Article

Free DIEAP and SGAP flap breast reconstruction after abdominal/gluteal liposuction

Authors:
  • Jan Yperman Ziekenhuis Ieper/ AZ West Veurne / AZ Damiaan Oostende
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Abstract

Perforator flaps are widely used in our unit for breast reconstruction. They provide ample tissue with minimal donor site morbidity together with long lasting aesthetic results. Increasing number of patients may have liposuction procedure which may jeopardise areas such as the abdomen and the buttock which are the donor sites for perforator-free flaps in breast reconstruction. Therefore, liposuction has been considered as a relative contraindication of raising perforator flaps. Six patients who had previous liposuction of the donor sites underwent autologous breast reconstruction with perforator-free flaps. Colour Duplex imaging was obtained in all cases preoperatively in order to evaluate the blood supply to the flap and to map the perforators. There were five deep inferior epigastric artery flaps (DIEP) and one superior gluteal artery perforator (SGAP) flap used. Total flap survival was obtained in all cases. Postoperative course was uneventful. Our results showed that raising perforator flaps after liposuction of the donor sites is possible. Preoperative radiological evaluation of the perforators is mandatory for such difficult cases.

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... In the first one, SAL and fat grafting to the breast were procedures performed in conjunction with implant-based reconstruction (Gabriel, Champaneria, & Maxwell, 2015;Kaoutzanis et al., 2016;Kim, Jung, Lew, & Lee, 2014). In the second category of patients, the abdominal liposuction was carried out purely for cosmetic purposes (De Frene et al., 2006;Hess, Gartside, & Ganz, 2004). ...
... It is therefore not uncommon for women who previously had SAL to develop breast cancer and seek the expertise of a plastic surgeon. The literature examining the use of autologous breast reconstructive methods after abdominal SAL is limited, and prior efforts have primarily focused on TRAM flaps(Avashia, Desrosiers, & Flores, 2012;De Frene et al., 2006;Farid, Nicholson, Kotwal, & Akali, 2014;Jandali, Nelson, Wu, & Serletti, 2010;Kim, Chang, Temple, Beahm, & Robb, 2004). ...
... Two patients with prior SAL were seen at our institution for autologous breast reconstruction with abdominal tissue. In these two cases, a DIEP or an SIEA flap was deemed unsafe due to significant abdominal contour defects on physical examination where depressions and discolorations on the patient's abdominal surface were observed.In addition, we noted extensive scarring (long hyperdense areas within the subcutaneous abdominal tissue) and somewhat compromised perforator appearance (perforators visualized by contrast material but not extending beyond scar tissue) on CTA imaging.Although the literature has described successful microsurgical free flap reconstructions with previously liposuctioned donor sites(Avashia, Desrosiers, & Flores, 2012;De Frene et al., 2006;Farid, Nicholson, Kotwal, & Akali, 2014;Godfrey & Godfrey, 1994;Jandali, Nelson, Wu, & Serletti, 2010;Kim, Chang, Temple, Beahm, & Robb, 2004;May, Silverman, & Kaufman, 1999), these studies focus on gluteal and TRAM flaps. Our series includes the first reported case of successful SIEA flap transfer after previous SAL. ...
Article
Introduction: Suction-assisted lipectomy (SAL) has been considered a relative contraindication for autologous breast reconstruction due to reservations about size and integrity of perforator vessels. Such patients are often not considered ideal candidates for breast reconstruction utilizing deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps. The aim of this article is to describe our experience with these flaps after SAL. Methods: Retrospectively, patient charts from 2005 to 2015 were analyzed and 9 patients (13 flaps) were identified who received breast reconstruction after prior donor-site SAL. Eight patients underwent DIEP and 1 patient an SIEA flap breast reconstruction. The patients' average age was 47.7 (ranging 33-64) years and their BMI 26.0 (ranging 21.1-36.5). Preoperative radiologic studies were obtained for all patients via either Doppler ultrasound or cross-sectional imaging to assess abdominal perforators. Abdominal SAL took place between 2 and 20 years before reconstruction. Results: On average, 2.4 (ranging 1-4) perforators with a mean diameter of 0.68 mm (ranging 0.2-2.5 mm) were included per DIEP flap and anastomosed to the internal mammary arteries. Median follow-up period was 1.2 (ranging 0.5-9.6) years without any flap loss, flap necrosis, hematoma, or unplanned reoperation. One breast seroma and one fat necrosis occurred. All patients had a successful reconstruction and finished treatment at our institution. Conclusion: Our results show that DIEP and SIEA flaps are safe and effective options for breast reconstruction in patients with previous abdominal SAL. Extensive preoperative patient evaluation and perforator imaging is important in identifying suitable candidates within this patient population.
... The range of time between liposuction and flap reconstruction in the articles where this was reported was 1.3 to 20 years (►Table 1). 6,9,10,[15][16][17][18] Six articles specified total follow-up period with a range of 4 months to 9 years (►Table 1). All 11 included articles reported 100% flap survival. ...
... 5,10,15-20 Among these studies, Doppler was the most commonly used modality, followed by computed tomography angiography (CTA). 5,10,15,[17][18][19] Two studies used magnetic resonance angiography (MRA) for three patients, 10,16 and one study used methylene blue angiography in one patient. 20 Additionally, one article utilized intraoperative imaging with indocyanine green angiography (ICGA) in five patients (six flaps) in addition to preoperative Doppler. ...
... 16 Of the seven articles that gave the length of time between a patient's most recent liposuction procedure and breast reconstruction surgery, 1.3 years was the shortest interval reported. 6,9,10,[15][16][17][18] Therefore, the question of whether or not time intervals less than 6 months between liposuction and reconstruction yields higher rates of ischemic flap complications cannot be explored. However, the need for a greater than 6-month interval does not seem well supported by more contemporary studies. ...
Article
Full-text available
Prior abdominal liposuction can be viewed as a relative or absolute contraindication to abdominally based autologous breast reconstruction given concerns for damaged perforators and scarring complicating intraoperative dissection. This systematic review aims to explore the outcomes of abdominally based breast reconstruction in patients with a history of abdominal liposuction. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided literature search was conducted using PubMed, Scopus, and Web of Science from the earliest available date through June 2020. Deep inferior epigastric perforator, muscle-sparing transverse rectus abdominis musculocutaneous (TRAM), superficial inferior epigastric artery, and pedicled TRAM flaps were included for evaluation. Complications included total or partial flap loss, fat necrosis, seroma, delayed wound healing, and donor site complications. After inclusion criteria were applied, 336 nonduplicate articles were screened, yielding 11 for final review, representing 55 flaps in 43 patients. There was no instance of total flap loss, eight (14.5%) flaps developed partial loss or fat necrosis, three (5.4%) flaps had delayed wound healing, and two (4.6%) patients had donor site complications. Most authors (8/11) utilized some type of preoperative imaging. Doppler ultrasonography was the most used modality, and these patients had the lowest rate of partial flap loss or flap fat necrosis (8%), followed by those without any preoperative imaging (10%). In conclusion, this review supports that patients undergoing abdominally based autologous breast reconstruction with a history of abdominal liposuction are not at an increased risk of flap or donor site complications. Although preoperative imaging was common, it did not reliably decrease complications. Further prospective studies are needed to address the role of imaging in improving outcomes.
... A total of 8 cases of autologous breast reconstruction using a DIEP flap after liposuction were identified in the literature review in addition to the 2 cases we present here. A study by De Frene et al. [7] describes five consecutive cases, and Jandali et al. [1] reports one case. In addition, Farid et al. [8] reported 2 cases involving DIEP flap breast reconstruction after multiple liposuction procedures. ...
... Previous literature suggests that harvesting perforator flaps from liposuctioned donor sites may not necessarily be a contraindication to free-flap breast reconstruction. [5,7] The largest reported series of DIEP flaps after liposuction was published by De Frene et al. [7] with five successful cases of breast reconstruction. The DIEP flap, introduced by Itoh and Arai [9] and Koshima and Soeda [10] and popularized by Allen and Treece, [11] Blondeel and Boeckx, [12] and Blondeel [13] has been described as the most appropriate way to reconstruct a breast to minimize donor morbidity. ...
... Previous literature suggests that harvesting perforator flaps from liposuctioned donor sites may not necessarily be a contraindication to free-flap breast reconstruction. [5,7] The largest reported series of DIEP flaps after liposuction was published by De Frene et al. [7] with five successful cases of breast reconstruction. The DIEP flap, introduced by Itoh and Arai [9] and Koshima and Soeda [10] and popularized by Allen and Treece, [11] Blondeel and Boeckx, [12] and Blondeel [13] has been described as the most appropriate way to reconstruct a breast to minimize donor morbidity. ...
Article
Full-text available
Autologous breast reconstruction with perforators has been previously avoided in tissues that have undergone liposuction. We present a case series and literature review of breast reconstruction with deep inferior epigastric perforator (DIEP) flaps after abdominal wall liposuction. An MEDLINE search was performed for all relevant articles describing breast reconstruction with DIEP flap technique following the abdominal wall liposuction. Key search words used included “DIEP”, “DIEAP”, “deep inferior epigastric perforator”, “liposuction” and “free flap”. All published data on the topic from 1965 to December 2014 were reviewed. Articles were assessed for reports of clinical cases, complications, age, liposuction amount, time since liposuction and number of perforators for comparison. We have also presented 2 patients who underwent a DIEP procedure with a previous history of liposuction. Eight cases of autologous breast reconstruction using a DIEP flap after liposuction were identified in the literature in addition to the presented cases. The preoperative and postoperative course was uneventful in all cases except one patient who had a mild cellulitis managed with antibiotics and a second patient with a drainable hematoma. The average age was 52 years ± 6.4 years old, one perforator was used in all cases except one where 2 were used, and the average amount of total liposuction was 1,084 mL. No major complications were reported. Previous liposuction is not an absolute contraindication for free-flap breast reconstruction. Preoperative management should include evaluation of suitable perforators by duplex ultrasound or computed tomography angiography. Larger case series are needed to better understand the safety of perforator flaps after liposuction.
