Superficial Inferior Epigastric Vessels Research Articles

The superficial inferior epigastric artery flap and its relevant vascular anatomy in korean women.

BackgroundLower abdominal soft tissue transfer is the standard procedure for breast reconstruction. However, abdominal wall weakness and herniation commonly occur postoperatively at the donor site. To reduce the morbidities of the donor site, the superficial inferior epigastric artery (SIEA) flap was introduced, but inconsistent anatomy of the SIEA has reduced its utility. In the present study, the anatomy of the superficial inferior epigastric vessels in Korean women was determined with regards to breast reconstructive surgery.MethodsThe vascular anatomies of the SIEA and superficial inferior epigastric vein (SIEV) were evaluated on 32 breast cancer patients receiving free transverse rectus abdominis musculocutaneous flap reconstruction after mastectomy. The existence, pulsation, location, external diameter, and depth of the SIEA and SIEV were measured at the lower abdominal incision level.ResultsSIEA and SIEV were present in 48/64 (75.00%) and 63/64 (98.44%) hemi-abdomens, respectively. Pulsation of the SIEA was found in 44/48 (91.67%) cases. The mean locations of SIEA and SIEV were +5.79 (±12.87) mm, and -8.14 (±15.24) mm from the midpoint between the anterior superior iliac spine and symphysis pubis, respectively. The mean external diameters of SIEA and SIEV were 1.20 (±0.39) mm and 1.37 (±0.33) mm, and they were found at a mean depth of 9.75 (±2.67) mm and 8.33 (±2.65) mm, respectively.ConclusionsThe SIEA was absent in 25% of Korean women and had a relatively small caliber. Therefore, careful preoperative assessment of the lower abdominal vasculature is required to achieve successful breast reconstruction using SIEA flaps.

Is It Possible To Increase Flap Viability by Hydrostatic Dilation? An Experimental Study in the Rat Abdominal Fasciocutaneous Flap Model

INTRODUCTION Ergun et al previously demonstrated the efficacy of hydrostatic dilation in a TRAM flap model in an experimental study. We investigated the effect of hydrostatic dilation on a fasciocutaneous flap model. METHODS Eighteen female Wistar rats were equally divided into 3 groups, of which 1 served as a control. In the second, the abdominal fasciocutaneous flap surgical delay procedure was performed by division of the left superficial inferior epigastric (SIE) vessels. In the third, hydrostatic dilation was performed on the left SIE artery and vein, with a mean pressure of 300 mm Hg, while elevating the flap on the right-sided SIE pedicle. The groups were compared by microangiography and by the survival ratio of abdominal flaps 7 days after elevation. RESULTS The mean (SD) flap necrosis rates were as follows: control group, 44.75% (4.31%); delay group, 33.32% (7.11%); and hydrostatic dilation group, 32.51% (5.03%). There was a significant difference between the control group and the other 2 groups (P < 0.05). There was no difference between the delay and hydrostatic dilation groups with respect to surface area necrosis. The microangiographies showed remarkable increased vascularity in the delay and hydrostatic dilation groups. CONCLUSIONS Hydrostatic dilation is a new method of enhancing flap viability that could be used in clinical cases in place of surgical delay once further studies and clinical trials are completed.

Application of Digital Infrared Thermographic Imaging (DITI) in the Monitoring of Change of Skin Temperature about Vascular Supply of Lower Abdominal Axial Flap in the Rabbit

MethodsEight male New Zealand white rabbits with average weight of 3kg were used. A 10 x 10 cm unipedicled fasciocutaneous island flap was elevated based on the left superficial inferior epigastric vessel. The surface temperatures on designed flap were checked with DITI for 24 hours after the operation. On 14th day after the operation, the surviving area was measured and compared with DITI image which was taken on 24 hours after the operation using digital analysis software ImageJ. Statistical analysis was evaluated by paired T-test ResultsOn DITI image 24 hours after the flap elevation, distal portion of the flap showed remarkable color change. The average percentage and the standard deviation of the survival area of the flap which is predicted by DITI and the average percentage and the standard deviation of the survival area of the flap which was actually measured 2 weeks after flap elevation were 55.3 (16.6), 56.2 (18.0), respectively. This shows no significant difference between the two. ObjectivesMonitoring viability of flap is important. The flap survival depends on the vascularity of the flap, on which the skin temperature depends. The authors applied digital infrared thermographic imaging (DITI) for monitoring the vascular supply of the flap and for the prediction of the prognosis of the flap survival. MethodsEight male New Zealand white rabbits with average weight of 3kg were used. A 10 x 10 cm unipedicled fasciocutaneous island flap was elevated based on the left superficial inferior epigastric vessel. The surface temperatures on designed flap were checked with DITI for 24 hours after the operation. On 14th day after the operation, the surviving area was measured and compared with DITI image which was taken on 24 hours after the operation using digital analysis software ImageJ. Statistical analysis was evaluated by paired T-test ResultsOn DITI image 24 hours after the flap elevation, distal portion of the flap showed remarkable color change. The average percentage and the standard deviation of the survival area of the flap which is predicted by DITI and the average percentage and the standard deviation of the survival area of the flap which was actually measured 2 weeks after flap elevation were 55.3 (16.6), 56.2 (18.0), respectively. This shows no significant difference between the two. ConclusionsThis study shows that DITI system could be used in evaluation of flap vascularity with ease, quickness and safety for patient and flap. Thus, it could be used clinically for the prediction of flap survival.

