Pedicled perforator flaps in breast reconstruction: a new concept.

INTRODUCTION: Pedicled perforator flaps have not been widely described for the breast. The aim of this study is to report our clinical experience with pedicled perforator flaps in breast reconstruction. MATERIAL AND METHODS: Between May 2000 and May 2003, pedicled perforator flaps were used in 31 patients. The indications were immediate partial breast reconstruction and thoracic reconstruction for carcinomatous mastitis or tumour recurrence. Perforators were identified by Doppler preoperatively. The Doppler-located thoracodorsal artery perforator (TDAP) or another perforator such as the intercostal artery perforator (ICAP) was looked for. If the perforators had good calibers, the flaps were then based solely on these perforators. If the perforators were tiny but pulsating, the TDAP flap was harvested as a muscle-sparing latissimus dorsi type I (MS-LD I) with a small piece of muscle (4x2 cm) included to protect the perforators. If the perforators were not-pulsating, a larger segment of the LD muscle was incorporated to include the maximum of perforators (MS-LD II flap). The nerve that innervates the rest of the LD muscle was always spared. If most of the LD was included in the flap, the flap was then classified as MS-LD III. RESULTS: The mean flap dimensions were 20x8 cm. Using this algorithm, the TDAP flap was harvested in 18 cases and the ICAP flap in three cases. In addition, there were 10 MS-LD flaps with a variable amount of muscle. In addition, one parascapular flap was dissected. A successful flap transfer was achieved in all but three patients, in whom limited partial necrosis occurred. Seroma was not encountered at the donor sites of the perforator flaps (0%) compared to four (40%) after a MS-LD flap. CONCLUSION: Our results show that pedicled perforator flaps are additional options for breast surgery and that they may be used whenever an adequate perforator can be found. This technique is safe and reliable if the algorithm described is used when choosing a flap.     

Versatility of the pedicled thoracodorsal artery perforator (TDAP) flap in soft tissue reconstruction

For the last decades, the latissimus dorsi skin-muscle flap has contributed to the efficient reconstruction of the loss of skin cover (especially in breast surgery) and in long-distance tissue defects. Unfortunately, the nonuse of such an important muscle as the latissimus dorsi for the patient, as well as the resulting thickness of the flap after reconstruction, has turned it into a second choice flap. However, this flap is still indicated in the reconstruction of areas which need a great amount of cutaneous and muscular tissue. The appearance of the perforator flaps and, specifically, thoracodorsal artery perforator (TDAP) flap, has meant a radical change in relation to lower morbidity of the donor site, thus highly ranking the use of these flaps in the reconstruction for similar defects. The aim of this publication is to present our experience with the pedicled TDAP flap in a series of 17 different cases. Of those, there were 14 cases of mammary reconstruction after sparing surgery, 2 cases of axillary reconstruction following severe recurrent hidradenitis, and a case of extensive substance loss in a patient's upper limb following a severe crush injury.     

Ischial pressure sore reconstruction using an inferior gluteal artery perforator (IGAP) flap.

Perforator-flap technique has revolutionised the practice of free tissue transfer with the goal of muscle sparing for function and strength. These concepts are being widely explored for breast reconstruction. The field of pressure-sore reconstruction presents a new application for this technique, preserving muscle for function in ambulatory patients and for future reconstruction in paraplegic patients. Just as the superior gluteal artery perforator flap holds promise for sacral and trochanteric reconstruction, the inferior gluteal artery perforator flap may provide a muscle-sparing alternative for ischial reconstruction. A case report of the successful use of an inferior gluteal artery perforator flap for ischial pressure-sore reconstruction is described, including the surgical technique employed for flap harvest, and 2 year's follow-up.     

A unique deep inferior epigastric artery perforator and implications for a muscle and fascia sparing vertical rectus abdominis myocutaneous flap: a case report

Despite the sacrifice of rectus abdominis muscle, the vertical rectus abdominis musculocutaneous (VRAM) flap is still a preferred option for perineal reconstruction. This journal has previously reported on the utility of preoperative computed tomographic angiography (CTA) in this setting to identify cases that are both suitable and unsuitable for rectus abdominis flaps after previous surgery. We report a case which highlights a unique example of the benefits of such imaging, with the largest deep inferior epigastric artery (DIEA) perforator described to date identified on imaging, and used to potentiate a donor-site sparing procedure. The use of this dominant perforator was able to limit donor site harvest to only a small cuff of anterior rectus sheath and a small segment of rectus abdominis, potentiating a muscle-sparing and fascia-sparing VRAM flap for perineal reconstruction. As such, preoperative CTA was found to be a useful tool in identifying a unique anatomical variant in the largest DIEA perforator described to date, and was used to potentiate a muscle-sparing and fascia-sparing VRAM flap for perineal reconstruction.     

