Serratus Anterior Fascia Flap Research Articles

Outcomes after elevation of serratus anterior fascia flap versus serratus muscle flap in direct-to-implant breast reconstruction following mastectomy: a prospective study.

The purpose of this study was to compare postoperative pain between SF flap and serratus anterior muscle (SM) in direct-to-implant breast reconstruction. This is a prospective cohort study that included 53 women diagnosed with breast cancer who underwent mastectomy and one-stage implant-based breast reconstruction from January 2020 to March 2021. Twenty-nine patients (54.7%) had SF elevation, and 24 patients (45.3%) underwent SM elevation. We evaluated patient-reported early postoperative pain on the first day after surgery. Also, it was reported that all surgical complications in the first month and patient reported outcomes (PROs) were measured with the BRECON 23 questionnaire. The serratus fascia group used implants with larger volumes, 407.6 ± 98.9 cc (p < 0.01). There was no significant difference between the fascial and muscular groups regarding the postoperative pain score reported by the patients (2 versus 3; p = 0.30). Also, there was no difference between the groups regarding early surgical complications and PROs after breast reconstruction. The use of SF seems to cause less morbidity, which makes the technique an alternative to be considered in breast reconstruction. Although there was no statistical difference in postoperative pain scores between the fascia and serratus muscle groups.

Correction of Rippling in Implant-based Breast Reconstruction with Serratus Fascia Flap.

Implant-based breast reconstruction represents the most popular procedure for the treatment of women undergoing skin-sparing mastectomy. In selected patients, it allows for obtaining an excellent appearance of the reconstructed breast with great satisfaction to the patient. However, aesthetic and functional results can be affected by complications requiring reoperation. Among them, rippling is an undesired occurrence associated with implant-based reconstruction. It consists of a cutaneous manifestation, visible and/or palpable, of the implant wrinkles and edge which appear mostly when the patient leans forward. To treat this contour deformity, several techniques have been described such as acellular dermal matrices and autologous tissues. In this study, we intend to add the serratus anterior fascial flap within the autologous options in the treatment of implant rippling, reporting our experience.

Use of the serratus anterior fascia in immediate implant-based breast reconstruction

Using the serratus anterior fascia may be a safe and effective option to recreate the lateral breast profile during subpectoral breast reconstruction, with minimal functional impact on the donor site. However, the literature is scarce when it comes to studies on this fascia flap in implant-based reconstruction. This article aimed to review the use of the serratus anterior fascia in immediate implant-based breast reconstruction, searching the electronic databases PubMed, Embase, Lilacs, and SciELO. The search was carried out by combining the following keywords: ‘breast reconstruction’ and ‘serratus anterior fascia’. In the Pubmed and Embase databases, the search yielded a total of 12 and 15 articles, respectively, of which seven were selected according to the scope of this article. We found no studies on serratus anterior fascia and breast reconstruction in the Lilacs and SciELO databases. All works have results favorable for the use of the serratus anterior fascia flap and agree that this technique can be considered in the algorithm for the coverage of the inferolateral portion during subpectoral breast reconstruction.

The modified serratus anterior fascia flap improves satisfaction and long-term results in immediate implant-based breast reconstruction: A retrospective study

After immediate implant-based breast reconstruction (IIBR) following skin-sparing mastectomy, postoperative complications such as implant exposure or badly defined mammary folds can occur. Acellular dermal matrix can provide good esthetic outcomes but remain expensive. This study evaluates a new technique of one-stage IIBR by using a modified serratus anterior fascia flap (MSFF group), providing lower implant coverage, as compared to the classical submuscular technique. In this retrospective study, we included all patients who underwent IIBR using either the MSFF technique or the classic technique between November 2012 and February 2015. We collected data regarding demographics, perioperative factors, postoperative complications, patient satisfaction (Breast-Q score), and esthetic outcomes. One hundred twenty-three patients who underwent IIBR, of which 61 breasts (59 patients) using the MSFF and 67 breasts (64 patients) the classical technique, were included. The size of the implants used were significantly higher in the MSFF group (p = 0.036). There were no statistically significant differences between the two groups with regard to the immediate complications rate. After a mean follow-up of 43.9 months, we observed more capsular contractures in the classic group (p<0.001). In the classic group, patients required more revision surgeries (p = 0.008), more implant changes (p<0.001), and higher volume of additional lipofilling (p<0.001). According to the Breast Q scores, patients' satisfaction was better in the MSFF group regarding their breasts (p = 0.001) and the outcomes (p = 0.009). The MSFF is a simple, safe, effective, and inexpensive autologous technique for IIBR, which improves implant coverage with a vascularized flap and provides satisfying outcomes as compared to classic IIBR, with less complications.