Evidence-Based Analysis of Lymph Node Transfer in Postmastectomy Upper Extremity Lymphedema

Upper extremity lymphedema is one of the most important sequelae of mastectomy and affects an estimated 16 to 39% of breast cancer patients [1]. Few surgical options for lymphedema have achieved satisfactory long-term results. Amongst previously described methods, the microvascular node transfer (LNT) is the most promising and appears to provide significant improvement, especially in early stage lymphedema. We evaluated the existing literature, looking at the influence of LNT on extremity lymphedema through a systematic review. We searched the PubMed database for English articles published from January of 1990 to March of 2012. Our keywords included postmastectomy upper extremity lymph node transfer, and node. This search was supplemented by a review of reference lists of potentially eligible studies. We excluded experimental studies, case reports, and studies in which the results were not separated for the and lower limbs. Two reviewers independently extracted data in two steps: titles and abstracts, and then full-text articles. Through our electronic and reference search, we identified 5 clinical studies (Table 1) [1-5]. All of the studies were case series (level IV evidence). Table 1 The five clinical studies on node transfer in extremity lymphedema In total, 73 patients received LNT for extremity lymphedema. The recipient site was the wrist in 32 patients (43.8%), the axilla in 32 patients (43.8%), the forearm in 2 patients (2.7%), and 7 patients (9.5%) received two LNTs (axilla and elbow). Lin et al. [1] used a groin flap containing nodes based on the superficial circumflex iliac vessels and the anastomoses were performed to the superficial radial artery and cephalic vein. Becker et al. [2,3] used a similar groin flap but as recipient vessels, used the circumflex scapula vessels. Gharb et al. [4] described a modification of the classic groin node flap. The authors used the superficial branch of the superficial circumflex iliac artery as the dominant vessel responsible for the vascularization of the nodes. The wrist was used as a recipient site, with the anastomosis to the radial artery end-to-side, and the concomitant veins of the radial artery end-to-end. Saaristo et al. [5] combined the breast reconstruction using abdominal flaps with the transfer of vascularized inguinal nodes based on the superficial circumflex iliac vessels or the superficial inferior epigastric vessels, and the anastomoses were performed from the deep inferior epigastric vessels end-to-end to the thoracodorsal vessels. According to the research, there is no consensus on the staging of lymphedema. Only three studies [2-4] have reported precise preoperative staging systems; however, each study used different criteria. Fifty-seven of 73 patients (78%) had postoperative improvement of the affected limb. In every study, a different postoperative evaluation method was used, and the relationship between the node recipient site (axilla, elbow, or wrist) and the anatomical site with the maximum improvement was not clearly reported. Becker et al. [2] reported that from the 18 patients, the limb perimeter returned to normal in 10 cases, remained unchanged in 2 cases, and decreased by more than 50% of its value in 6 patients and less than 50% of its value in 6 other patients. Two years later, Becker et al. [3] evaluated the influence of LNT in neuropathic pain in 6 patients. All of the patients had relief of the symptoms and in 5 patients the lymphedema resolved. Gharb et al. [4] compared the classic groin node flap with a groin flap based on hilar perforators and reported that differences between the preoperative and postoperative measurements were statistically significant only in the perforator-based group at the levels below the elbow, wrist, and midpalm. Saaristo et al. [5] achieved reduction of the affected limb in 7 of 9 patients. Even though it is implied that at early stage lymphedema, the LNT has better results, the influence of LNT at each stage of lymphedema is not clear. In addition, 17.8% of the patients required an additional procedure (suction assisted lipectomy [SAL] or skin excision) due to lack of sufficient improvement after LNT. According to existing clinical studies, LNT is able to alleviate extremity lymphedema. However, the improvement is variable and no conclusions have been drawn regarding which technique, group of donor nodes, or recipient site can ensure the maximum reduction of the affected limb. More clinical studies are needed, and a consensus about the staging system of lymphedema and the evaluation methods for postoperative results should be established to enable drawing more certain conclusions.

