Thoracodorsal Vessels Research Articles

Use of Thoracodorsal Artery Perforator (Tdap) Flap to Cover a Laparoscopically Harvested Omental Flap After Modified Radical Mastectomy; a Case Report

Omental flap was introduced for breast reconstruction after mastectomy either alone or as an adjunct to prosthetic reconstruction. Laparoscopically harvested omental flap was used successfully for this issue. Most of reports had described its use after partial mastectomy, skin or nipple areola sparing mastectomies. In this case, we used the thoracodorsal artery perforator (Tdap) flap as a cover for the omental flap in a patient who underwent modified radical mastectomy. Modified radical mastectomy was done in the usual fashion. The descending branch of the thoracodorsal vessel was traced till its main perforator in an antegrade fashion. Then, the supplied skin island flap was created and rotated to cover the laparoscopically harvested omental flap that was delivered after its mobilization through a small epigastric wound from underneath the inner aspect of the lower mastectomy flap. The overall operative time was around 150min. No blood transfusion was required. Pain score was around 6-7 in the early postoperative hours. No major complications were encountered, and the patient was discharged at the third postoperative day. The overall esthetic score was expressed as "good." To our knowledge, this is the first time to report usage of laparoscopically harvested omental flap after modified radical mastectomy with skin coverage by the thoracodorsal artery perforator (Tdap) flap. One criticism that may arise is the dual flap reconstruction; however, this method still as an alternative to the myocutaneous flaps with a reasonable operative time and minimal donor site and overall morbidities with good esthetic outcome. Modified radical mastectomy can be safely and efficiently reconstructed using a laparoscopically harvested omental flap with a cutaneous coverage using the thoracodorsal artery perforator (Tdap) flap.

The extended latissimus dorsi–serratus anterior chimeric local free flap for salvage of the complicated posterolateral thoractomy incision

BackgroundComposite chest wall reconstruction, following the assurance of chest wall stability, often requires well-vascularized soft tissue coverage with flaps to insure adequate wound healing. Unfortunately, prior surgical approaches such as the posterolateral thoractomy incision or extensive wound breakdown may impede the availability of local or regional choices. A free flap would then be a reasonable option, but in the unstable patient a new donor site is unreasonable. Instead, the otherwise inadequate muscle remnants often transected by the usual thoracotomy incision can be extended by microvascular grafts to provide the necessary reach to the defect. MethodThe ipsilateral cephalic latissimus dorsi and/or serratus anterior muscle remnants following their transection by a posterolateral thoractomy incision can be simultaneously raised as a chimeric flap pedicled in common by the thoracodorsal vessels. The distance the pedicle must be extended to reach the defect requiring coverage is measured, and a vascular graft from the descending branch of the lateral circumflex femoral vessels of the same length is harvested. The thoracodorsal vessels are divided, the vascular graft inserted and anastomosed end-to-end to the cut ends of the former, and then the flap can be stretched the required distance for insetting. ResultA case example of use of the ipsilateral latissimus dorsi–serratus anterior muscle remnants used after extension with arterial and venous grafts to the thoracodorsal vessels as the recipient site is presented with successful salvage of a life-threatening posteriolateral thoractomy wound dehiscence. ConclusionTransection of muscles from a posterolateral thoracotomy incision does not preclude their use as flaps in extenuating circumstances. Their pedicle can be extended using vascular grafts and microvascular techniques in a sense to create a local free flap to provide another solution to a challenging problem.

Free-flap breast reconstruction on experimental porcine model

IntroductionFree flaps require mastering microsurgical technique. In addition, breast reconstruction implies accuracy not only in flap survival, but also satisfying aesthetic outcome. Thus, such complex abilities can be acquired by creating experimental models for surgical training. Materials and MethodsIn accordance with relevant anatomy data found in literature, we chose a porcine model and performed a flap similar to the human deep inferior epigastric perforator (DIEP). Furthermore we developed a surgical protocol for a free flap transfer similar to a double-pedicle DIEP flap. The adipo-cutaneous flap was harvested as a free flap based on the superior abdominal vascularization and microsurgical anastomoses were performed to both the internal thoracic and thoracodorsal vessels. ResultsWe were able to harvest a superior epigastric double-perforator free flap with increased similarity to the human DIEP flap. Microsurgical anastomoses were possible to both to the internal thoracic vessels and thoracodorsal vessels, which both proved to have optimal caliber for termino-terminal anastomosis. ConclusionAlthough there are several differences when comparing a swine experimental model with human anatomy, our protocol enhances the possibilities for training in breast reconstruction.