胸背动脉穿支皮瓣在乳腺癌保乳手术一期乳房部分重建中的应用

目的 评价保乳手术联合应用带蒂胸背动脉穿支(thoracodorsal artery perforator,TDAP)皮瓣行一期乳房部分重建(immediate partial breast reconstruction,IPBR)的皮瓣设计、手术结果、重建乳房外观以及供皮区并发症情况.方法 回顾性分析复旦大学附属肿瘤医院乳腺外科2004年11月-2010年11月13例应用带蒂TDAP皮瓣行BCS+ IPBR手术的乳腺癌患者随访资料.结果 胸背动脉主要穿支的位置位于腋后线、腋皱襞下7.5～9.5 cm(中位距离8.0 cm),穿支术前多普勒超声体表定位与术中解剖的位置符合率为100％.单纯解剖穿支1例,余12例均在穿支周围保留1.0～3.0cm宽度的部分背阔肌.术后随访4～71个月,中位随访时间41个月.所有皮瓣均存活,供区均无血清肿及背阔肌功能障碍.重建乳房的外观以患者自我评价及门诊随访医生评价相结合的方式进行评估,结果9例为优良,3例为一般,1例为差.结论 TDAP皮瓣能满足乳腺癌保乳术后任何象限的局部缺损修复和重建,特别对于肿块局部切除活检后保乳的患者来说,能很好的重塑乳房外形,患者满意度较高.术前应用手持式多普勒超声对胸背动脉的主要穿支进行体表定位,有助于术中快速找寻及解剖穿支,减少血管损伤及血管危象的发生.     

Soft tissue reconstruction with the superior gluteal artery perforator flap

The development of the perforator flap technique revolutionized the practice of soft tissue transfer. The main goal of this technique is muscle sparing at the donor site for function and strength. Meanwhile, this concept is being widely applied for reconstruction of tissues throughout the entire body. Perforator flaps are the ultimate upgrade of the well-known myocutaneous flaps. Theoretically, any myocutaneous flap can be harvested as a perforator flap if skin resurfacing is needed. Although the DIEP flap, the anterolateral thigh flap, and the TAP flap are probably more frequently used for breast, trunk, and upper and lower limb reconstruction, as well as head and neck reconstruction, the SGAP flap takes its own position in the large group of perforator flaps and has its own specific indications.     

Randomized clinical trial of the effect of quilting latissimus dorsi flap donor site on seroma formation

BACKGROUND: Latissimus dorsi (LD) flap breast reconstruction is associated with a high incidence of donor site seromas, despite the use of surgical drains. The aim of this study was to evaluate the use of donor site quilting sutures, as well as drains, on the incidence, volume and frequency of seroma aspiration. METHODS: The trial randomized 108 women undergoing LD breast reconstruction to quilting procedures (54) or control group (52) for intention-to-treat analysis; two were excluded. Outcome measures were the incidence and volume of postoperative seroma. Secondary outcome measures included postoperative back pain, analgesic consumption, shoulder movement and duration of hospital stay. RESULTS: Quilting significantly reduced the overall incidence of seroma from 46 of 48 (96 per cent) to 43 of 52 (83 per cent) (P = 0.036), including the 38 women who had extended LD flap (with or without implants). There were further significant reductions in seroma volume (P = 0.004), frequency of aspiration (P = 0.001) and overall seroma volumes, including surgical drainage and symptomatic seromas (P = 0.013). Subset analyses for LD-implant (60 women) and extended LD (with or without implant) showed similar significance. Quilting did not affect back pain or compromise shoulder mobility. CONCLUSION: Quilting significantly reduced overall seroma volumes after LD breast reconstruction including extended LD, and is recommended in combination with surgical drains.     