Sub-Scarpal Fat Pad Thickness May Predict Perfusion Patterns In Abdominal Wall Flaps

INTRODUCTION: Abdominal wall flaps are routinely used in reconstructive procedures. Large caliber of the deep inferior epigastric vessels lends these flaps to good outcomes. Occasionally, these deep system perforators are of limited caliber, which may lead to either poor flap perfusion or venous congestion from poor drainage. The superficial inferior epigastric vessels are occasionally of sufficient size to allow for microvascular revascularization, however they have a higher rate of fat necrosis from poor perfusion. We designed this study to look at the relationship of the sub and supra-scarpal fat layers, to the number of deep system perforators and SIEV size METHODS: 14 abdominal/pelvic CTA s were examined of women (ages 34 -70). The CTAs were examined for number of perforators, SIEV size at 10 cm below the umbilicus, height of sub-scarpal fat pad and supra-scarpal fat pad at 10 cm below the umbilicus at the edge of rectus fascia. These data were gathered for each hemi abdomen giving 28 data points. RESULTS: The average supra-fascial height was 20.73 mm with a range of 4.3 to 50 mm. Average sub-fascial height was 7.06mm with a range of 2.0 to 14.5 mm. The average ratio of fat pads was 3.72 with a range of 1.13 to 11.5. Average SIEV diameter was 2.86 range (1.48-5.4mm). Average number of perforators was 3.4, range (1-7). Hemi-abdomens with supra-fascial fat greater than 21 mm in height had greater vein diameter 3.8 v 2.26mm but fewer perforators 3.1 v 3.6. Sub-fascial fat greater than 7mm had less perforators 2.3 v 4.1 and greater SIEV diameter 3.5 v 2.42mm. Neither an above or below average ratio of the fat layer heights had a difference in SIEV size (2.74 v 2.9 mm respectively). Above average ratios had 3.7 perforators verses 3.2 for below average ratios. CONCLUSION: A sub-scarpal fascial layer thicker than 7mm may indicate poorer abdominal flap perfusion off the deep inferior epigastric system as these hemi-abdomens had fewer perforators and larger SIEVs. This may serve to warn us during harvesting to preserve the superficial vessels in patients who fit this criteria.

Vascularised fat flaps lose 44% of their weight 24 weeks after transplantation

Microsurgical transfer of the vascularised fat flaps has become a well-established method for soft-tissue augmentation because it has been believed to provide the restoration of symmetry without atrophy. Yet little has been reported on the long-term fate of the vascularised fat flaps. The purpose of this study was to evaluate the postoperative changes that occur in the vascularised fat flaps after transplantation. The superficial epigastric fat flaps based on the superficial inferior epigastric vessels in rats were used for this study. Postoperative changes were analysed by comparing pre- and postoperative weight, histological examination and fluorescent angiography. The weight of vascularised fat flaps was 56±18% of the original weight (corrected for body weight gain) 24 weeks after transplantation. In histological examinations, the vascularised fat flaps had almost normal appearances throughout the experimental period. Apoptosis of adipocytes was detected in the vascularised fat flaps using terminal deoxynucleotidyl transferase (TdT)-mediated deoxy-uridine triphosphate (dUTP)-biotin nick end-labelling (TUNEL) method during the first 4 weeks after transplantation. The vascularised fat flaps reduced in weight by about 44% over a period of 24 weeks after transplantation. Apoptosis may partly explain the weight loss.

Extravascular Injection of Sclerotic Agents does not Affect Vessels in the Rat: Experimental Implications for Percutaneous Sclerotherapy of Arteriovenous Malformations

ObjectivesSclerotherapy is useful for the treatment of arteriovenous vascular malformations. However, intravascular administration of sclerotic agents into small arteriovenous niduses is often difficult. Extravascular administration of sclerotic agents causes reduction of vascular flow on Doppler echo during clinical sclerotherapy. Therefore, we aimed to investigate whether the extravascular injection of sclerotic agents affects tiny vessels. DesignAnimal study. MaterialsThe effect of extravascular injection of sclerotic agents on vessels was investigated using rat femoral and superficial inferior epigastric vessels. MethodsAfter surgical exposure of vessels, absolute ethanol, 5% ethanolamine oleate and 3% polidocanol were injected into perivascular surrounding tissues, and their effect on vessels was evaluated after 14 days using histology and coloured silicone rubber injection. ResultsThe integrity of the vascular lumen, endothelial cells and vascular patency were not affected by injection of sclerotic agents. ConclusionsAttenuation of vascular flow of an arteriovenous shunt after extravascular injection of sclerotic agents is transient and/or trivial and does not cause disruption of vessels. Therefore, sclerotic agents should be delivered to obtain sufficient destruction of arteriovenous malformation lesions and blood flow.