3D-SPA, a method to quantity the three dimensional static prosthetic alignment during conventional gait analysis

The aim of this pilot study was to determine, in a new experimental model, whether complex bioartificial monoblocs of relevant size and stability can be prefabricated in a defined three-dimensional design, in which the latissimus dorsi muscle serves as a natural bioreactor and the thoracodorsal vessel tree is prepared for axial construct perfusion. Eighteen sheep were included in the study, with six animals in each of three experimental groups. Vitalization of the β-tricalcium phosphate-based constructs was performed by direct application of unmodified osteogenic material from the iliac crest (group A), in vivo application of nucleated cell concentrate (NCC) from bone marrow aspirate (group B), and in vitro cultivation of bone marrow stromal cells (BMSC) in a perfusion bioreactor system (group C). The contours of the constructs were designed digitally and transferred onto the bioartificial bone grafts using a titanium cage, which was bent over a stereolithographic model of the defined subvolume intraoperatively. At the end of the prefabrication process, only the axial vascularized constructs of group A demonstrated vital bone formation with considerable stability. In groups B and C, the applied techniques were not able to induce ectopic bone formation. The presented computer-assisted workflow allows the prefabrication of custom-made bioartificial transplants.

Clinical effects of free deep inferior epigastric perforator flap carrying lymphatic groin flap for treatment of upper limb lymphedema after radical mastectomy and breast reconstruction

Objective: To explore the clinical effects of free deep inferior epigastric perforator flap carrying lymphatic groin flap for treatment of upper limb lymphedema after radical mastectomy and breast reconstruction. Methods: From October 2014 to December 2016, 10 female patients, aged 37-60 (48±8) years, who had lymphedema in the upper limb after radical mastectomy, were admitted to Department of Oncology Plastic Surgery of Hunan Cancer Hospital. Three patients suffered recurrent erysipelas infections, and 4 patients suffered consistent neuropathic pain in the upper limb. Free deep inferior epigastric perforator flap carrying lymphatic groin flap was used for breast reconstruction and lymphedema treatment. Operation was performed by 2 surgeon groups including recipient site prepare group and flap harvest group. In the 10 patients, the length of the flaps was (26.2±0.3) cm, the width of the flaps was (13.4±0.4) cm, and the thickness of the flaps was (3.4±0.3) cm. All the donor sites in the abdomen were closed directly. The choices of vascular pedicles and vessels in the recipient sites, operation time, complications, operation effects, and follow-up were recorded. Results: (1) Bilateral vascular pedicle was adopted in flaps of 5 patients. Unilateral vascular pedicle was adopted in flaps of 5 patients. The recipient vessels were proximal and distal ends of internal thoracic vessels in 4 cases, the proximal end of thoracodorsal vessels in 3 cases, the proximal end of internal thoracic vessels in 2 cases, and the proximal end of internal thoracic vessels and thoracodorsal vessels in 1 case. (2) The operation time of the patients was 330-480 (406±55) min. (3) Subcutaneous edema was observed in flaps of 2 patients and donor site of 1 patient, which were all healed by dressing change therapy. The other flaps survived successfully. The reconstructed breasts were in good shape and elasticity. Nine patients had different degrees of relief in lymphedema in the upper limb. All 10 patients were followed up for 6 to 28 months, no one had recurrent erysipelas infections, and neuropathic pain in the upper limb was relieved in 2 patients. Only linear scar was left in the donor sites of 10 patients, and the function of abdomen was not affected without related complications. Conclusions: Free deep inferior epigastric perforator flap carrying lymphatic groin flap can simultaneously accomplish breast reconstruction and upper limb lymphedema treatment, which is worthwhile to be popularized in clinic.

Choice of recipient vessels in muscle-sparing transverse rectus abdominis myocutaneous flap breast reconstruction: A comparative study.

