DIEP flap was harvested and folded upward to reconstruct the breast. An inferiorly based mastectomy flap was raised and rolled into a tube. The free end of the flap was sutured to the reconstructed breast mound to allow revascularization. After serial stages, a sufficient tissue bulk from the mastectomy flap was transferred to the apex of the breast mound and remolded into a new nipple. Reconstructed breasts and nipples survived well postoperatively. The mean nipple projection was 9.2 ± 2.7 mm at the 1-year follow-up. In total 24 patients ranked the overall nipple and breast reconstruction to be very good or good. Based on DIEP flap breast reconstruction, the staged immediate nipple reconstruction with local mastectomy tube flap could maintain a long term residual projection with aesthetically acceptable outcomes.

Repair of large area skin defect of forearm with overlength thoracic umbilical conjoined perforator flap with double blood supply

Objective To explore the surgical method and clinical effect of repairing the large area skin defect of forearm with the perforator flap pedicle with the inferior epigastric artery perforator and the lateral cutaneous branch of the posterior intercostal artery. Methods From January, 2006 to January, 2016, 14 cases of forearm large area of skin defects were treated with the overlength flap at one stage. The proximal flap to the inferior epigastric artery umbilical perforation and the flap distal to the posterior interphalangeal artery perforation were used for the blood supply of superficial flap. The length of the flap was 25-43 cm (average, 36 cm) . The width of the flap was 5-14 cm (average, 9 cm) . All patients were followed-up regularly. The content of the follow-up included three aspects: appearance, hand function and the recovery of the donor site. Results Twelve cases of postoperative flaps successfully survived. Arterial crisis was seen in 1 flap 28 hours after surgery. The re-surgical exploration was adopted after conservation treatment for 1 h without remission and the proximal anastomotic flap embolization was confirmed. The flap survived. Venous crisis was seen in 1 case. The flap survived with the help of removing the suture, smoothing drainage and bleeding for 5 d. The wounds and the donor site of the thoracic and abdominal region healed at the first stage. The follow-up time was 8-72 months, with an average of 31 months. The flaps had no obvious bloated, the skin texture was close to forearm skin and the flaps were restored protected sensation. There was no ulceration, infection and other complications. The healing of skin graft was satisfactory in 2 cases in abdominal donor site. No skin graft contracture occurred. The remaining 12 cases had linear scar in the abdomen of the donor site. The edge of the scar was soft and no obvious contracture occurred. Conclusion Super long thoracic umbilical conjoined perforator flap can repair the lager area skin defect of forearm with double blood supply. The length of flap is significantly longer with enough-blood-supply of distal part of the flap. The clinical efffect is satisfactory. Key words: Conjoined flap, perforator flap; Inferior epigastric artery; Posterior intercostal artery; Forearm; Defects