A Reappraisal of the Free Groin Flap in Aesthetic Craniofacial Reconstruction

Craniofacial defects are often associated with 3-dimensional volumetric contour deficiencies. The free groin flap was historically popular though technical limitations subsequently caused its use to fall from favor. We sought to determine if a role remained for the free groin flap in aesthetic craniofacial reconstruction. From May 2005 to July 2010, 15 patients had 18 consecutive free groin flaps performed by the senior surgeon at the R Adams Cowley Shock Trauma Center and the Johns Hopkins Medical Institute. Data collected included age, sex, operative date, etiology, defect size, recipient vessels, complications, donor-site closure, and follow-up time. Eighteen groin flaps were used for the patient cohort consisting of 10 males and 5 females (mean age, 26 years; range, 18-40 years) who underwent reconstruction necessitated by various oncologic, traumatic, infectious, and congenital etiologies. The average defect size was 7.3 × 6.3 cm (range, 3-10 × 1-10 cm). Seventeen flaps were based on the superficial circumflex iliac vessels and 1 on the superficial inferior epigastric vessels. Seventeen flaps used the superficial temporal artery and vein as the recipient vessels, and the remaining flap used the superior thyroid artery and retromandibular vein. Of the 18 flaps, 17 survived (94% survival rate). All donor sites were closed primarily. Follow-up time ranged from 6 to 60 months. The free groin flap is generally underused in the reconstruction of complex craniofacial facial defects. Its unique characteristics and minimal donor-site morbidity should prompt the reconstructive surgeon to retain the free groin flap in his or her armamentarium.

Short-Term Application of Doxorubicin Chemotherapy Immunosuppressive Side Effects for Composite Tissue Allotransplantation

Adjuvant chemotherapy is often required for the treatment of bone cancers after tumor resection, which often results in a large continuity defect. The immunosuppressive side effects could instead be exploited to allow immediate reconstruction with a composite tissue allograft (CTA) that would provide for replacement of tissues. We used a short course of doxorubicin to achieve a novel method of immunosuppression in a rat model undergoing CTA to create an immunological environment for allograft survival. The Institutional Animal Care and Use Committee-approved protocol consisted of 3 experimental groups. Groups 2 and 3 consisted of Brown Norway rats (n = 5) as allograft donors and Lewis rats (n = 5) as transplant recipients. An abdominal wall CTA was harvested off the superficial inferior epigastric vessels. Doxorubicin therapy was administered in group 3 animals. Survival of the CTA was assessed by physical examination and histological analysis. Allotransplant without treatment showed complete clinical and histologic rejection by day 7. Allotransplant rats treated with doxorubicin had clinically and histologically normal grafts through day 10. Kaplan-Meier survival analysis showed a statistically significant difference, with increased CTA survival time to end point with doxorubicin treatment, from a mean of 8.8 days in group 2 to 16.4 days in group 3. Allotransplant flaps without treatment developed complete clinical and histological rejection. The allotransplant group which received doxorubicin showed a delay of allograft rejection with an 86% increased CTA graft survival time. This demonstrates the feasibility of the immunosuppression side effect caused by chemotherapy to prevent rejection of a CTA.

Mesenchymal Stem Cells Transduced by Stromal Cell–Derived Factor-1α Augment Ischemic Free Flaps' Survival

Mesenchymal stem cells (MSCs) have the potential for differentiating into vascular endothelial cells. Stromal cell-derived factor-1α (SDF-1α) plays an important role in neovascularization of ischemic flaps. The authors evaluated the feasibility of applying MSCs transduced by SDF-1α gene to the treatment of early and partial ischemic free flaps survival. MSCs were isolated from Lewis rats and cultured in vitro. Recombinant adenovirus encoding SDF-1α gene (Ad-SDF-1α) was transduced into the MSCs. Lewis rats that underwent epigastric free flaps based on medial and lateral branches of superficial inferior epigastric vessels and femoral vessels were equally randomized into 4 groups, and injected with Ad-SDF-1α-transduced MSCs, MSCs, Ad-SDF-1α, and normal saline, respectively. Gene transduction, flaps survival, neovascularization, and expression level of SDF-1a protein were detected. The results showed that Ad-SDF-1α-transduced MSCs expressed higher SDF-1α both in vitro and in vivo, yielded more survival area, and resulted in higher neovascularization than any other groups. Interestingly, the necrotic sites of all free flaps were in the proximal end rather than in the distal end. In conclusion, Ad-SDF-1α-transduced MSCs can increase neovascularization of early and partial ischemic free flaps and augment the surviving areas.