BackgroundThoracodorsal vessels (TDVs) and internal mammary vessels (IMVs) have both been widely employed as recipient vessels for use in free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps. However, whether TDVs or IMVs are preferable as recipient vessels for autologous breast reconstruction with a free MS-TRAM flap remains controversial. The purpose of this study was to compare the clinical outcomes when TDVs were used as recipient vessels to those obtained when IMVs were used as recipient vessels for autologous breast reconstruction with a free MS-TRAM flap.MethodsA retrospective matched-cohort study was performed. We retrospectively reviewed data collected from patients who underwent a free MS-TRAM flap for autologous breast reconstructions after mastectomy between March 2003 and June 2013. After a one-to-one matching using age, 100 autologous breast reconstructions were selected in this study. Of the 100 breast reconstructions, 50 flaps were anastomosed to TDVs and 50 to IMVs. Patient demographics and clinical outcomes including operation time, length of hospital stay, postoperative complications, and aesthetic score were compared between the two groups.ResultsNo statistically significant differences were found between the two groups in patient demographics and clinical outcomes, including the complication rates and aesthetic scores. There were no major complications such as total or partial flap loss in either group.ConclusionsThe results of our study demonstrate that both TDVs and IMVs were safe and efficient as recipient vessels in terms of the complication rates and aesthetic outcomes.

Predictable Location of Breast Sensory Nerves for Breast Reinnervation.

The sensory innervation to the breast originates from the medial and lateral cutaneous branches of the third to fifth intercostal nerves, which are at risk for injury or loss during mastectomy. Providing reinnervation after mastectomy was introduced almost 20 years ago, but it is not widely performed, perhaps because of the difficulty of locating a recipient nerve. The authors have performed cadaveric dissections to allow for precise anatomical localization of the lateral intercostal branch providing breast sensation. Bilateral chest dissections were performed on 10 female cadavers. The lateral intercostal nerve providing sensation to breast tissue was identified. The distances from the sternum, the midclavicular line, and the lateral pectoralis minor-in addition to nerve diameter-were measured. The nerve was successfully identified bilaterally in all cadavers. The majority of nerves (16 of 20) exited from under the fourth rib. The average distance from the sternum was 13.1 ± 1.3 cm (range, 10 to 15 cm) and the average distance from the midclavicular line was 11.8 ± 2.2 cm (range, 8 to 16 cm). The nerve exited at the lateral border of the pectoralis minor or within 2 cm from the lateral border for all cadavers. The diameter of the nerve was consistently 2 mm. The nerve traveled under the thoracodorsal vessels, aiding in identification. The authors identified the predictable location of the lateral intercostal nerve providing sensation to the breast. The authors hope that by enabling surgeons to locate this nerve, more well-conducted studies will be performed investigating techniques and outcomes for breast reinnervation.

Septocutaneous thoracodorsal artery perforator flaps: a retrospective cohort study

This study aimed to investigate the versatility of septocutaneous thoracodorsal artery perforator (TDAP-sc) flaps in various areas in the body and the running pattern of septocutaneous perforators. This retrospective cohort study included 20 consecutive patients who underwent reconstruction of an oncological defect with a TDAP-sc flap from May 2014 to January 2018. Fifteen flaps were free, and the remaining five were pedicled. Surgical details and postoperative complications were investigated. The flap size ranged from 13 × 6.5 to 22 × 15 cm. The defect location was the upper extremity in eight patients, the head and neck in six, the lower extremity in four, and the trunk in two. The septocutaneous perforator arose from the thoracodorsal vessels proximal to the serratus anterior branch in 10 (50.0%) patients, from the thoracodorsal vessels distal to the serratus anterior branch in six (30.0%), and from the serratus anterior branch in four (20.0%). All flaps completely survived, except the one with partial necrosis. The scapula was simultaneously harvested based on the angular branch in three patients who underwent mandibular reconstruction. The TDAP-sc flap can be a versatile option for various types of reconstruction if a dominant septocutaneous perforator is present. Prevalence of a dominant TDAP-sc is estimated at approximately 50%. However, this flap can be harvested without tedious intramuscular dissection, and the two-team approach is possible during tumor resection. The presence of a dominant septocutaneous perforator can expand indication of the TDAP flap.

Nipple-sparing mastectomy and breast reconstruction with a deep inferior epigastric perforator flap using thoracodorsal recipient vessels and a low lateral incision.