... In the past previous abdominoplasty, liposuction and active smoking were regarded as absolute contraindications [26]. However technical refinements and preoperative imaging have largely rendered what were once absolute to relative contraindications [27]. Obesity is not a contraindication for surgery itself, however it may increase the anaesthetic related complication, preoperative weight loss in the obese may be of benefit to the surgeon as perforators undergo irreversible dilation with an increase in body weight which is maintained with subsequent weight loss [28]. ...
Article
Full-text available
Autologous microvascular breast reconstruction is widely accepted as a key component of breast cancer treatment. There are two basic donor sites; the anterior abdominal wall and the thigh/buttock region. Each of these regions provides for a number of flaps that are successfully utilised in breast reconstruction. Refinement of surgical technique and the drive towards minimising donor site morbidity whilst maximising flap vascularity in breast reconstruction has seen an evolution towards perforator based flap reconstructions, however myocutaneous flaps are still commonly practiced. We review herein the current methods of autologous microvascular breast reconstruction.
... De Frene et al. 15 demonstraram ser possível a realização de reconstrução mamária com TRAM (retalhos livres microcirúrgicos) em pacientes que tinham lipoaspiração abdominal prévia, confirmando os trabalhos de Graf e Munhoz na manutenção dos vasos perfurantes abdominais após lipoaspiração. ...
Article
Full-text available
INTRODUCTION: The cosmetic and functional deformities of the abdomen always represented a great challenge for plastic surgery. In search of solutions to these problems, we developed the abdominoplasty, which over the years has had modifications and improvements, looking for better cosmetic and functional results, with lower complication rates. Lipoabdominoplasty was developed in 2000 by Saldanha and published in 2001, when that term was first used in the literature, and represents a safe option for the combination of liposuction and abdominoplasty. The technique is based on the preservation of abdominal perforating vessels, branches of the superior and inferior epigastric deep artery. METHODS: We compared the incidence of complications between the classic abdominoplasty and lipoabdominoplasty carried out from January 1979 to June 30, 2010, at Saldanha's Clinic, in Santos - SP. DISCUSSION: The selective displacement between the edges of the rectus abdominis muscles, as advocated by technique, promotes a decrease in the area of detachment of the flap and preserves the abdominal wall perforator vessels account for 80% of the blood supply to the region and, consequently, reduces bleeding and risk of hematoma, and ischemic necrosis of the flap. CONCLUSION: Associating abdominoplasty with liposuction and advocating a selective detachment with preservation of the perforating vessels, it is possible to achieve better cosmetic results and lower postoperative morbidity and reducing the rate of surgical revisions.
... 57.8% of abdominal perforators were not detected at 2 weeks or 3 months postoperatively. However, Salgarello et al showed 'no significant injury to most perforating vessels' at 6 months following superficial subdermal liposuction, as detected by colour and pulsed-wave Doppler sonography. 1 Five DIEP flaps after single-episode liposuction were reported by DeFrene et al. 6 The minimum interval between liposuction and reconstruction was 4 years. Our report demonstrates safe DIEP flap breast reconstruction 16 months following multiple liposuction procedures. ...
Article
Full-text available
Previous abdominal wall surgery is viewed as a contraindication to abdominal free tissue transfer. We present two patients who underwent multiple abdominal liposuction procedures, followed by successful free deep inferior epigastric artery perforator flap. We review the literature pertaining to reliability of abdominal free flaps in those with previous abdominal surgery. Review of case notes and radiological investigations of two patients, and a PubMed search using the terms "DIEP", "deep inferior epigastric", "TRAM", "transverse rectus abdominis", "perforator" and "laparotomy", "abdominal wall", "liposuction", "liposculpture", "fat graft", "pfannenstiel", with subsequent appraisal of relevant papers by the first and second authors. Patient 1 had 3 episodes of liposuction from the abdomen for fat grafting to a reconstructed breast. Subsequent revision reconstruction of the same breast with DIEP flap was preceded by CT angiography, which demonstrated normal perforator anatomy. The reconstruction healed well with no ischaemic complications. Patient 2 had 5 liposuction procedures from the abdomen to graft fat to a wide local excision defect. Recurrence of cancer led to mastectomy and immediate reconstruction with free DIEP flap. Preoperative MR angiography demonstrated a large perforator right of the umbilicus, with which the intraoperative findings were consistent. The patient had an uneventful recovery and good healing with no fat necrosis or wound dehiscence. We demonstrate that DIEP flaps can safely be raised without perfusion-related complications following multiple liposuction procedures to the abdomen. The safe interval between procedures is difficult to quantify, but we demonstrate successful free flap after 16 months.
... This series included 3 cases of free transverse rectus abdominis myocutaneous flap breast reconstruction after abdominoplasty and 3 cases of free transverse rectus abdominis myocutaneous or DIEP flaps after abdominal liposuction. In addition, De Frene et al6 reported DIEP flap reconstruction after liposuction. In this series, color Doppler was used to assess perforator patency. ...
Article
Full-text available
Objective: The report herein presents a case of a 49-year-old woman with left breast cancer who presented seeking immediate autologous reconstruction. Surgical history included an abdominal hysterectomy and an abdominal contouring procedure. This is a first description of a deep inferior epigastric perforator flap after abdominal wall manipulation of this magnitude. Methods: Computed tomographic angiography identified patent medial row perforators. Doppler confirmed the location of the perforators. The flap was designed with the inferior incision at the previous lower abdominal scar. Laser-assisted indocyanine green imaging confirmed adequate flap perfusion on the basis of a single left deep inferior epigastric perforator. Results: The flap was harvested on one perforator and anastomosed to the internal mammary system. The postoperative course was complicated by venous anastomosis kinking, requiring revision, but otherwise unremarkable. Conclusion: Computed tomographic angiography confirmed presence of perforators, communication with the deep inferior epigastric system, and location acceptable for flap design. Laser-assisted indocyanine green angiography facilitated perforator selection and provided intraoperative assessment of flap perfusion. Utilization of these modalities allowed safe completion of an operation considered contraindicated by conventional algorithms and highlights their role in complex perforator flap reconstruction.
... Ongoing progress in microsurgical reconstructive procedures strives to minimize donor-site morbidity. 1 An alternative strategy to treat soft-tissue defects is the use of autologous lipoaspirate material. Adipose tissue can be obtained in large amounts without any substantial donor-site morbidity. ...
Article
: Successful soft-tissue reconstruction requires autologous tissue transfer in respect to the increasingly important "replace like-with-like" principle. Autologous lipoaspirate material for fat grafting can easily be obtained in large amounts without substantial donor-site morbidity. The exact nature and fate of the different cells in the transplanted fat graft and their contribution to tissue reconstruction, however, remain largely unknown. : Adipose tissue was harvested from healthy female patients. CD34 adipose-derived stem cells were isolated through magnetic-activated cell sorting and brought into co-culture with mature adipocytes in various culture medium conditions. Proliferation and differentiation of the adipose-derived stem cells were examined through histology, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assays, and polymerase chain reaction assays. : This study demonstrates that adipose-derived stem cells from fresh adipose tissue can be isolated within a few hours via magnetic-activated cell sorting with selection for CD34 cells. All unpassaged adipose-derived stem cells in fresh adipose tissue are CD34. Subsets include CD34CD31 and CD34CD271. No CD34CD45 cells were present. Histological staining, polymerase chain reaction, and MTT assays confirm that purified mature adipose cells incite adipose-derived stem cells proliferation and adipose differentiation in vitro. : This in vitro study demonstrates important interactions between the main actors in the adipose graft, the adipose-derived stem cells and the mature adipocytes. Although the eventual fate of these cells in a clinically implemented fat graft is still largely unknown, the results of this study support the theory that lipofilling can be conceived as an in vivo tissue engineering approach in which the mature adipocytes within fat grafts support proliferation and differentiation in the co-grafted stromal cell population.
... La liposucción abdominal previa está considerada como una contraindicación casi absoluta para el uso de DIEP, sin embargo su uso requiere estudio eco doppler preoperatorio (40) o angiotac para asegurar indemnidad de los vasos perforantes. ...
Article
Full-text available
En la actualidad somos capaces de ofrecer una cantidad no despreciable de técnicas de reconstrucción mamaria incluyendo aquellas basadas en el uso de prótesis, colgajo miocutáneo con isla transversa abdominal (TRAM), colgajo miocutáneo de latissimus dorsi y transferencia de tejidos libres. Se analizan indicaciones, ventajas y desventajas. Se presentan detalles sobre resultados cosméticos. La reconstrucción con tejidos autólogos representa menos de un 25% de todas las reconstrucciones mamarias. La reconstrucción basada en expansor/implante es la forma más común de reconstrucción mamaria. Diferentes series demuestran que entre el 20 y el 30% de los pacientes puede requerir algún tipo de revisión o reposición. Dada la evolución permanente del tema y la alta demanda de solución, se requiere que el cirujano plástico tenga competencias en técnicas de reconstrucción mamaria que varían según el contexto y las circunstancias individuales de cada paciente.