Fiabilisation du lambeau de SIEA par angiographie fluorescente peropératoire au vert d’indocyanine en reconstruction mammaire

The lower abdominal skin and fat have become a standard for breast reconstruction. For 30 years, techniques have evolved, seeking to reduce the morbidity while increasing the reliability of the flap. The Superficial Inferior Epigastric flap Artery (SIEA) spares the abdominal fascia and provides a very satisfying autologous breast reconstruction. However, the pedicle of this flap and its angiosome exhibit a considerable variability, making its use less reliable than other abdominal flaps. The Indocyanine green (ICG) is soluble dye. When illuminated by an near-infrared light, the ICG emits fluorescence that is not trapped by the skin. A single device (Photo Dynamic Eye(®)) provides the emission of the near-infrared light and the reception of the fluorescence. It provides therefore a simple and efficient intraoperative real-time surface angiographic imaging. SURGICAL PROTOCOL: After dissecting the superficial inferior epigastric vessels, the abdominal flap was harvested from the abdominal wall preserving one perforator arising from the deep inferior epigastric vessels. The perforator was then clamped, and the vascular territory of the SEIA artery was visualized using laser-induced fluorescence of the indocyanine green. The surgical technique was modified depending on the indication for surgery and the result of perfusion measurements. The authors present four clinical cases of breast reconstruction with SIEA to illustrate this procedure. The SIEA flap is another surgical technique to achieve autologous breast reconstruction without abdominal morbidity or muscular dissection. Intraoperative angiographic imaging with ICG makes this flap more reliable.

Internal Mammary Artery Perforators for the Salvage of a Superficially Dominant Free Flap Breast Reconstruction

Sir: The deep inferior epigastric perforator (DIEP) flap is becoming widely popular for autologous breast reconstruction because preservation of the rectus abdominis musculature can lead to less abdominal wall morbidity and postoperative pain. Alternatively, a muscle-sparing free transverse rectus abdominis musculocutaneous flap offers many similar advantages. In both cases, deep inferior epigastric vessels are usually anastomosed to the recipient internal mammary vessels in the third intercostal space. However, perforating vessels from the internal mammary circulation have also proven to be reliable recipients for anastomosis.1,2 Using the internal mammary perforators primarily obviates the need for partial rib resection and allows the internal mammary vessels to be preserved for potential future use as coronary revascularization grafts. To our knowledge, use of internal mammary perforators for salvage of a congested flap with patent internal mammary anastomoses has not been previously described. In a recent case of a bilateral free flap breast reconstruction, we noted mild congestion in half of the flap, shortly after dividing the superficial inferior epigastric vein (SIEV). The congestion improved slightly with time while the flap remained connected to the deep circulation, and the decision was made to complete the procedure as a muscle-sparing free transverse rectus abdominis musculocutaneous flap with one arterial anastomosis from the deep inferior epigastric artery to the internal mammary artery, and two venous anastomoses from the inferior epigastric venae comitantes to the two internal mammary veins that were present. The other half of the flap had a normal appearance, and a DIEP flap was performed to reconstruct the left breast. However, the right breast flap appeared mildly congested at the completion of the operation, initially improved, and then worsened over the first postoperative day, necessitating operative exploration. At the time of exploration, all arterial and venous anastomoses were found to be widely patent but, once the SIEV was opened, a continuous jet of venous flow was seen, indicating venous congestion despite the two venous anastomoses (Fig. 1). We augmented the venous outflow by coupling a saphenous vein graft between the SIEV and a perforating vein of the internal mammary circulation in the second intercostal space that had been left intact during the mastectomy (Fig. 2). After placement of the interposition graft, the abnormal tissue turgor and congested color of the flap improved immediately and remained normal throughout the postoperative course.Fig. 1.: A continuous jet of venous blood from the SIEV after venotomy in preparation for salvage vein grafting.Fig. 2.: A saphenous vein graft interposed between the SIEV of the flap and a perforating vein of the internal mammary circulation.This case demonstrates the importance of preserving alternative vessels in cases of microvascular breast reconstruction. It also shows that a superficially dominant hemiflap can become congested, even when harvested as a non-DIEP flap with most of the normal deep circulation preserved. The senior author has previously reported a technique for venous augmentation in a DIEP flap by draining the SIEV to one of the venae comitantes.3 Other options for venous augmentation include an interposition vein graft from the SIEV, superficial circumflex iliac vein, or contralateral pedicle to the cephalic vein4 or to recipient thoracodorsal, lateral thoracic, or intercostal veins.5 Internal mammary perforators should be added to the list of venous augmentation recipient vessels. We recommend routine dissection and preservation of the superficial inferior epigastric vessels during flap harvest, and close communication with the breast surgeons to preserve any sizable internal mammary perforators found during the mastectomy. No additional recipient vessel dissection is necessary. If these vessels had not been preserved in this case, salvage of the congested flap would have been more technically difficult. DISCLOSURE No financial support or benefits have been received by any of the authors, by any member of their immediate families, or by any individual or entity with whom or with which the authors have a relationship from any commercial source that is related directly or indirectly to the scientific work reported in this article. Brian D. Cohen, M.D. Nicholas Vendemia, M.D. Division of Plastic and Reconstructive Surgery New York-Presbyterian Hospital New York, N.Y. Jason A. Spector, M.D. Division of Plastic and Reconstructive Surgery Weill-Cornell Medical Center/New York-Presbyterian Hospital New York, N.Y. Christine H. Rohde, M.D. Division of Plastic and Reconstructive Surgery Columbia University Medical Center/New York-Presbyterian Hospital New York, N.Y.