Nipple-sparing mastectomy poses challenges in providing esthetically-pleasing immediate autologous breast reconstruction. This study was to investigate the outcomes of nipple-sparing mastectomy with breast reconstruction using free abdominal flaps between two different recipient sites. Between 2010 and 2016, 79 patients who underwent nipple-sparing mastectomy with autologous breast reconstruction using thoracodorsal (TD) vessels in 30 cases or internal mammary (IM) vessels in 49 cases were investigated. Demographics, intraoperative findings, complications, and quality of life using Breast-Q questionnaire were compared between two groups. All flap survived. There was no statistical difference in age, BMI, ischemia time, and flap-used percentage. The TD artery had a statistically smaller diameter 1.8 ± 0.4 mm than the IM artery 2.7 ± 0.43 mm (p = 0.02). At a mean follow-up of 44.4 ± 35.2 months, there was no statistical difference in total complication rates between TD and IM groups (23.3% and 36.7%, respectively, p > 0.05). The "psychosocial well-being" of Breast-Q in TD group 83.9 ± 14.6 was statistically greater than IM group 72.8 ± 17.6 (p = 0.04). Nipple-sparing mastectomy with immediate breast reconstruction using TD vessels with a low lateral scar is a safe procedure that provides an inconspicuous scar with better cosmesis and minimal complication rate.

Salvaging Breast Reconstruction: Profunda Artery Perforator Flaps Using Thoracodorsal Vessels.

Background:Over the years, the choice of recipient vessels for free flap autologous breast reconstruction has shifted from the thoracodorsal to the internal mammary vessels due to ease of flap inset and predictability of anatomy. However, thoracodorsal vessels are still great recipient vessels, and can be useful, especially in the previously failed or staged autologous breast reconstruction. In this study, we present our experience using thoracodorsal or serratus vessels for profunda artery perforator flaps.Methods:Of the 792 autologous free flap breast reconstruction performed, we identified 12 patients (21 flaps) who underwent reconstruction using thoracodorsal or serratus vessels from 2012 to 2017. Flap, patient characteristics, and demographic data and perioperative details were collected.Results:Twenty-one flaps were used to reconstruct 14 breasts in 12 patients. The mean age of patients was 49.6 years old (range, 42–54), the mean flap weight was 354.7 g (range, 170–540 g), the mean body mass index was 28 (range, 23.2–34.4), and the average operative time was 496.1 minutes (266–680). Majority of these patients underwent additional staged free flap reconstruction (following previous deep inferior epigastric perforator flaps) for severe breast contour defects (58%) and for failed previous breast reconstruction (42%). The anastomosis was performed using thoracodorsal (43%), serratus (43%), and profunda artery perforator side branch (14%) vessels.Conclusion:Determining appropriate flap and recipient vessels in a previously failed or staged breast reconstruction is very challenging. Thoracodorsal and serratus vessels are excellent recipient vessels in patients who already have exhausted internal mammary vessels for previous breast reconstruction.

A stratified reconstructive approach for the post burn axillary adduction contractures based on the anatomical study of thoracodorsal vessel perforator system

Background Post-burn axillary adduction contractures (PBAAC) are commonly seen burn sequelae. They occur in various forms. By imposing colossal restriction on the range of mobility of the shoulder, they completely intervene with the upper limb over head functions.

Pedicled Descending Branch Latissimus Dorsi Mini-flap for Repairing Partial Mastectomy Defect: A New Technique.

Volume loss is 1 of the major factors influencing cosmetic outcomes of breast after partial mastectomy (PM), especially for smaller breasts, and therefore, volume replacement is critical for optimizing the final aesthetic outcome. We present a novel technique of raising a pedicled descending branch latissimus dorsi (LD) mini-flap for reconstruction of PM defects via an axillary incision. After PM, the LD mini-flap is harvested through the existing axillary incision of the axillary dissection or the sentinel lymph node biopsy. The descending branches of thoracodorsal vessels and nerve are carefully identified and isolated. The transverse branches are protected to maintain muscle innervation and function. The LD muscle is then undermined posteriorly and inferiorly to create a submuscular pocket and a subcutaneous pocket between LD muscle and superficial fascia. Once the submuscular plane is created, the muscle is divided along the muscle fibers from the deep surface including a layer of fat above the muscle. Finally, the LD mini-flap is transferred to the breast defect. Given the limited length and mobility of the LD mini-flap, this approach is best utilized for lateral breast defects. However, for medial defects, the lateral breast tissue is rearranged to reconstruct the medial breast defect, and an LD mini-flap is then used to reconstruct the lateral breast donor site. This technique can therefore be employed to reconstruct all quadrants of the breast and can provide aesthetic outcomes without scars on the back, with minimal dysfunction of LD muscle.