Free Serratus Fascia Flap for Reconstruction of Soft Tissue Defects Involving the Distal Upper and Lower Extremity.

Free fascial flaps are widely used for the reconstruction of defects located on the distal extremities as they provide thin yet durable soft tissue coverage. The serratus anterior fascia flap stands out from other fascial flap alternatives as it has optimal anatomical properties that can provide ideal coverage in a wide range of reconstructive challenges. The purpose of this study was to present our experience with the serratus anterior fascia flap in a variety of complex soft tissue defects. A retrospective review was conducted on patients who underwent reconstruction with the free serratus anterior fascia flap for complex soft tissue defects involving the distal extremities. Complex soft tissue defects of 13 patients were reconstructed using the free serratus fascia flap. No major postoperative complications such as flap loss, dehiscence, infection, or hematoma were encountered in any of the patients. All of the patients demonstrated durable and harmonious long-term flap coverage that facilitated movement without any signs of scar contractures and tendon adhesions at the site of reconstruction. The serratus anterior fascia flap demonstrates versatility and stability for the closure of complex distal extremity defects. It creates thin yet durable coverage that facilitates underlying tendon gliding while providing harmony with the natural contours of these anatomic areas and has low donor site morbidity, making it a primary choice in the reconstruction complex soft tissue defects involving the hands and feet.

The Use of Serratus Anterior Fascial Flap in Integrated Mastectomy and Implant Reconstruction.

Tissue reinforcement with acellular dermal matrix (ADM) in implant-based breast reconstruction contributes to the coverage of the implant and avoids its direct exposure to skin incision, yet not without risk of infection. Our integrated technique makes use of the in situ serratus anterior fascia as a support of the implant following mastectomy, which serves the same purpose of ADM in terms of aesthetic outcomes, but minimizes the hazard of infective complications. We retrospectively reviewed all the nipple-sparing mastectomies with direct-to-implant immediate reconstruction in Hong Kong Sanatorium and Hospital from 2012 to 2016. The authors made use of the serratus anterior fascial flap as inferolateral coverage for the subpectoral implant. Consequently, the implant would be completely covered by autologous tissues. Among the 51 women included, primary breast cancers account for 91.8% of our indications for these 61 procedures of integrated mastectomy and implant reconstruction. The remaining five (8.2%) were performed as contralateral prophylactic mastectomy. Almost three quarters of the patients had a bra cup size of B or below. After a mean follow-up of 28.9months, there was no reported post-operative complication of skin flap or nipple-areolar complex necrosis, or infection or extrusion of the implant. Our series support that the serratus anterior fascial flap could provide autologous coverage in integrated mastectomy and implant breast reconstruction, especially in small- and medium-sized breasts. Appropriate patient selection, as well as meticulous surgical technique, is critical for its success.

Abstract: Adipofascial Flap Versus ADM: An Intraoperative Selection Algorithm for Implant Coverage in Immediate Breast Reconstruction