Computed Tomographic Angiography in Planning Abdomen-Based Microsurgical Breast Reconstruction: A Comparison with Color Duplex Ultrasound

To plan abdominal perforator-based microsurgical breast reconstruction, duplex ultrasound is often employed to preoperatively identify the location of abdominal wall perforating vessels. Recently, several groups have published the use of computed tomography angiography for preoperative planning in perforator flap breast reconstruction. The purpose of this study was to compare the accuracy of computed tomography angiography in locating clinically useful abdominal wall perforators with that of duplex ultrasound. A prospective study was conducted of 22 consecutive patients undergoing 30 abdomen-based microsurgical breast reconstructions using both preoperative computed tomography angiography and duplex ultrasound. Perforator data were obtained with both computed tomography angiography and ultrasound. The two largest perforators were chosen per abdominal side for comparison between studies. In addition, the locations of perforators were confirmed at surgery. Computed tomography angiography preoperatively identified 83 of the largest perforators, while only 55 of these large perforators (66.3 percent) were preoperatively identified on ultrasound. No superficial inferior epigastric arteries were identified by ultrasound. However, in all eight breast reconstructions performed with the superficial inferior epigastric system, the superficial inferior epigastric arteries were identified preoperatively as adequate size for microsurgical transfers, with an average diameter of 1.6 mm. There are many advantages to preoperative computed tomography angiography for planning abdominal perforator-based microsurgical breast reconstruction, including accurate identification of perforating vessels, the underlying branching pattern of the deep inferior epigastric artery, and the presence of the superficial inferior epigastric vessels. This study demonstrates the superiority of computed tomography angiography over duplex ultrasound as a tool for preoperative planning of perforator-based breast reconstruction.

Comparison of Two Different Vascular Delay Methods in a Rat Cranial Epigastric Perforator Flap Model

The effectiveness of vascular delay in transverse rectus abdominis muscle flaps has been demonstrated in many studies. In deep inferior epigastric perforator flaps, however, the effectiveness of ligation of deep versus superficial epigastric vessels in producing delay is unclear. Using a rat model, we compared ligation of deep and superficial vessels with each other and with a (nondelayed) control group (n = 10). One vascular delay group (n = 10) had ligation of the contralateral cranial epigastric vessels (homolog to the human deep inferior epigastric vessels); the other (n = 10) had ligation of contralateral superficial inferior epigastric vessels. One week later, cranial epigastric perforator flap elevation was performed. Both vascular techniques were effective in producing delay, and there was no statistically significant difference between the 2 groups. Ligation of superficial inferior epigastric vessels, deep inferior epigastric vessels, or both, at least 1 week prior to the deep inferior epigastric perforator flap elevation may increase the usable skin paddle area in humans.