... The other vessels that could be used are anteromedial perforators of intercostal vessels and thoracodorsal artery perforator flap (TDAP) [6]. These flaps have been used for partial breast reconstruction predominantly for lateral defects after cancer resection [5] and for autologous breast augmentation after massive weight loss [10,1,3]. ...
Article
Background The lateral chest wall perforator flaps offer an excellent option for partial breast reconstruction (PBR) in women undergoing breast conservation surgery (BCS) for laterally placed tumours in small to moderate non-ptotic breasts. Methods We have performed 40 PBR, including LICAP (Lateral intercostal artery perforator) and LTAP (Lateral thoracic artery perforator) flaps over a three-year period. 29 were performed as one-stage whilst 11 were performed as two-stage approach. The latter approach was undertaken for patients with high tumour to breast ratio in an attempt to extend the indication for breast conservation. Results Out of 40 patients, 27 were symptomatic and 13 were screen-detected with a mean age of 49 years. The overall median tumour size on pre-op imaging was 35 mm and was 47 mm for the ones selected for two-stage approach. 11 patients underwent neo-adjuvant chemotherapy and additional 14 had adjuvant chemotherapy. All but one patient had adjuvant radiotherapy to the breast. 4 patients (10%) required further surgery to the breast due to incomplete cancer excision; 2 underwent successful re-excision and 2 (5%) were recommended completion mastectomy. A high satisfaction scores were reported both by the patients and surgical team with regards to the aesthetic outcome. There were no significant differences observed in complications, aesthetic outcome or patient satisfaction levels with the two approaches. Patients undergoing two-stage approach had an extra periareolar scar (in majority of the cases), which faded well with radiotherapy. Conclusion We recommend considering two-stage approach in women with high tumour to breast size ratio to ensure successful BCS prior to PBR.
... LICAP flaps are based on the lateral cutaneous branch of the posterior intercostal vessels as they course through the costal groove of the ribs. This have been described as a perforator flap that may be used as a free or island flap (3), it has since been used for PBR predominantly for lateral defects after cancer resection (4) and for autologous breast augmentation after massive weight loss (5)(6)(7). The LTA is a branch of the 2nd part of the axillary artery with a rich blood supply to the axillary skin, via two to three perforators. ...
Article
Full-text available
Background: The lateral chest wall perforator flaps (CWPF) offer an excellent option for partial breast reconstruction (PBR) in women undergoing breast conservation surgery (BCS) for laterally placed tumours in small to moderate non-ptotic breasts. Methods: A total of 20 patients underwent PBR with lateral CWPF over the last 4 years, as two-stage approach. This approach was undertaken for patients with high tumour to breast ratio (>30% predicted resection) in an attempt to avoid mastectomy. The reconstruction was carried out 2-4 weeks after wide local excision in order to ensure clear margins prior to undertaking PBR. Results: Twenty-three women were selected for attempt at BCS with 2-stage approach. Three patients had extensive disease so they were then counseled for mastectomy after the first surgery and 20 patients had successful BCS. Out of 20 patients, 13 were symptomatic and 7 were screen-detected with mean age of 49 years. The median tumour size on pre-op imaging was 43 mm (23-75 mm). A percentage of 50% women with unifocal cancers undergoing primary surgery had disease overestimated on pre-op imaging. The complication rate was low. Good to excellent aesthetic outcomes were reported in 90% cases. Patients reported high satisfaction scores. Conclusions: We recommend considering two-stage approach in selected women with high tumour-breast ratio to ensure successful BCS prior to PBR. This approach facilitates BCS and avoids mastectomy in borderline cases, particularly lobular cancers, DCIS, bifocal cancers and post neoadjuvant chemotherapy where pre-operative disease estimation could be challenging. Our small series has shown that this approach results in safe oncological surgery with good aesthetic outcomes in the selected group of women.
... 12,16,17 This information is highly beneficial in patients with lower abdominal scars, as it facilitates selection of the best perfused region of abdominal tissue supplied by the dominant perforator. 12,26,27 CTA is a three-dimensional, non-invasive, operator-independent method, highly reproducible, requiring a short scanning time of 5 minutes 11,12 . Apart from the high spatial resolution, [28][29][30] there is availability of free software for post processing 3D digital reconstruction for detailed mapping of the vascular anatomy. ...
... 2,3 When a deep inferior epigastric perforator (DIEP) flap is not available, this flap should be considered instead of providing an unsatisfactory result or sacrificing other donor sites with a risk of higher morbidity and permanent functional impairment. [3][4][5][6][7] In this article, we report our eight years of experience in breast reconstruction using SGAP free flap; discuss our results, how our procedures have evolved, the outcomes and complications rates and how to perform this procedure efficiently while managing the challenges inherent to this type of flap. ...
Article
Introduction: The SGAP flap represents an alternative for autologous breast reconstruction when DIEP is not available. In this article, we report eight years of experience in breast reconstruction using SGAP free flap and discuss our results, how our procedures have evolved, the outcomes and complications rates and how to perform this procedure efficiently while managing the challenges inherent to this type of flap. Materials and methods: A retrospective study was conducted from June 2009 and June 2017. Patients requiring SGAP flap breast reconstruction were enrolled. Donor site availability was categorised into 4 classes according to the availability of tissue. An ad hoc outcome scale was created to standardise the results and ensure data comparability. Results: A total of 119 patients were enrolled in the study. We recorded 18 cases of excellent results, 57 good, 30 moderate and 14 poor. Our results show that donor site class impacts complications and patient outcome. The odds ratio analysis demonstrated that the third class donor site has a protective impact on complications and has a direct correlation with good patient outcomes. Conclusions: SGAP flap can provide very good outcomes, and it should be considered as another option when DIEP is not available. Patient selection and efficiency are the keys to achieve optimal results and minimise complications. Although this flap is available for patients with a low BMI, the donor site has to provide enough tissue to achieve symmetry with the contralateral breast and allow a tension-free closure without contour deformity.
... The mean length of reconstruction after liposuction was 8.9 years, ranging from 1.5 to 23 years reported in 23 patients. The reconstructed breast volume was reported in nine patients in four studies with a mean volume of 1,026.6 mL (range 500-1,600 mL) [5][6][7][8]. ...
Article
Background: Over recent years, liposuction has become the most commonly used surgical procedure used to refine male and female body contours. In the last four decades, the incidence of breast cancer has increased. Of these patients, there are more women requiring breast reconstruction who have undergone liposuction in the past. There is little in the literature that discusses harvesting perforator flaps from previously liposuctioned donor sites. The authors report on their experience and review the current literature on the autologous abdominal-based free flap for breast reconstruction after previous liposuction of the abdominal wall. Methods: Five electronic databases were searched (Medline (PubMed), Scopus, Web of Science, Cochrane) from inception to March 2021. Also, we searched our patients records and included our experience. Results: We included three cases who had previous liposuction prior to their breast reconstruction procedure. We report no flap loss in our cases. Moreover, the database search showed 30 patients (83.33%) underwent deep inferior epigastric perforator (DIEP) reconstruction. The age ranged from 32 to 73 years (mean of 51.7 years). The mean length of reconstruction after liposuction is 8.9 years, ranging from 1.5 years to 23 years reported in 23 patients. Seven patients (19.4%) had partial loss of the flap. Twenty patients (55.55%) had CT angiography pre-operatively for the assessment of the perforators. Conclusion: A careful combination of preoperative scanning, handheld Doppler and clinical examination reduce the chance of an unsuccessful outcome.
... In select cases, the assurance of the presence of suitable perforator vessels may allow a patient with a history of abdominal surgery, which would have previously been considered a contraindication, to undergo an abdominal perforator flap procedure. 20 As a dramatic example, we present a patient imaged preoperatively with CTA. The patient had a history of central abdominal liposuction and a miniabdominoplasty 18 years ago, but desired the abdomen as the donor site for breast reconstruction. ...
Article
Full-text available
The tremendous variability of the inferior epigastric arterial system makes accurate imaging of the vasculature of the anterior abdominal wall an essential component of optimal perforator selection. Preoperative imaging of the abdominal vasculature allows for preoperative perforator selection, resulting in improved operative efficiency and flap design. Abdominal wall perforators of 1-mm diameter can be reliably visualized without exposing patients to ionizing radiation or iodinated intravenous contrast through advances in magnetic resonance imaging angiography (MRA). In this study, MRA imaging was performed on 31 patients who underwent 50 abdominal flaps. For each flap, the location, relative to the umbilicus, of the three largest perforators on both the left and right sides of the abdomen was determined with MRA. Vessel diameter and anatomic course were also evaluated. Postoperatively, a survey was completed by the surgeon to assess the accuracy of the MRA with respect to the intraoperative findings. All perforators visualized on MRA were found at surgery (0% false-positive). In 2 of 50 flaps, the surgeon transferred a flap based upon a vessel not visualized on the MRA (4% false-negative). This article details our experience with MRA as a reliable preoperative imaging technique for abdominal perforator flap breast reconstruction.
... Color Doppler ultrasound not only provides more information about the course, origin, and structures surrounding the perforator but also gives a hemodynamic evaluation 12 . It has high sensitivity and 100% concordance with intraoperative findings in expert hands, even in previous surgical sites 13 . Despite the above, it is a time consuming and operator-dependent method, with no 3D reconstruction. ...