The anatomy of the musculocutaneous latissimus dorsi flap for neophalloplasty.

In transgender surgery, the ideal neophallus is one that: (a) is constructed using a reproducible procedure, (b) possesses tactile and erogenous sensation, (c) is large and rigid enough (naturally, or using a prosthesis) to permit penetrative intercourse, (d) leaves acceptable donor site morbidity, (e) results in esthetically satisfactory appearance, and (f) allows for voiding while standing. The musculocutaneous latissimus dorsi (MLD) flap has favorable results in the area of neophalloplasty. Among its advantages are acceptable donor site appearance, stiffness sufficient for intercourse, and esthetically satisfactory genital appearance. The anatomy of the MLD flap supports the creation of a neophallus for transsexual anatomy revision. Herein, we give an overview of the advantages and disadvantages of the procedure, and the anatomical details and surgical steps involved. Novel illustrations were created from standard surgical text descriptions to clarify this topic for surgical training and patient understanding and decision making. A review of the relevant literature regarding the anatomy, procedure development, and outcomes is presented. The MLD flap uses part of the latissimus dorsi muscle with branches of the thoracodorsal vessels and nerve to construct a neophallus. A thin strip of muscle around the pedicle is harvested, resulting in a slightly curvilinear scar. The blood supply is connected to the femoral artery and saphenous vein or the deep inferior epigastric artery and vein, while the nerve is connected to the ilioinguinal nerve or the obturator nerve. The MLD flap for neophalloplasty is a reliable graft with a well concealed scar and low donor site morbidity. Clin. Anat. 31:152-159, 2018. © 2017 Wiley Periodicals, Inc.

Determining the best recipient vessel site for autologous microsurgical breast reconstruction with DIEP flaps: An anatomical study

The deep inferior epigastric perforator (DIEP) flap is a reliable and reproducible technique for autologous microsurgical breast reconstruction. Several recipient vessels sites for microvascular anastomosis have been described such as the internal thoracic vessels, the thoracodorsal vessels, and the circumflex scapular vessels. Nonetheless, the choice of the recipient site depends mainly on individual operator's experience and preferences, and currently the best recipient vessel site is under debate. This anatomical observational study aimed to determine whether anatomy could address this dilemma by determining the best vessel diameter to match the donor with these three recipient sites. Our series reports 80 dissections of the three anatomical regions of interest. Forty formalin-preserved female cadavers were dissected bilaterally. Internal vessels diameter measurements were recorded with a vascular gauge ranging from 1.0 to 5.0mm with successive half-millimeter graduations. The median diameter of the deep inferior epigastric (DIEA), internal thoracic (ITA), circumflex scapular (CSA), and thoracodorsal arteries (TDA) were: 2.0, 2.5, 2.5, and 1.5mm, respectively. The median diameter of the deep inferior epigastric, internal thoracic, circumflex scapular, and thoracodorsal veins were: 3.0, 3.0, 3.0, and 2.5mm, respectively. At the individual level, the perfect match between DIEA and ITA was significantly more frequent than between DIEA and TDA (p=0.002), and it was more frequent between DIEA and CSA than between DIEA and TDA (p=0.009). This study supports the use of the internal thoracic pedicle as the first recipient vessel choice, which should be considered, at least anatomically, as the best one with the closest diameter matching with the donor pedicle.

Computed tomography angiographic study of internal mammary perforators and their use as recipient vessels for free tissue transfer in breast reconstruction.

Context:The internal mammary artery perforator vessels (IMPV) as a recipient in free flap breast reconstruction offer advantages over the more commonly used thoracodorsal vessels and the internal mammary vessels (IMV).Aims:This study was designed to assess the anatomical consistency of the IMPV and the suitability of these vessels for use as recipients in free flap breast reconstruction.Patients and Methods:Data from ten randomly selected female patients who did not have any chest wall or breast pathology but had undergone a computed tomography angiography (CTA) for unrelated diagnostic reasons from April 2013 to October 2013 were analysed. Retrospective data of seven patients who had undergone mastectomy for breast cancer and had been primarily reconstructed with a deep inferior epigastric artery perforator free flap transfer using the IMPV as recipient vessels were studied.Results:The CTA findings showed that the internal mammary perforator was consistently present in all cases bilaterally. In all cases, the dominant perforator arose from the upper four intercostal spaces (ICS) with the majority (55%) arising from the 2nd ICS. The mean distance of the perforators from the sternal border at the level of pectoralis muscle surface on the right side was 1.86 cm (range: 0.9–2.5 cm) with a mode value of 1.9 cm. On the left side, a mean of 1.77 cm (range: 1.5–2.1 cm) and a mode value of 1.7 cm were observed. Mean perforator artery diameters on the right and left sides were 2.2 mm and 2.4 mm, respectively.Conclusions:Though the internal mammary perforators are anatomically consistent, their use as recipients in free tissue transfer for breast reconstruction eventually rests on multiple variables.