Superficial Inferior Epigastric Vessels in the Massive Weight Loss Population: Implications for Breast Reconstruction

Breast cancer risk and reconstructive options after massive weight loss are undefined. Use of the resulting pannus for autologous reconstruction is possible, with one option being the superficial inferior epigastric artery (SIEA) flap. Large superficial inferior epigastric vessels have been observed in massive weight loss patients during abdominal contouring procedures, but their anatomical features have not been assessed. Thirty-two consecutive massive weight loss patients undergoing abdominal contouring had their superficial inferior epigastric vessels measured intraoperatively to assess correlation with body mass indices and pannus weight using appropriate statistical analyses. Sixty-four hemiabdomens were assessed. Mean age was 46 +/- 9.8 years. Mean maximum body mass index was 49.5 +/- 8.3, current body mass index was 29.6 +/- 6.0, change in body mass index was 19.9 +/- 5.6, and mean pannus weight was 3338.4 g. Mean artery size was 1.7 mm and mean vein size was 2.9 mm. Thirty-two of 62 hemiabdomens (52 percent) had a usable vessel (>or=1.5 mm). Maximum body mass index was related to the overall presence of a SIEA (p = 0.009) or usable artery (p = 0.04), whereas both current body mass index and maximum body mass index were related to superficial inferior epigastric vein size (p < 0.001). Pannus weight was correlated to superficial inferior epigastric vein and SIEA size (p < 0.001) and strongly correlated to current body mass index (r = 0.78) and maximum body mass index (r = 0.46). The superficial inferior epigastric vessel system is commonly present in massive weight loss patients. Body mass index before weight loss is the strongest predictor of SIEA presence and usability. When massive weight loss patients present for breast reconstruction, careful patient selection along with weight loss history and assessment of pannus size may aid in determining the likelihood of using the SIEA flap.

A Novel Model for Supermicrosurgery Training: The Superficial Inferior Epigastric Artery Flap in Rats

The purpose of this study was to determine the usefulness of a new flap model, the superficial inferior epigastric artery (SIEA) flap for supermicrosurgical training. Experimental groups were randomly divided into three groups of 10 rats each. In each group SIEA flaps were elevated and then returned to their original locations with or without vascular anastomosis of the superficial inferior epigastric vessels. Group 1: free SIEA flap, group 2: free SIEA flap with 1 hour ischemia time, group 3: free SIEA flap with 4 hours ischemia time, group 4: SIEA flap without vascular anastomosis. The viability rate was 80% with group 1, 50% with group 2, and 40% with group 3. All nonvascularized flaps (group 4) underwent complete necrosis. These findings suggest that preservation of blood flow in a flap has a beneficial effect on the prevention of microthrombosis in the subcutaneous capillary network of the skin and increases the flap survival rate. The SIEA flap with preserved circulation is an ideal model for developing supermicrosurgical skills.

Effect of Hydrostatic Dilation on Flap Viability of the Transverse Rectus Abdominis Musculocutaneous Flap Model in Rats

The technique of intraoperative vessel hydrostatic dilation is sometimes used to facilitate microvascular anastomosis and prevent vasospasm. Currently, delay procedures remain a reliable method of maximizing flap survival. The authors aimed to increase rat transverse rectus abdominis musculocutaneous (TRAM) flap viability by imitating the physical effect of a surgical delay procedure with hydrostatic dilation. Forty-five male Sprague-Dawley rats were randomly assigned to one of three TRAM flap groups (15 rats in each group): the control group, the delay group, and the hydrostatic dilation group. The surgical delay procedure was performed by division of right-sided cranial epigastric vessels and contralateral superficial inferior epigastric vessels. While elevating the flap, hydrostatic dilation was performed to the cranial epigastric artery and vein with a mean pressure of 250 mm Hg. The groups were compared by means of microangiography and survival ratio of TRAM flaps and mean artery lumen area, mean vein lumen area, and mean artery wall area of the flap pedicle 48 hours after elevation. There was a significant difference between the control and hydrostatic dilation groups in favor of surface area viability and angiographic assessment (p < 0.01). Surgical delay has traditionally been accepted as the most reliable method of enhancing flap viability. No significant difference was revealed between the surgical delay and hydrostatic dilation groups (p > 0.05). In the hydrostatic dilation group, compared with the control group, an increase in vein diameter, a thinning of the artery wall, and an increase in lumen diameter were observed. The physical effect of blood flow is achieved acutely with hydrostatic dilation. This simple, dependable, one-stage hydrostatic dilation procedure can be used in clinical applications.