Article
Introduction: Perioperative microsurgical planning increases the likelihood of successful results. Augmented reality (AR) is the addition of artificial information to allow the user to perform tasks more efficiently. The aim of our study is to report the use of AR for microsurgical planning with a smartphone (ARM-PS) as a dissection route map. Patients and methods: AR was used for superficial circumflex iliac artery perforator (SCIP) flap planning. Three-dimensional (3D) reconstruction images of the inguinal and lower abdomen vascular anatomy were obtained by computed tomography angiography. These 3D images were imported to a smartphone and an AR app was used to superimpose them with the camera. The drawings performed with ARM-PS were correlated with handheld Doppler and intraoperative findings. Results: The correlation of ARM-PS drawings with handheld Doppler results was 100% for superficial inferior epigastric artery (SIEA) and superficial and deep branches of SCIP in 60 inguinal areas studied. Intraoperative findings matched perfectly in all 30 cases with ARM-PS drawings for the location of the mentioned vessels and lymph nodes. Flap harvest time decreased in 20% compared with our traditional timing. Conclusions: ARM-PS is an easy, noninvasive, and accurate method that provides a dissection route map, thereby standardizing flap harvesting, and shows a perfect correlation with intraoperative findings. It reduces operating time and may improve operative results, thus decreasing donor site morbidity.
... The majority of previous studies compared uni-and bilateral breast reconstructions using DIEP flaps [15,16] or evaluated a single flap type for breast reconstruction, such as superior gluteal artery perforator (SGAP) flaps [17,18] or TMG flaps [6]. A cohort study comparing two large patient cohorts that underwent bilateral simultaneous reconstructions with either double DIEP or double TMG flaps has not been conducted so far. ...
Article
Full-text available
Background: A two center retrospective cohort study of simultaneous bilateral breast reconstructions using double deep inferior epigastric perforator (DIEP) flaps and double transverse myocutaneous/upper gracilis (TMG) flaps was conducted. The aim of this study was to compare surgical procedures, complications, and overall outcome. Patients and methods: Two study groups, either receiving a simultaneous bilateral breast reconstruction, with double DIEP flaps (n = 152) in group 1, or double TMG flaps (n = 86) in group 2, were compared. A detailed risk and complication analysis was performed. Patient characteristics, operative time and the need for further operations were evaluated. Results: Double DIEP patients had donor site complications in 23.7% and double TMG patients in 16.3% (p = 0.9075, RR 1.45). Flap loss rates of 3.5% (double TMG) and 2.6% (double DIEP) were recorded (p = 0.7071, RR 1.33). The need for postoperative lipofilling was significantly higher in double TMG patients (65.1% vs. 38.2 %, p = 0.0047, RR 1.71). Conclusion: Complication analysis favors the double DIEP procedure. Donor site morbidity was lower and less severe in the double TMG group. Later fat grafting was more frequently needed after double TMG reconstructions. Further studies, preferably of prospective nature, are needed to evaluate the benefit of bilateral simultaneous breast reconstructions.
Article
The aim of this overview is to describe the various methods for vascular mapping of flaps together with their advantages and drawbacks. The PubMed database was used. Relevant search terms included 'flap' in combination with 'hand-held Doppler' (HHD), 'colour duplex sonography' (CDS), 'digital subtraction angiography' (DSA), 'computed tomography angiography' (CTA) and 'magnetic resonance angiography' (MRA). All studies found between January 2000 and January 2010 was evaluated. A total of 72 articles were found. Of these, 62 were usable for this overview. Recommendations could not be found for all types of flaps. Therefore, no uniform guidelines can be provided; some findings are, however, unequivocal. In general, HHD is cheap and easy to use, but relatively unreliable in determining the exact site of emergence at fascia level of perforators. CTA and MRA provide the best three-dimensional images. CTA offers more detailed images, MRA has the advantage however of not using radiation. CDS can be of value to offer information about the amount of flow in vessels or in cases in which CTA or MRA are contraindicated. DSA appears to be fading out slowly. CTA and MRA are currently the best methods available to map the vasculature of donor sites of perforator flaps with variable anatomy such as anterolateral thigh (ALT) and deep inferior epigastric perforator (DIEP). In flaps with standard anatomy and superficial vasculature, HHD or no mapping at all remains the method of choice.
Article
The lateral thoracodorsal flap and the pedicled latissimus dorsi flap have been extensively described for breast reconstruction. In search of an alternative, non-microsurgical, autologous method of breast reconstruction we used both flaps combined to achieve adequate volume. The technique was used on three patients who had had a mastectomy at least two years previously. All flaps healed uneventfully with the appearance of an ordinary latissimus dorsi breast reconstruction. The method shows promising initial results and can be used as an alternative when reconstruction with autologous tissue is preferred.
Article
Full-text available
Preoperative imaging using a range of imaging modalities has become increasingly popular for preoperative planning in plastic surgery, in particular in perforator flap surgery. Modalities in this role include ultrasound (US), magnetic resonance angiography (MRA), and computed tomographic angiography (CTA). The evidence for the use of these techniques has been reported in only a handful of studies. In this paper we conducted a non-systematic review of the literature to establish the role for each of these modalities. The role of state-of-the-art vascular imaging as an application in perforator flap surgery is thus offered.
Article
Perforator flaps have become increasingly popular tools in microvascular breast reconstruction. Previous criticism of these techniques, particularly deep inferior epigastric artery perforator (DIEAP) flap, have included the variability in the path of the perforators through the rectus muscle, the tedious and time-consuming need to look for and to clamp various perforators to determine the "dominant" perforator, and uncertainty whether adequate perforators exist following previous abdominal surgery. Preoperative imaging has contributed significantly to the reliability, speed, and minimal donor site morbidity of these procedures. A major evolution in preoperative imaging has been the introduction of multidetector row computed tomography (MDCT) as a replacement for color duplex imaging. There are multiple advantages to MDCT with few disadvantages, and so it has become the gold standard for the preoperative planning of DIEAP flap breast reconstruction in the practices of both authors, completely eliminating the use of color duplex. Improvements in the preoperative understanding of the anatomy of each perforator from its branching pattern in the subcutaneous fat, to its perforation through the anterior rectus sheath and rectus muscle toward the groin facilitate this type of surgery in a manner only possible with MDCT and not duplex imaging.
Article
Various flaps are available for autologous breast reconstruction. However, there is no accepted standard. The superior gluteal artery perforator (sGAP) flap is one possible option for autologous breast reconstruction. Eighty-one sGAP flaps were performed for breast reconstruction. Patient data regarding age, body mass index, medical history, timing of reconstruction, operating time, success of the operation, and complications were retrospectively analyzed. The success rate was 93% ( N = 75). Thrombosis occurred in nine flaps, and three revisions were successful. There was no partial necrosis. All but one bilateral breast reconstruction was performed in two stages. The average time between the reconstructions was 3 and 5 months (2 to 6). The average operating time was 7 hours 36 minutes (5'45 to 9'33). For autologous breast reconstruction, there is no universally accepted standard and no flap meets all the requirements. The deep inferior epigastric perforator flap is our first choice. We favor the sGAP as a second choice particularly for larger breast sizes. For a staged bilateral reconstruction, the sGAP flap advances to be our first choice. The sGAP flap is a safe and reliable perforator flap providing a good breast projection, cosmetically pleasing outcome on the breast, and an acceptable outcome on the buttock with the disadvantage of a demanding dissection.
Article
Free superior gluteal artery perforator (SGAP) flaps are a reliable option for breast reconstruction in patients with insufficient abdominal tissue or abdominal scarring. Liposuction in a donor site is a relative contraindication for harvesting a free flap, despite current case reports challenging this tenet. We describe a case of a 36-year-old woman who underwent unilateral breast reconstruction with free SGAP flap. She underwent liposuction of the contralateral buttock for symmetry. Approximately, one year post-operatively, she developed local recurrence of the breast cancer. Previously liposculpted buttock was used as donor site for a second free SGAP flap anastomosed to internal mammary artery. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.
Article
Patients are well informed and seek autogenous breast reconstruction. The motivating factors include a preference for autologous tissue reconstruction and the complementary improvement in body contour, safety concerns surrounding implants, and implant-related complications in the setting of previous radiation therapy. In this article a variety of perforator flaps from donor sites that include the trunk (thoracodorsal artery perforator and intercostal artery perforator), abdomen (deep inferior epigastric artery perforator and superficial inferior epigastric artery), and buttock (superior gluteal artery perforator and inferior gluteal artery perforator) are described. Flaps from the trunk can be pedicled for partial breast reconstruction, and free flaps from the other donor sites can completely restore a natural-looking breast. The information obtained from preoperative CT and MRI can direct the surgeon toward the most successful operative plan. However, the decision as to which flap may be most appropriate for an individual patient is complex. This article reviews pertinent surgical anatomy, preoperative planning, intraoperative decision making in flap elevation, and reported outcomes.
Article
BACKGROUND: The lower abdominal region offers a multitude of flaps for breast reconstruction, which include the pedicled and free transverse rectus abdominis myocutaneous flap (TRAM), the deep inferior epigastric artery perforator flap (DIEAP), and the superficial inferior epigastric artery flap (SIEA). METHODS: This literature overview examines the history and the practice of breast reconstruction using flaps from the lower abdomen. All relevant studies and experiences have been included. RESULTS: The decision-making process in regard of the choice of flap to use is complex and depends on a variety of factors. A clear trend in using flaps which lower donor site morbidity and higher aesthetic outcome is seen. CONCLUSIONS: This article serves to review surgical anatomy, preoperative planning, intraoperative decision making in flap elevation, and reported outcomes in terms of complications and patient satisfaction. GRUNDLAGEN: Die Abdominalregion ist eine vielseitige Quelle für mehrere Gewebe, welche als Lappen zur Wiederherstellung der weiblichen Brust geeignet sind. Diese beinhalten den gestielten und freien Transverse Rectus Abdominis Myocutaneous Lappen (TRAM), den Deep Inferior Epigastric Perforator Lappen (DIEAP) und den Superficial Inferior Epigastric Lappen (SIEA). METHODIK: Diese Übersicht stellt Geschichte und Technik der Wiederherstellung der Brust mittels Lappen vom Abdomen dar. Alle relevanten Studien und Erfahrungen wurden berücksichtigt. ERGEBNISSE: Der Entscheidungsprozess zur Lappenwahl ist komplex und abhängig von einer Reihe von Faktoren, wobei Lappen mit niedrigerer Hebemorbidität deutliche Vorteile zeigen und ein postoperativ verbessertes ästhetisches Resultat der Hebestelle die Patientenakzeptanz deutlich erhöhen kann. SCHLUSSFOLGERUNGEN: In dieser Übersicht werden Anatomie und präoperative Planung in dieser Spenderregion, Fragen zur intraoperativen Entscheidungsfindung sowie Resultate und Patientenzufriedenheit behandelt.