Bilateral free profunda artery perforator flaps(PAP) for immediate unilateral breast reconstruction: a case report and review of literature

Objective To investigate the possibility of using the profunda artery perforator flap (PAP) for breast reconstruction cases who are not the good candidates for back and abdominal donor sites. Methods This case was a breast cancer patient who required an i mmediate breast reconstruction with autologous tissue,skinny, bilateral severe breast atrophy and mastoptosis after lactation, twice cesarean delivery and umbilical hernia in August, 2016. Portable Doppler was used to detect the profunda artery perforator. The donor sites were designed according to the tissue defect after the mastectomy. The incisions were designed near to the inferior gluteal folds and medial gluteal areas. The left PAP flap was 20 cm × 5 cm, and the right PAP flap was 18 cm × 5 cm. The pedicles length of the both flaps were about 6.0 cm, and the perforator artery diameter of the both flaps were 2.2 mm. The right PAP vessels were connected to the left thoracodorsal vessels with end-to-end anastomosis. The left PAP vessels were connected to the proximal part of left internal ma mmary vessels with end-to-end anastomosis. The indocyanine green angiography under microscope showed the signs of patency in all the vessel anastomosis. Results The intraoperative patho-logic diagnosis was extensive intraductal carcinoma, and the sentinel lymph nodes biopsy showed negative result. The re-constructive breast has a nice appearance, natural and proper IMF. Both of the PAP flaps survive 100%, and the donor sites healed well and remained inconspicuous. The patient can walk freely on the 5th day postoperative, and back to home on the 7th day. Within the follow-up for one month, the patient was very satisfied with the new breast and a better gluteal appearance. Conclusion The free PAP flaps provide an excellent alternative to an abdominal and back donor sites for achieving the breast reconstruction due to the relaible supplying pedicle vessels and invisible donor scars. Key words: Profunda artery perforator (PAP); Breast reconstruction; Autologous tissue; Perforator flap

New Possible Surgical Approaches for the Submammary Adipofascial Flap Based on Its Arterial Supply.

Introduction. Submammary adipofascial flap (SMAF) is a valuable option for replacement of the inferior portion of the breast. It is particularly useful for reconstruction of partial mastectomy defects. It is also used to cover breast implants. Most surgeons base this flap cranially on the submammary skin crease, reflecting it back onto the breast. The blood vessels supplying this flap are not well defined, and the harvest of the flap may be compromised due to its uncertain vascularity. The aim of the work was to identify perforator vessels supplying SMAF and define their origin, site, diameter, and length. Materials and Methods. The flap was designed and dissected on both sides in 10 female cadavers. SMAF outline was 10 cm in length and 7 cm in width. The flap was raised carefully from below upwards to identify the perforator vessels supplying it from all directions. These vessels were counted and the following measurements were taken using Vernier caliper: diameter, total length, length inside the flap, and distance below the submammary skin crease. Conclusions. The perforators at the lateral part of the flap took origin from the lateral thoracic, thoracodorsal, and intercostal vessels. They were significantly larger, longer, and of multiple origins than those on the medial part of the flap and this suggests that laterally based flaps will have better blood supply, better viability, and more promising prognosis. Both approaches, medially based and laterally based SMAF, carry a better prognosis and lesser chance for future fat necrosis than the classical cranially based flap.

Dual-Pedicle Flap for Unilateral Autologous Breast Reconstruction Revisited: Evolution and Optimization of Flap Design over 15 Years.