Double-pedicle abdominal perforator free flaps for unilateral breast reconstruction: new horizons in microsurgical tissue transfer to the breast

The DIEAP (deep inferior epigastric artery perforator) flap is a suitable option for breast reconstruction resulting in excellent aesthetic outcome, and minimal donor site morbidity. Contraindications for use of the DIEAP flap may include previous abdominal liposuction and/or surgery, or lack of abdominal tissue. The purpose of this paper is to describe options of using abdominal perforator flaps, based on double-pedicle techniques, despite these contraindications. A retrospective evaluation was carried out on a series of 16 patients who required abdominal double-pedicle free perforator flaps for unilateral breast reconstruction since June 2002. The indications were multiple abdominal scars, previous abdominal liposuction and thin patients in five, three and eight cases, respectively. Preoperative mapping of the vascular network was done using Duplex and/or multi-detector CT scan imaging. Clinical evaluation of medical charts was done regarding patients' characteristics, surgical techniques, ischaemia/total operative time and complications. A clinical evaluation was done on all patients with average follow up of 15 months. Fat necrosis was investigated clinically and by mammogram examination. Different microsurgical techniques were performed to provide enough blood supply to the requested flaps: Perforator (P) to contralateral Deep Inferior Epigastric (DIE) anastomosis (P/DIEAP), in two patients; bilateral DIE vessels (DIEAP/DIEAP) in seven patients; and DIE with SIE (superficial inferior epigastric) vessels in seven patients (DIEAP/SIEA). One pedicle was always anastomosed to the internal mammary vessels. The second pedicle was anastomosed end-to-end to a side branch of the DIE or end-to-side with the DIE pedicle in 13 cases. The thoracodorsal vessels were used as recipient vessels for the second pedicle in three cases. Average operative time was 6h 30min (range 5h 30min-8h). All 16 flaps survived and fat necrosis occurred in one case. The harvesting of perforator free flaps may be contraindicated in some patients, however they are still a feasible option as long as the vessels to the skin are present. Preoperative planning combined with high expertise in microsurgical techniques are the key points in the high success rate in these difficult cases.

The superficial inferior epigastric artery fascia flap in the rabbit

In reconstructive surgery, fascial flaps provide thin, pliable tissue for mucosal closure or serve as a highly vascularized support for skin grafts. Their angiogenic potential is used for experimental neovascularization of avascular tissue grafts. However, most fascial flaps in animal surgery have random pattern design with short reach. As a pilot study for a femur revascularization project in rabbits, a new axial fascial flap is described based on the superficial inferior epigastric (SIE) vessels. They were used in this species previously only as ligated bundles or in fasciocutaneous flaps. The topographical anatomy of the SIE-vessels, lower abdominal fascia, and panniculus carnosus are outlined. The angiogenic capabilities are demonstrated microangiographically by abundant vessel formation in a femur allograft. Used in a pedicled fashion, this flap is an alternative to femoral and saphenous vessels for prefabrication or revascularization procedures in the lower abdomen, genital area, and thigh. Distant recipient sites seem possible with microsurgical transfer.

Bovine hemoglobin-based oxygen-carrying solution (HBOC-201) improves flap survival in a rat model of epigastric flap failure

Despite continued improvements in surgical technique and postoperative management of pedicled flaps, partial flap necrosis continues to be a substantial problem. Several researchers sought interventions that would decrease the incidence of this complication. The hypothesis of this study is that a bovine hemoglobin-based, oxygen-carrying solution (HBOC-201) will increase oxygen delivery, thus decreasing the area of necrosis of the marginally perfused portions of a pedicled flap. Eighty male Sprague-Dawley rats were randomly assigned to one of four groups (20 animals in each group): group 1, controls (surgical creation of flap only); group 2, HBOC-201, 2 g i.v., administered preoperatively and on days 3 and 5; group 3, HBOC-201, 4 g i.v., administered preoperatively and on days 3 and 5; and group 4, hemodilution (lactated Ringer's solution) administered preoperatively and on days 3 and 5. A ventral fasciocutaneous flap (5 x 7 cm) was elevated, based on unilateral superficial inferior epigastric vessels, and the flap was replaced and sutured. Animals were examined daily and euthanized on day 7. Prior to euthanasia, digital photographs were taken of each subject, and the images were analyzed for total area of the flap and area of necrosis, using ImagePro software. Using the calculated percentage of necrosis for each animal, a mean value of percent necrosis was obtained for each animal group and used for statistical analysis. Animals in group 2 demonstrated a decreased area of necrosis when compared with the control group (9.14% vs. 22.24%, P = 0.014). In conclusion, the oxygen therapeutic HBOC-201, at a dose of 2 g, administered preoperatively and on days 3 and 5, decreased the area of necrosis in a rat model of epigastric skin-flap failure. Further investigation of this drug and its effects on flap survival is warranted.