Article
Although preoperative imaging of perforator vasculature in planning microvascular reconstruction is commonplace, there has not been any clear demonstration of the evidence for this practice, or data comparing the many available modalities in an evidence-based approach. This article aims to provide an objective, evidence-based review of the literature on this subject. The evidence supporting the use of various modalities of imaging was investigated by performing focused searches of the PubMed and Medline databases. The articles were ranked according to the criteria set out in March 2009 Oxford Centre for Evidence-Based Medicine definitions. Endpoints comprised objective outcome data supporting the use of imaging, including flap loss, unplanned returns to theater, operative time reduction, and surgeon-reported stress. The objective high level of evidence for any form of preoperative perforator imaging is low with only small number of comparative studies or case series investigating computed tomographic angiography (CTA), magnetic resonance angiography, handheld Doppler, color duplex, and classic angiography. Of all modalities, there is a growing body of level 2b evidence supporting the use of CTA. While further multicenter trials testing hard outcomes are needed to conclusively validate preoperative imaging in reconstructive surgery, sufficient evidence exists to demonstrate that preoperative imaging can statistically improve outcomes, and that CTA is the current gold standard for perforator mapping.
Article
The inferior gluteal artery perforator flap, which is vascularised by perforator branches of the inferior gluteal artery (formerly ischiatic artery) is harvested in the gluteal crease. The purpose of this anatomical study was to clarify the anatomical features of this flap and locate the perforators of the inferior gluteal artery destined to the flap, in view to facilitate its surgical removal, as free flap for breast reconstruction. We performed 12 dissections on fresh cadavers, after selective injection of the inferior gluteal artery with a gelified solution. During harvesting, we located the perforators which arise from the inferior gluteal artery and perfuse the flap. We distinguished four zones, defined relatively to anatomical landmarks of the region, according to the frequency of perforators. This anatomical study makes possible an improvement of the technique to raise this flap in its free shape with view to use it for breast autologus reconstruction especially given its numerous advantages: a constant volume of fat even in thin patients and minimal donor site morbidity.
Article
Perforator flaps are preferable for breast reconstruction after mastectomy in many patients. Preoperative imaging of the perforators and source vessels is desirable to reduce surgeon stress, limit donor and recipient site complications, and minimize operative time and associated costs. Computed tomographic angiography (CTA) has been shown to provide highly accurate representations of vascular anatomy with excellent spatial resolution. A critical review of the currently available literature was performed to identify the benefits of preoperative imaging (specifically CTA) in perforator flap reconstruction.
Article
Introduction: Recently, perforator flap surgery has been introduced in phalloplasty procedures. Especially the anterolateral thigh (ALT) flap has found its application as a pedicled flap for the penile reconstruction. Adequate shaping of the flap and the need of transferring the shaped flap on its pedicle to the pubic area requires precise localisation and preoperative evaluation of the perforators. Also preoperative measurement of the subcutaneous fat tissue is necessary to allow adequate patient selection and optimal shaping of the phallus. The objective of this report is to demonstrate the usefulness of a multidetector CT scan (MDCT) in the preoperative planning of patients undergoing an ALT flap phalloplasty. Methods: Between September 2009 and July 2011, 13 patients were operated for ALT phalloplasty and had preoperative perforator mapping with the MDCT. An algorithm was set up to select the best perforator. Indocyanine green angiography was used in 5 patients to confirm the perforator selection. A mathematical formula was developed to calculate the necessary flap width from the flap thickness. Results: Accurate identification of the main perforators was achieved in all patients with a very satisfactory concordance between the MDCT scan and surgical findings. Indocyanine green angiography confirmed the MDCT perforator selection in all cases. The flap size could be determined preoperatively in all patients by measuring the thickness of the subcutaneous fat layer. Conclusions: Preoperative evaluation of ALT perforators and the subcutaneous fat tissue layer is feasible with an MDCT scan and provides precise data to make an adequate patient and perforator selection and determine the exact flap size.
Article
A particular flap with rising prominence in breast reconstruction is the transverse upper gracilis (TUG) flap. With the increasing prevalence of patients opting for various forms of elective liposuctions, breast reconstruction with flaps has necessitated a more meticulous yet perhaps more flexible screening for potential donor sites. We present a case of a bilateral breast reconstruction using TUG flaps in a patient with a previous history of liposuction to her abdomen and thighs. The dimensions of the TUG flaps were 7 × 31 cm². The patient did not undergo any flap or donor site complications. We speculate that perhaps much of the tissue and muscle in the medial thigh region is more robust than previously thought and that there is high potential for neo-vascularization in the thigh region following a liposuction. Accordingly, we advocate the effective use of the TUG flap for breast reconstruction in spite of previous liposuctions to the thighs.
Research
Full-text available
PhD thesis on Multidisciplinary Approach to Facial Transplantation
Article
Objectives: Deep inferior epigastric perforator (DIEP) flaps have become the state of the art in breast reconstruction. We compared the diagnostic performance of multidetector computed tomography (CTA) and magnetic resonance angiography (MRA) in DIEP flap planning. Methods: Twenty-three women (mean age 48.0 years, range 26-72 years) underwent preoperative blinded evaluation using 64-slice CTA and 1.5-T MRA. Perforator identification, measurement of their calibre, intramuscular course (IMC), assessment of direct venous connections (DVC) with main superficial veins, superficial venous communications (SVC) between the right and left hemi-abdomen and deep inferior epigastric artery (DIEA) branching type were performed. Surgery was carried out by the same team. Intraoperative findings were the standard of reference. Results: Accuracy in identifying dominant perforators was 91.3 % for both techniques and mean error in calibre measurement 1.18 ± 0.35 mm for CTA and 1.63 ± 0.39 mm for MRA. Accuracy in assessing perforator IMCs was 97.1 % for CTA and 88.4 % for MRA, DVC 94.4 % for both techniques, SVC 91.3 % as well, and DIEA branching type 100 % for CTA and 91.3 % for MRA. Image acquisition and interpretation time was 21 ± 3 min for CTA (35 ± 5 min for MRA). Conclusions: In a strategy to optimise DIEP flap planning avoiding radiation exposure, MRA can be proposed alternatively to CTA. Key points: • Identification of deep inferior epigastric perforators (DIEP) is important before breast reconstruction. • Both CT and MR angiography are accurate in identifying DIEA perforator branches. • CTA and MRA are equivalent in demonstrating perforator-venous connections. • MRA can be proposed as an alternative to CTA in DIEP planning.
Chapter
The inferior gluteal artery perforator flap, which is vascularized by perforator branches of the inferior gluteal artery (formerly ischiatic artery) is harvested in the gluteal crease. The purpose of this anatomical study was to clarify the anatomical features of this flap and locate the perforators of the inferior gluteal artery destined to the flap, in view to facilitate its surgical removal, as free flap for breast reconstruction.. The authors performed 12 dissections on fresh cadavers, after selective injection of the inferior gluteal artery with a gelled solution. During harvesting the perforators were located which arise from the inferior gluteal artery and perfuse the flap. There are four zones, defined relatively to anatomical landmarks of the region, according to the frequency of perforators. This anatomical study enables to steer the surgical harvesting of this flap in its free shape for breast autologous reconstruction especially given its numerous advantages: a constant volume of fat even in thin patients and minimal donor site morbidity.
Article
Background: Approximately half of all patients presenting for autologous breast reconstruction have abdominal scars from prior surgery, the presence of which is considered by some a relative contraindication for abdominally based reconstruction. This meta-analysis examines the impact of prior abdominal surgery on the complication profile of breast reconstruction with abdominally based free tissue transfer. Methods: Literature search was conducted using PubMed, Scopus, and Web of Science. Included studies examined patients with a history of prior abdominal surgery who then underwent abdominally based free flap breast reconstruction. Prior liposuction patients and those with atypical flap designs were excluded. The Newcastle-Ottawa Scale was used to assess study quality. Flap complications included total and partial flap loss, fat necrosis, infection, and reoperation. Donor-site complications included delayed wound healing, infection, seroma, hematoma, and abdominal wall morbidity (hernia, bulge, laxity). Relative risk and 95% confidence intervals (CIs) between groups were calculated. Forest plots, I2 statistic heterogeneity assessments, and publication bias funnel plots were produced. Publication bias was corrected with a trim-and-fill protocol. Overall effects were assessed by fixed-effects and random-effects models. Results: After inclusion and exclusion criteria were applied, 16 articles were included for final review. These included 14 cohort and 2 case-control studies, with 1,656 (46.3%) patients and 2,236 (48.5%) flaps having undergone prior surgery. Meta-analysis showed patients with prior abdominal surgery were significantly more likely to experience donor-site delayed wound healing with a risk ratio of 1.27 (random 95% CI [1.00; 1.61]; I2= 4) after adjustment for publication bias. No other complications were statistically different between groups. Conclusion: In patients with a history of prior abdominal surgery, abdominally based free tissue transfer is a safe and reliable option. Abdominal scars may slightly increase the risk of delayed donor-site wound healing, which can aid the surgeon in preoperative counseling.