PURPOSE: Acellular dermal matrix (ADM) has gained popularity1 to enhance lower pole coverage in immediate implant or expander reconstruction. Advantages of ADM include improved rapid reconstruction, postoperative expander filling and lower capsular contracture. Potential trade-offs include higher seroma, infection2,3 and cost. Alternatives for implant coverage include local fascial flaps and inferior dermal flaps as autologous options in select patients.4,5 Given the controversy about the use of ADM, this study provides an intraoperative algorithm for its selective use and review of clinical outcomes in two-stage immediate breast reconstruction. METHODS: A 2 year retrospective chart review of women who underwent the first-stage of two-stage immediate tissue expander reconstruction following skin-sparing mastectomy by two senior surgeons. Patients who had an inferior dermal flap were excluded. Patients were divided into two groups: Group 1 was reconstructed with ADM as an adjunct, and group 2 had a local adipofascial flap. Primary outcomes measures included intraoperative and first visit expander-fill volume, time to reach final fill volume, expansion ratios and clinic visits. Secondary outcome measures included the size of expander, pain during inpatient stay, and complications. RESULTS: 84 patients (148 expanders) were included: group 1 (ADM) had 41 patients (72 breasts) and group 2 (No ADM) had 43 patients (76 breasts). There were no statistical differences in patient demographics, mastectomy weight (P=0.10), and expander placement plane. There were no significant differences between the two groups of tissue expanders for intraoperative expansion volume (P=0.15), total expansion volume (P=0.28), and number of inflations required (P=0.18). Multivariate models adjusted for expander placement and postoperative radiation demonstrated that ADM patients had 0.13 higher expansion ratio intra-operatively (P=0.02) and at the first postoperative fill (P=0.001), but this did not differ significantly for final expansion volumes (P=0.58). There were 10 complications, 6 in the ADM and 4 in the no ADM groups. Complications were treated conservatively except two patients who had previous radiotherapy and requiring explantation for infection (ADM, N=1) and mastectomy skin flap necrosis (No ADM, N=1). CONCLUSION: We provide an anatomical and simple surgical approach to successfully assess and perform adipofascial flaps for implant coverage. Autologous adipofascial tissue, if present, can provide reliable comparable coverage to the inferior pole of the implant with no increased morbidity, complications, and comparable outcomes and can have a beneficial cost reduction. REFERENCES: 1. Gurunluoglu R, Gurunluoglu A, Williams SA, Tebockhorst S. Current trends in breast reconstruction: survey of American Society of Plastic Surgeons 2010. Ann Plast Surg. 2013;70(1):103–10. 2. Antony AK, McCarthy CM, Cordeiro PG, et al. Acellular human dermis implantation in 153 immediate two-stage tissue expander breast reconstructions: determining the incidence and significant predictors of complications. Plast Reconstr Surg. 2010;125(6):1606–14. 3. Berry T, Brooks S, Sydow N, et al. Complication rates of radiation on tissue expander and autologous tissue breast reconstruction. Ann Surg Oncol. 2010;17 Suppl 3:202–10. 4. Saint-Cyr M, Dauwe P, Wong C, Thakar H, Nagarkar P, Rohrich RJ. Use of the serratus anterior fascia flap for expander coverage in breast reconstruction. Plast Reconstr Surg. 2010;125(4):1057–64. 5. Kijima Y, Yoshinaka H, Owaki T, Funasako Y, Aikou T. Immediate reconstruction using inframammary adipofascial flap of the anterior rectus sheath after partial mastectomy. Am J Surg. 2007;193(6):789–91.

Diaphragmatic Reconstruction Using Combined Reversed Extended Latissimus Dorsi and Serratus Anterior Fascia Flaps

The autologous or "extended" latissimus dorsi flap is a standard technique in breast reconstruction. The authors report a case of gastrobronchial fistula after sleeve gastrectomy managed by a new option, combing a reversed "extended" latissimus dorsi flap and a serratus anterior fascia flap. It provides good quality autologous living tissue to treat thoracoabdominal infection associated with diaphragmatic necrosis. Aggressive management, such as surgical resection, should be performed for these patients with a benign but life-threatening disease.

Use of the Serratus Anterior Fascia Flap for Expander Coverage in Breast Reconstruction

Postmastectomy partial submuscular tissue expander placement can prevent the upper pole fullness commonly seen with complete submuscular prosthesis placement. The resultant inferior and lateral margins require coverage to prevent prosthesis exposure. The fascial layer overlying the serratus anterior muscle can be used as an alternative to previously defined techniques to provide composite lateral coverage. This method offers adequate coverage, prevents expander lateralization, and minimizes use of allogenic material. This study reports the anatomy, surgical procedure, clinical outcomes, and aesthetics following use of the serratus anterior fascial flap for lateral expander coverage in postmastectomy expander-based breast reconstruction. Twenty-two patients (31 breasts) who underwent breast reconstruction with serratus fascia were included in a retrospective case-note analysis after approval by the institutional review board. Demographics, perioperative factors, postoperative complications, patient satisfaction, and aesthetics were recorded as relevant endpoints. Ten fresh cadaver hemichests were dissected, and the serratus fascia for each was measured for length and width. At a mean follow-up of 197 days (range, 71 to 370 days), seroma occurred in two breasts, wound infection occurred in one breast, partial mastectomy skin flap necrosis occurred in four breasts, and minor wound dehiscence occurred in one breast. There were no incidences of capsular contracture or hematoma. Four patients (five breasts) reported very mild tightness or banding in the lateral chest wall. The mean length of cadaver serratus fascia was 164.3 mm and the mean width was 122.8 mm. The serratus anterior fascia flap is a versatile and safe alternative for providing vascularized composite lateral prosthesis coverage in expander-based breast reconstruction.