In thin patients or when a significant amount of skin is needed, use of the entire abdomen to reconstruct a single breast may be necessary. In this article, the authors present their 15-year experience in dual-pedicle flap evolution and optimization of flap design. A retrospective review was conducted of all bipedicle flaps performed from 2000 to 2015. Overall, 57 patients (mean age, 49.2 years; mean body mass index, 26.2 kg/m) underwent dual-pedicle flap reconstruction of a unilateral mastectomy defect. Thirteen patients had a history of smoking, 30 patients had previously undergone irradiation, and 21 patients underwent immediate reconstruction. Eleven bipedicle flaps were performed with a pedicle transverse rectus abdominis musculocutaneous (TRAM) flap coupled to a free TRAM (n = 4), muscle-sparing TRAM (n = 4), or deep inferior epigastric artery perforator (DIEP) (n = 3) flap, and all were performed from 2000 to 2007. The thoracodorsal vessels (n = 8) were used more frequently earlier in the study period with the internal mammary vessels, whereas the antegrade/retrograde internal mammary vessels were used in the remaining patients, except for three patients in whom the internal mammary vessels and an internal mammary vessel perforator were used. Over the study period, there was an increase in the use of DIEP and superficial inferior epigastric artery flaps and the internal mammary vessels as recipients. Complications included delayed wound healing (n = 6), abdominal bulge (n = 2), cellulitis (n = 4), seroma (n = 3), and fat necrosis (n = 4). There was one partial flap loss where the superficial inferior epigastric artery portion of the dual-pedicle flap was lost. Dual-pedicle free flaps can be performed safely and reliably. Use of DIEP flaps maximizes pedicle length, and the internal mammary vessels can be used reliably in an antegrade and retrograde fashion to perfuse both components of the dual-pedicle flap. Therapeutic, IV.

Stacked and bipedicled abdominal free flaps for breast reconstruction: considerations for shaping.

Stacked and bipedicled abdominal flaps are useful in women who require a large breast reconstruction but have relative paucity of abdominal tissue. A new classification system is described to assist the surgeon in achieving the best possible aesthetic outcome. A retrospective review of 25 consecutive stacked and/or bipedicled deep inferior epigastric perforator (DIEP) flap reconstructions was assessed from 2009 to 2014. Demographic data and key variables were prospectively collected in our breast reconstruction database and an aesthetic classification devised. There are four main subtypes, (I) folded; (II) divided; (III) coned; and (IV) divided and folded. Each of these subtypes can be moulded in a symmetrically or asymmetrically fashion depending on the contralateral breast shape together with distribution and consistency of fat within the abdominal flap. Of the 25 patients, three-quarter were immediate reconstruction, with an average age of 48 years and a median follow-up of 2 years 10 months. Just over half the patients (57%) had bipedicle flaps with two recipient donor vessels with the remaining 43% had stacked flaps. The most common recipient sites are the thoracodorsal vessels (62%) and intercostal perforators (26%). The average abdominal pannus weight was 610 grams (SD: 320 grams), with a hemi-abdominal weight of 305 grams. Two patients had haematomas, of which one lost their reconstruction. Another patient had a venous congestion flap which was salvaged. Bipedicled or stacked abdominal flaps allow the all four zones of the abdominal tissue to be used in unilateral breast reconstruction. The approach of tailoring the abdominal flaps to match the contralateral breast reconstruction is largely an art form. The paper aims to bring some meaningful system to aid the surgeon to achieve the best possible outcome with the components presented to them.

Usability of the internal mammary recipient vessels in microvascular breast reconstruction

Although the internal mammary vessels are, for many surgeons, the recipient vessels of choice in microvascular breast reconstruction, there continues to be some debate regarding their use. The reliability of these vessels, particularly the vein, has been called into question, with high rates of conversion to alternative vessels being reported. This study investigates the true usability rate of the internal mammary vessels in a large series of consecutive patients without preselection. A review of all patients who underwent microvascular breast reconstruction at the University Health Network between September 2007 and December 2013 was conducted, and the conversion rate to alternative vessels was determined. A total of 759 microvascular breast reconstructions were performed in 515 patients. The internal mammary vessels were explored in all cases and found to be suitable for anastomosis in 756 of 759 reconstructions. Conversion to the thoracodorsal vessels was required in three reconstructions (0.4%) due to unusable internal mammary arteries. There was no significant increase in unusable vessels with timing or laterality of reconstruction or other factors such as smoking, vascular co-morbidities and adjuvant chemotherapy or radiotherapy. Total flap failure occurred in four reconstructions (0.5%), whereas partial flap loss occurred in five (0.6%). The internal mammary vessels can be safely and reliably used in almost all patients undergoing microsurgical breast reconstruction with low rates of microvascular complications.