Article
Classically, history of prior abdominal liposuction has been considered a relative contraindication for breast reconstruction using deep inferior epigastric perforator (DIEP) flap. The rationale for this is based on the fact that liposuction can possibly damage perforating vessels, which could compromise flap survival. However, multiple recently published reports have shown that imaging using CT angiography or colour Duplex ultrasonography could be used to accurately assess the adequacy of the perforating vessels before DIEP flap harvest. This contraindication is currently being reconsidered in the scientific literature. We present a case of partial DIEP flap loss in a patient with history of abdominal liposuction that happened despite preoperative identification of adequate perforators using CT angiography and intraoperative clear evidence of patent anastomoses. This occurrence reopens in our view the question of whether DIEP flaps can be safely performed on patients with a history of abdominal liposuction, even in the presence of adequate perforators on regular CT angiography or Doppler ultrasonography. While abdominal liposuction may not injure perforating vessels, its detrimental effect on linking micro-vessels within the flap cannot be fully evaluated using CT Angiography. Therefore, the use of another imaging modality, such as the indocyanine green laser angiography, to assess perfusion before DIEP flap harvesting is performed and could be considered in patients with history of abdominal liposuction.
Chapter
The deep inferior epigastric artery perforator (DIEP) flap was first described by Koshima and Soeda in 1989, able to provide the volume of fat and overlying skin taken in the TRAM flap without the sacrifice of any rectus abdominis muscle. Its low donor site morbidity, combined with its reliability, has popularised the DIEP flap as the most common option for autologous breast reconstruction.
Chapter
In this chapter we describe the background to the use of volume replacement flaps after breast-conserving surgery. We consider patient selection, surgical technique including planning and patient positioning, incision placement and operative technique and also describe the literature on oncological and cosmetic outcome and complications. The literature in this area is sparse, and more work is needed to confirm the relevant place of the different types of flap and to directly compare objective outcome and patient satisfaction with the alternative, namely, mastectomy and immediate breast reconstruction.
Article
This article reviews the indications and controversies in abdominally based autologous breast reconstruction. The evidence regarding these indications and controversies will be appraised and summarized. Finally, we will provide a summary of our approach and technique for the patient undergoing autologous breast reconstruction using abdominally based free flaps.
Article
Resumen La reconstrucción mamaria microquirúrgica con tejido autólogo puede asociar complicaciones relacionadas con el colgajo y la zona donante. Nuestro objetivo fue valorar la evidencia clínica en seguridad, complicaciones y factores de riesgo en pacientes reconstruidas con colgajo de perforantes basado en la arteria epigástrica inferior profunda (DIEP). Se realizó una revisión sistemática en Medline de artículos publicados entre septiembre de 1995 y septiembre de 2015. Se recogieron las características demográficas de las pacientes, las medidas de los colgajos y las complicaciones de la cirugía incluyendo la necrosis completa, la necrosis parcial y la necrosis grasa. Se identificaron 34 artículos que incluían 35 series de casos, 2.761 pacientes y un total de 3.927 colgajos. La media del índice de masa corporal fue superior a 24,5 kg/m², mientras que la tasa de obesidad se situó por encima del 14,5%. Ningún artículo aportó información acerca del peso, superficie o volumen del colgajo tras su tallado en la zona receptora. Las tasas de necrosis completa y parcial fueron del 1,9% (75/3.811) y del 2,6% (68/2.575) respectivamente. La necrosis grasa se diagnosticó en el 8,2% (308/3.746) de los colgajos, con una desviación estándar de 6,9. El 5,5% (107/1.940) de los colgajos requirieron reintervención quirúrgica. La incidencia de hematoma en la zona receptora y de hernia o debilidad abdominal fue de un 3% (59/1.952 colgajos y 52/1.725 pacientes). En conclusión, la incidencia de complicaciones en reconstrucción mamaria con colgajo DIEP fue baja, aunque la necrosis grasa presentó una dispersión elevada.
Chapter
Liposuction is a common aesthetic procedure and it has been used in defatting flaps and other procedures than aesthetic. Reconstruction with flaps needs good blood supply. If liposuction has previously been done, there can be a question of the vascularity of a flap. The authors present a patient who had prior liposuction of the abdomen and medial thighs, and also bilateral mastectomies were reconstructed with implants and the latissimus dorsi on the left. Because the abdomen was not suitable for further reconstruction, bilateral transverse gracilis myocutaneous flaps were utilized and there were no postoperative complications. Although the history of previous liposuction contouring procedures may present a potential increased risk in perforator flap harvest, it has been demonstrated that it is not an absolute contraindication.
Article
Subcostal scars pose a risk of upper abdominal flap ischaemia when raising a free abdominal flap. The aim of this study was to describe a clinical approach to increase flap reliability and donor site healing in the presence of transverse abdominal scars while harvesting lower abdominal free flaps. A total of 11 patients who had subcostal scars and one who had an extended subcostal scar (rooftop or chevron incision) underwent free abdominal flaps for breast reconstruction. Preoperative radiological imaging was used to evaluate the blood supply to the planned flaps. A classification of clinical approaches (I-IV) was used. When the cranial (the abdominal closure) flap width was equal to or greater than half length, a caudal (the breast) flap could safely be harvested (Type I); if not, the cranial flap was enlarged by more caudal flap planning (Type II), an oblique design of the free flap (Type III) or by lowering the free flap marking more distally (Type IV) with a sparing of the peri-umbilical perforators to preserve blood supply to the caudal (abdominal closure) flap. Unilateral free deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps were successfully harvested in eight and two cases, respectively. In two cases, a bipedicled DIEP/SIEA flap was harvested for unilateral breast reconstruction. Slight abdominal wound slough occurred in one patient; however, no ischaemia resulted in flaps or at donor sites. Using a pragmatic approach to flap design, based on clinical classification, we have found that both flap and donor site morbidity can be avoided in patients who have previous upper abdominal scars. IV, Therapeutic.
Chapter
The evolution of techniques in abdominal surgery, with low postoperative morbidity and lower complication rates, has always motivated surgeons to search for innovations in plastic surgery [1–16]. Lipoabdominoplasty was developed and patterned as a safe and functional option with which to perform liposuction and abdominoplasty during the same surgical procedure, promoting the benefits of both techniques. This technique generates a better aesthetic result and can be learned quickly because surgeons are accustomed to performing each procedure (liposuction and abdominoplasty) separately. This technique does not involve simply using liposuction while performing abdominoplasty; it has a much wider concept, respecting the complete abdominal anatomy. Traditional undermining is substituted with cannula undermining. As a consequence, the blood supply coming from the abdominal perforating vessels is not stopped.
Chapter
Every surgeon who performs breast reconstructive surgery should appreciate the nuances of breast form, volume and its complex three dimensionality. Hence this chapter begins with a detailed analysis of breast position and shape, and its implications for surgical reconstruction. It offers the reader a comprehensive review of current reconstructive techniques and the principles behind them. Procedures involving autologous tissue are described separately, with their anatomical background, indications and contraindications. Alloplastic options such as implants and tissue expanders, with or without the use of acellular dermal matrix, are explained with up-to-date references and guidelines. This chapter is therefore designed to offer the practitioner a ready reference for what we trust will be a meticulously if not passionately executed endeavour.
Article
Background: Early studies have shown that near-infrared monitoring with tissue oximetry shows promise in providing earlier detection of free flap vascular compromise. However, large-scale clinical evaluation of this technology on flap outcome has not previously been established. This study examines the effect of tissue oximetry on flap reexploration rates and salvage over a 10-year period. The learning curve for this new technology is also assessed. Methods: A retrospective review was performed of prospectively maintained data on all microsurgical breast reconstructions performed at an academic institution from 2004 to 2014. Patients were divided into two separate cohorts-standard clinical monitoring and standard clinical monitoring plus tissue oximetry-and rates of reexploration and flap salvage were compared. Subgroup analysis (tertiles) was performed to assess outcomes with increasing experience. Results: A total of 380 flaps (36.2 percent) received standard clinical monitoring, and 670 flaps (63.8 percent) received additional tissue oximetry monitoring. The rate of flap salvage before implementation of tissue oximetry monitoring was 57.7 percent and increased to 96.6 percent (p < 0.001). The number of complete flap losses decreased from 11 (2.9 percent) to one (0.1 percent) with the use of tissue oximetry (p < 0.001). Subgroup analysis demonstrated significantly fewer reexplorations in the third tertile. Conclusions: Inclusion of continuous tissue oximetry in the postoperative monitoring protocol of microsurgical breast reconstruction is associated with significantly improved salvage rates and fewer flap losses. Furthermore, learning curve assessment demonstrates that use of tissue oximetry can decrease the rate of reexploration over time.