Free serratus anterior fascia flap for reconstruction of hand and finger defects

Reconstruction of the dorsal surface of hand defects requires thin, pliable, well vascularized tissue with a gliding surface for the extensor tendon course. Also defects of the palmar hand and degloved fingers need non-bulky soft tissue for reconstruction. We present a retrospective analysis of nine patients with free serratus anterior fascia flaps used to cover defects of the palmar and dorsal hand and of degloved fingers. Three of the patients presented limited range of hand motion due to full-thickness burns; one patient had defects of the dorsum of one hand after acute burn injury. Two patients had an acute trauma of the dorsum of the hand with extensor tendon injury, another patient a soft-tissue defect of his thumb and dorsal hand due to an avulsion injury. One patient presented dorsal defect of three fingers after degloving injury. One patient had a palmar defect after industrial crush injury with exposed tendons, vessels, and nerves. The flaps were applied as pure fascial flaps with an immediate partial-thickness skin graft. One patient presented a partial necrosis of <10% flap size. All other flaps survived completely. Two of the patients presented wound healing problems of the skin graft that healed secondarily. All patients recovered useful hand function without a bulky contour of their hand or fingers. Except for the scar, no donor-site morbidity was reported. The free serratus anterior fascia flap has good functional and cosmetic properties and there is low donor-site morbidity. It is an excellent flap for soft-tissue reconstruction combined with extensor tendon reconstruction on the dorsum of the hand. The flap is also very useful for palmar and finger defects.

The interpectoral fascia flap

Despite the great number of pedicled and free flaps that are available for defect and contour repair, the number of fascia flaps with an axial blood supply are sparse. Such flaps with their gliding function are mandatory, whenever coverage with very thin, well-vascularized tissue is necessary. To the currently established fascia flaps, (the temporoparietal fascia flap, the radial forearm fascia flap, the lateral arm fascia flap, and the serratus anterior fascia flap), we want to add a new fascia flap, the interpectoral fascia flap. We dissected the interpectoral fascia flap from 20 cadavers. In each of the 40 hemichests, the trunk of the thoracoacromial vessels was selectively injected with red polyurethane and the tissue containing the pectoral branches was separated from the overlying pectoralis major muscle and converted into an independent fascia flap. The maximum flap length was 13.5 cm and the maximum breadth was 10.3 cm. The length of the vascular pedicle before entering the flap was 3.9 cm +/- 1.4 cm with a range of 1.5-6.8 cm. Concerning the arc of rotation, all 40 flaps reached the posterior axillary fold, and 29 flaps (73%) reached the mandibular border. This new fascia flap has applications as pedicled and as free flap. The pedicled flap is used in the neck region, in the axillary region and as gliding tissue between the nipple-areola complex and the pectoralis major muscle. The usage of the fascia flap as a free flap has similar characteristics as the other fascia flaps.

Devastating Massive Knee Defect Reconstruction Using the Cornucopian Chimera Flap from the Subscapular Axis: Two Case Reports

Two cases of successful reconstruction of massive defects around the knee with multiple-island combined flaps based on the subscapular axis are reported. Both defects resulted from aggressive debridement for acute osteomyelitis after open fixation of high-energy fractures around the knee. In Case 1, a four-island combined flap consisting of the scapular flap, the lattissimus dorsi muscle flap, the serratus anterior muscle flap, and the scapular osseous flap, based on the same subscapular axis, was used. Partial bone transport using the Ilizarov apparatus was added as reinforcement of arthrodesis. In Case 2, a five-island combined flap, consisting of the scapular, parascapular flap, the lattissimus dorsi muscle flap, the serratus anterior fascial flap, and the scapular osseous flap, was used. Consequent ankylosis of the knee joint afforded the patient painless full weight bearing without secondary arthrodesis. Multiple-island combined flaps based on the subscapular axis can provide three-dimensional reconstruction of destructive knee defects.

Reconstruction of the Replanted Hand with Latissimus Dorsi Muscle and Serratus Anterior Fascia Combined Flap

Reconstruction with the latissimus dorsi muscle flap, combined with the serratus anterior fascia flap, was performed to cover two large and separate palmar and dorsal forearm skin defects in a patient, whose hand had been replanted 20 days earlier after traumatic amputation at the distal forearm level. As a result, a total forearm amputation was salvaged by microsurgical replantation and a free combined flap of the subscapular system. This new application of the combined flap allowed the reconstruction of large and separate wounds of the replanted hand, and provided gliding surfaces for tendons.