Article
The lower abdominal region has evolved as the workhorse donor site for use in breast reconstruction. In particular, the deep inferior epigastric artery perforator (DIEP) flap has become popular in the hands of microsurgeons because of the balance between protection of the donor site and reliability for autologous breast reconstruction. The transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction was first described by Holstrom1 and Robbins.2 It was Koshima and Soeda3 who brilliantly transformed this into a flap with complete muscle preservation, now known as the DIEP flap. When compared with the traditional pedicled TRAM flap, the DIEP flap has a lower incidence of fat necrosis or partial flap loss and has a lower incidence of hernia and abdominal bulge rates. When compared with the free TRAM flap, the DIEP flap, when properly raised, preserves all muscle function and abdominal fascia so that hernia and bulge rates are again lower4 and flap success rates are comparable. It should be noted that as the free TRAM flap has evolved to become more muscle-sparing, these structural abdominal donor site differences may be less.5 While the superficial inferior epigastric artery (SIEA) flap maintains the privilege of absolutely no violation of the abdominal wall, it cannot be carried out in all patients because of anatomical absence of the SIEA. Furthermore, the SIEA may not be able to reliably supply as much of the lower abdominal tissue for transfer as the DIEP flap, and failure rates in reported series are higher than for DIEP flap reconstruction. Although the DIEP flap appears to provide an ideal balance between reliability and low donor site morbidity, successful breast reconstruction using the DIEP is multifactorial, and proper patient selection and intraoperative decision making is essential.
Article
In the last 20 years, enormous progress has been made in flap design, and several flaps have been created based on the perforating vessels to minimize donor-site morbidity. However, the exact location of perforators varies on a case-by-case basis, and preoperative vascular mapping has been introduced to help identify the dominant perforator and its course, in order to reduce the operative duration. A variety of imaging methods are currently available for this purpose, including hand-held Doppler, color duplex ultrasound, digital subtraction angiography, multidetector-row computed tomography, and magnetic resonance angiography. In this review, the various vascular mapping systems are described in detail, along with their advantages and drawbacks, as well as the level of evidence in the planning of free flaps.
Article
In cases were the deep inferior epigastric perforator flap (DIEP flap) is not available and unilateral transverse myocutaneous gracilis flap (TMG flap) is not sufficient for breast reconstruction, we perform double TMG flaps as a reconstructive method. In this report, we present our results of the use of double TMG free-flap-transfer for unilateral breast reconstruction. Between August 2004 and June 2012 we performed 58 TMG flaps in 29 patients for unilateral breast reconstruction. Patient data were analyzed and operative outcome (operation time, complication rate and aesthetic results) were investigated. Aesthetic outcome was evaluated retrospectively via photo documentation by an independent plastic surgeon. The results were classified in;unsatisfactory, satisfactory, good and very good. The average operating time was 6 hours 55 minutes (295 - 650 minutes). Of 58 TMG flaps, 57 (98.3%) were successful. Thrombosis occurred in seven (12%) cases (1 arterial, 6 venous). Flap salvage was successful in six cases and flap failure occurred in one (1.7%) case. The results of 25 patients were graded as good and very good. Three patients showed satisfying and one patient unsatisfying results. Double TMG flaps in unilateral breast reconstruction could lead to good operative results. This method further expands the range of options with autologous tissue in reconstructive breast surgery. © 2015 Wiley Periodicals, Inc. Microsurgery, 2015. © 2015 Wiley Periodicals, Inc.
Article
The reliability of deep inferior epigastric artery perforator (DIEP) flap reconstruction following abdominal liposuction is controversial. The authors' early cases were technically successful; however, they experienced high partial flap loss and fat necrosis rates. The authors sought to compare DIEP flap outcomes in the setting of prior liposuction after the use of intraoperative indocyanine green angiography compared to when flaps were assessed on clinical grounds alone. A retrospective review of a consecutive series of DIEP flaps following liposuction at a single institution was performed, comparing those evaluated on clinical grounds alone and those in which indocyanine green angiography was used intraoperatively. Outcomes measured included anastomotic complications, total flap loss, partial flap loss, fat necrosis, and postoperative abdominal wounds. Thirteen DIEP flaps following prior liposuction were performed on 11 patients from July of 2003 through January of 2014. All patients had preoperative imaging with duplex ultrasound or computed tomographic angiography to analyze perforator suitability before surgical exploration. Seven flaps were evaluated intraoperatively on clinical grounds alone. Six flaps were assessed and modified based on indocyanine green angiography. All flaps were successful; however, partial flap loss and fat necrosis rates dropped from 71.4 percent to 0 percent when indocyanine green angiography was used intraoperatively (p = 0.02). Indocyanine green angiography is an excellent vascular imaging modality for intraoperative use to assess flap perfusion, and improves outcomes in DIEP flaps when harvested after prior abdominal suction lipectomy.
Article
The latissimus dorsi musculocutaneous flap has been widely used for breast reconstruction. It is a reliable method with low complications. Thoracodorsal pedicle is constant but might have been dissected and injured previously, for example, in case of axillary lymph node dissection. The purpose of our study is to assess the benefit of systematic preoperative echo-doppler imaging of the thoracodorsal pedicle. Seventy-four consecutive patients with unilateral axillary lymph node dissection undergoing latissimus dorsi flap underwent doppler and color duplex sonography of the thoracodorsal pedicle preoperatively. Non operated and contralateral pedicle served as reference. A total of 12.2% patients had differences between operated and non operated pedicle, 9.5% had smaller operated pedicle and 2.7% patients had stenosis with altered blood flow. Stenosis of the pedicle contraindicates, in our unit, latissimus dorsi flap because of altered blood flow. There were no flap necrosis in our series. The percentage of stenosed pedicle in our series is similar to percentage of flap necrosis in the literature. We think that systematic doppler and color duplex sonography of the thoracodorsal pedicle increase the reliability of latissimus dorsi flap by excluding pedicle with altered blood flow.
Article
Full-text available
Scientific reports of clinical in vivo research into the effects and side-effects of ultrasonic-assisted liposuction (UAL) are scarce. Advocates of UAL claim that the damage to vascular and nervous structures is limited and even less than with conventional and/or tumescent liposuction (CL). The effect of tumescent infiltration alone and combined with either CL or UAL was assessed by performing injection studies of the panniculus adiposus of the lower abdominal wall of 20 fresh cadavers and five abdominoplasty specimens. Besides the control and infiltration groups (n=5 in each), there was an additional group of ten cadaver flaps and five abdominoplasty flaps that underwent infiltration followed by UAL in the right half of the flap and infiltration followed by CL in the left half of the flap. Radiographs of these flaps were shown to a blinded panel of ten plastic surgeons, who were asked to evaluate and compare the damage on the basis of the number and magnitude of contrast-medium extravasations in the flap. Vascular damage to the perforating vessels was seen even after infiltration alone, although it was very limited. A variable amount of damage (ranging from little to extensive) was observed in the CL and UAL groups. Statistical analysis of the judgments of the observers could not show that either technique was less damaging than the other. UAL is, therefore, probably more beneficial to the surgeon than to the patient. The financial investment in the device is justified for surgeons with large liposuction practices, mainly, and probably solely, because of the reduced physical strain for the surgeon.
Article
In this clinical study, the effect of conventional liposuction on musculocutaneous and fasciocutaneous perforator vessels was investigated. The perforator vessels in the abdominal and lateral and medial thigh regions in 7 patients and in the abdominal region in 3 patients (a total of 38 anatomic regions in 10 patients) were marked preoperatively by color Doppler ultrasonography. Following a standard liposuction procedure, the changes in the number of the perforators in those regions were detected by the same method postoperatively at 2 weeks and 3 months. The number of cannula passes employed and total volume of the aspirate for each region were also recorded. The results of the Doppler examinations showed that 57.8% of abdominal, 50.0% of lateral thigh and 53.8% of medial thigh perforators could not be detected at 2 weeks and 3 months (p
Article
The author describes a revolutionary body contouring technique based on the surgical use of ultrasonic energy. It allows the selective destruction of only excess adipose tissue. The technique is based on three fundamental steps: (1) preparation of the areas to be treated with a large infiltration of a special solution, (2) treatment of the areas with ultrasonic energy through special titanium probes, (3) manual remodeling of the treated areas to eliminate the fluid from the bursted adipocytes (fatty acids). The advantages of this new technique are selective destruction of just the undesired tissues, elimination of the fluid from the adipose tissues, and the possibility of a real "lifting" of the skin of the treated areas, and a reduction of physical strain on the surgeon. The author has already treated more than 280 patients with excellent results and without contraindications or undesired side effects. The fundamental steps of ultrasonic liposculpturing, including a description of the physical principles on which the technique is based, are presented.
Article
The effect of suction-assisted lipectomy on cutaneous blood vessels of inguinal skin flaps was studied and compared in 191 rats. Different types of cannula tips were used; the number of passes was standardized. In one experiment, following suctioning, 3 X 2 cm groin island flaps based on inferior epigastric pedicles were raised and then reattached. Fluorescein dye study and microangiography were performed to evaluate flap viability. Flap survival was determined clinically and by histologic examination on the fifth postoperative day. Three-sided inguinal random-pattern flaps were raised in a second experiment and reattached following suctioning. On the fifth postoperative day, surviving flap areas were measured using standard photographs and an imaging computer and were compared with controls. Results showed that cannula passes accompanied by vacuum are harmful to vessels, while those unaccompanied by vacuum are not. The greater the number of suctioning passes, the more trauma there is to vessels and the greater is the likelihood of flap necrosis. Conical and spatula tips were more harmful to vessels than spherical, cobra, keel cobra, or Fournier tips. These results support the conclusion that suction-assisted lipectomy enhances the possibility of skin necrosis by traumatizing the vascular pedicle of a flap, especially when it is used as an adjunct to flap elevation.
Article
Subcutaneous photographs of tissues treated by suction lipectomy have been obtained by adapting fiberoptic endoscopy equipment. These photographs document the presence of an intact neurovascular supply to the overlying skin and lend support to the concept of suction lipectomy with the blunt cannula. The technique of subcutaneous endoscopy is described, and additional uses for the method are suggested.
Article
We describe a patient for whom bilateral transverse rectus abdominis musculocutaneous flap breast reconstruction was successfully accomplished several years after liposuction of the lower abdominal tissues making up the flaps. A history of liposuction within the area of a proposed musculocutaneous flap does not preclude use of that flap. Issues related to flap elevation in sites of previous liposuction are discussed.
Article
Perforator flaps have become the first choice in free flap reconstruction of contour defects or skin and fat replacement in our department. The Deep Inferior Epigastric Perforator (DIEP), the Superior Gluteal Artery Perforator (S-GAP) and the Thoracodorsal Artery Perforator (TAP) flaps are now routinely used. By evaluating the vascular anatomy of these flaps preoperatively, we intend to improve our surgical strategy so that these operative procedures can proceed in a faster and safer way. In this study, the results of the colour Duplex scanning in 50 consecutive DIEP flap patients are reviewed and evaluated for their sensitivity and positive predictive value. Also the preoperative information from unidirectional Doppler flowmetry in 30 S-GAP flaps and 11 TAP flaps is evaluated for its reliability. Due to the variable vascular anatomy of the lower abdominal wall and the dorso-lateral thoracic wall we now prefer using the colour Duplex scanning for planning the DIEP and TAP flaps. The more constant course of the branches of the superior gluteal artery allows us to use the easier and cheaper unidirectional Doppler flowmetry for planning the S-GAP flap.
Article
Abdominal wall function is a major concern for plastic surgeons performing breast reconstruction with TRAM flaps. The deep inferior epigastric perforator (DIEP) free flap spares the whole rectus abdominis muscle, includes skin and fat only, and therefore, preserves adequate abdominal wall competence. Between January of 1995 and May of 1997, a total of 50 breast reconstructions in 42 patients were performed by using the DIEP flap. Eight patients had bilateral procedures. Five breast reconstructions were immediate and 45 were delayed. All patients were collected prospectively and no patients were excluded from this study. The average age of patients was 47 years (range, 22 to 59 years) and the average weight was 65 kg (range, 51 to 103 kg). Seventy percent of patients had one or more risk factors for TRAM flap reconstruction. The mean postoperative follow-up period was 13 months (range, 3 to 30 months). Twenty consecutive patients (17 single and 3 bilateral DIEP flap breast reconstructions) within this group underwent evaluation of their abdominal wall function preoperatively and then 3 and 6 months postoperatively by using Lacote's muscle grading system. Average flap harvesting time was 120 minutes and average blood loss was 420 cc. Total flap loss and partial necrosis occurred in one (2 percent) and three flaps (6 percent), respectively. Abdominal wound infection occurred in seven patients (17 percent). Unfortunately, one patient died of adult respiratory distress syndrome on the seventh postoperative day. Fat necrosis was found in three flaps (6 percent). Postoperative abdominal wall examination did not reveal any hernia, but bulging was found in two patients (5 percent). All patients were able to resume their daily activities. Abdominal wall function tests in the series of 20 patients showed that all patients had reached or even improved their preoperative level of upper and lower rectus muscle function 6 months after the operation. The external oblique muscles were the most affected by the procedure of flap harvesting, but only two patients (10 percent) were found to have a measurable impairment after 6 months. Patient satisfaction with the reconstructed breast and the donor site was rated high. The free DIEP flap is, therefore, a reliable and valuable method of breast reconstruction. The donor site morbidity was decreased, and the more tedious flap dissection did not affect the overall outcome.
Article
The Transverse Rectus Abdominis Myocutaneous (TRAM) flap has been the gold standard for breast reconstruction until recently. Not only autologous but also immediate reconstructions are now preferred to offer the patient a natural and cosmetically acceptable result. This study summarises the prospectively gathered data of 100 free DIEP flaps used for breast reconstruction in 87 patients. Primary reconstructions were done in 35% of the patients. Well-known risk factors for free-flap breast reconstruction were present: smokers 23%, obesity 25%, abdominal scarring 28% and previous radiotherapy 45%. Free DIEP flaps vascularised by a single (52%), two (39%) or three (9%) perforators were preferentially anastomosed to the internal mammary vessels at the level of the third costochondral junction. Of 74 unilateral DIEP flaps, 41 (55%) flaps were well vascularised in zone IV. Two flaps necrosed totally. Partial flap loss and fat necrosis occurred in 7% and 6% of all flaps, respectively. One patient presented with a unilateral abdominal bulge. Mean operating time was 6 h 12 min for unilateral reconstruction and mean hospital stay was 7.9 days. These data indicate that the free DIEP flap is a new but reliable and safe technique for autologous breast reconstruction. This flap offers the patient the same advantages as the TRAM flap and discards the most important disadvantages of the myocutaneous flap by preserving the continuity of the rectus muscle. The donor site morbidity is reduced, a sensate reinnervation is possible, postoperative pain is less, recovery is quicker and hospital stay is reduced. The more complex nature of this type of surgery, leading to increased operating time, is balanced by the permanent and gratifying results achieved.
Article
The superior and inferior myocutaneous gluteal free flaps have been considered as valuable alternatives to the latissimus dorsi or TRAM flap since 1975. The superior gluteal artery perforator (S-GAP) flap is the ultimate refinement of this myocutaneous flap as no gluteus maximus muscle is harvested. The flap is vascularised by one single perforator originating from the superior gluteal artery. This study summarises the prospectively gathered data on 20 free S-GAP flaps used for breast reconstruction in 16 patients. Immediate reconstruction was performed in six breasts and delayed in 14 breasts. Mean follow-up was 11.1 months. Two risk factors, Raynaud's disease and radiotherapy, were the cause of flap revision in two different patients. Total flap loss occurred in one case. Partial flap loss was not observed and a small area of fat necrosis was diagnosed by mammography in one other patient. All flaps were anastomosed to the internal mammary vessels at the 3rd costochondral junction. The anatomy of the sensate nerves of the S-GAP flap is described. Two nervous repairs provided early sensory recovery. The free S-GAP flap has become my personal second choice for autologous breast reconstruction after the DIEP (deep inferior epigastric perforator) flap. The S-GAP flap is indicated in patients with an asthenic body habitus or with excessive abdominal scarring. The advantages are the abundance of adipose tissue in this area even in thin patients, a long vascular pedicle, a hidden scar, improved projection of the reconstructed breast compared to the DIEP and TRAM flaps and the preservation of the entire gluteus maximus muscle. The donor morbidity is extremely low.
Article
This technique or its modification (using other dyes) may play a beneficial role in other clinical scenarios where the reconstructive plastic surgeon preoperatively needs to know the integrity of vessels that are too small to image using standard angiographic techniques. In addition, flap perfusion mapping can demonstrate the pattern of skin that is physiologically perfused by the intact vessels. Knowledge of the perfusion characteristics of the tissues to be transferred before surgery may, at the least, alter the design of the tissues to be transferred and, in the extreme case, could affect the nature of the operative choice altogether.
Article
After the reported safe transverse rectus abdominis myocutaneous (TRAM) flap after liposuction of the abdomen, two cases of bipedicled reconstruction with this flap after abdominoplasty were successfully performed. This operation has not previously been considered possible because of the transection of the perforator arteries during the undermining of the abdomen. To examine the possible reperfusion of the perforator arteries, the authors studied the perforator arteries of 10 patients before they underwent abdominoplasty and at 1 week, 3 months, and 6 months after the operation. The arteries were studied with color-duplex scanning and power Doppler, using 10-MHz superficial probes, and their position was marked on a map. A cadaver study of a woman who had had an abdominoplasty 10 years before her death is also presented. In every patient, reperfusion of all perforator arteries was documented, starting from the control at 1 month. In no case was the caliber of the reperfused vessels more than 40 percent of the original diameter (maximum: 0.53 mm). This was also confirmed by the cadaver study. In conclusion, after an abdominoplasty operation, constant reperfusion of the perforator arteries of the rectus muscles occurs. However, the diameter of the arteries may not be enough to provide the necessary blood supply for a TRAM flap, which is therefore strongly discouraged by the authors after abdominoplasty in favor of a vertical rectus abdominis muscle (VRAM) flap. A liposuction, which does not necessarily disrupt the perforators, is not an absolute contraindication for a TRAM flap, provided that an accurate color-duplex scanning study is done.
Article
Liposuction is the most common cosmetic surgical procedure performed for women today. A large percentage of these cases involve abdominal liposuction, and more than 75 percent of these patients are younger than 50 years old.(1) Concomitantly, the incidence of breast cancer is increasing, with one out of every eight women affected.(2) Eighty percent of breast cancer cases are diagnosed in women older than 50.(3-5) Therefore, the number of women With breast cancer who have undergone abdominal liposuction will most likely increase. Many of these women may wish to undergo autologous tissue breast reconstruction after mastectomy. The safety and Success of performing a transverse rectus abdominis muscle (TRAM) flap breast reconstruction after abdominal liposuction have yet to be determined. No preoperative test has been conclusively shown to document the patency of the perforating vessels from the deep interior epigastric system. Two case reports have documented successful TRAM flap reconstruction after abdominal liposuction. We present a series of three patients Who Underwent five free TRAM flaps after abdominal liposuction and describe the preoperative assessment used to help determine which patients were candidates for this procedure.
  • M Zocchi
  • Ultrasonic Liposculpturing
Zocchi M. Ultrasonic liposculpturing. Aesthetic Plast Surg 1992;16:287e98.
Ultrasonic liposculpturing
  • M Zocchi
Zocchi M. Ultrasonic liposculpturing. Aesthetic Plast Surg 1992;16:287e98.