Rethinking the superficial inferior epigastric artery flap in breast reconstruction: Video demonstration of a rapid,reliable harvest technique

Abdominal-based autologous free tissue breast reconstruction has undergone significant changes over the past decade. The evolution has focused on limiting morbidity of the donor site. The transition from the transverse rectus abdominus muscle free flap to the muscle-sparing transverse rectus abdominus muscle free flap to the deep inferior epigastric artery perforator free flap has markedly improved abdominal-based autologous breast reconstruction. However, all of these flaps involve an incision through the anterior rectus fascia and potential damage of intercostal motor and sensory nerves. The superficial inferior epigastric artery flap (SIEA) reliably perfuses the ipsilateral hemiabdomen, yet does not violate the fascia or any motor nerves. As a result, the incidence of hernia, abdominal wall weakness and bulging is essentially eliminated. Nevertheless, use of the SIEA flap remains marginal. Vessel size, dissection difficulties and lack of understanding of the relevant anatomy have limited its acceptance. The present article describes a rapid, reliable and safe dissection technique with an algorithm for harvesting the SIEA flap in autologous breast reconstruction.     

Muscle sparing-2 transverse rectus abdominis musculocutaneous flap for breast reconstruction: a comparison with deep inferior epigastric perforator flap

Breast reconstruction using free transverse rectus abdominis musculocutaneous (TRAM) flap can be divided into 4 muscle-sparing (MS) types: conventional TRAM flap containing full width muscle as MS-0, while deep inferior epigastric perforator (DIEP) flap containing absolutely no muscle as MS-3. We include only the muscle portion between the medial row and lateral row perforator vessels in TRAM flap, which is designated as MS-2. Between October 1999 and April 2006, the same surgeon performed 82 breast constructions using MS-2 free TRAM flaps in 79 patients. All the flaps survived. Postoperative complications included partial fat necrosis in 8 cases, all corresponding to zone IV or zone II. Bulging of donor site occurred in 5 patients, 4 of whom were obese and 1 had bilateral flap harvest. Compared with our own reconstructions using DIEP flap (30 cases), there were no significant differences in operative time and blood loss between the two techniques. In conclusion, MS-2 free TRAM flap is a useful technique for breast construction considering the easy surgical techniques, length of the vascular pedicle that can be harvested, and the degree of freedom of the flap.     

Thoracodorsal artery perforator (TDAP) flap in immediate breast reconstruction and the role of preoperative mapping: a clinical experience

Background

Oncoplastic approach to reconstruct partial breast resection is always challenging. Nowadays, pedicle perforator flaps have been described for partial breast mastectomy reconstruction

Methods

The study comprised all patients who received partial breast resection due to external quadrant breast cancers and who were reconstructed with thoracodorsal perforator flap between August 2010 and August 2011. Twenty-two patients received the thoracodorsal artery perforator (TDAP) for breast reconstruction. The mean surgical time (including oncology resection and reconstruction) was 160 min. Eleven patients (50 %) underwent Doppler and Computed tomographic angiography (AngioCT) presurgical planning, the rest Doppler alone.

Results

The mean stay was 3.27 days. Seroma formation in the donor site was found in five cases. No flap failures were detected. No breast size changes were observed after surgical and radiotherapy treatment.

Conclusions

We conclude that TDAP flap is suitable for partial breast reconstruction (quadrantectomy) in moderate breast cancer. Level of Evidence: Level IV, therapeutic study.     

Transverse Upper Gracilis Flap with Implant In Postmastectomy Breast Reconstruction: a Case Report

Autologous flaps can be used in combination with prosthesis in postmastectomy breast reconstruction. The deep inferior epigastric perforator (DIEP) flap is considered the preferred choice among autologous tissue transfer techniques. However, in patients with a peculiar figure (moderately large breasts and large thighs with flat stomach), who cannot use their abdominal tissue, the transverse upper gracilis (TUG) flap with implant is investigated as a further option for breast reconstruction. This report presents a patient who underwent the TUG flap plus implant reconstruction. A bilateral skin‐sparing mastectomy was performed removing 340 g for each breast. The volume of the TUG flaps was 225 g (left) and 250 g (right). Preoperative volumes were restored by placing under the TUG muscle a round textured implant. No complications occurred during the postoperative period both in the recipient and donor site and the outcomes of the procedure were good. In cases where the use of the DIEP flap is not possible because of past laparotomies or inadequate abdominal volume, the TUG flap plus implant may be considered as a valid alternative. © 2013 Wiley Periodicals, Inc. Microsurgery 34:149–152, 2014.     

Thoracodorsal artery perforator fasciocutaneous flap: A versatile alternative for coverage of various soft tissue defects

Objective:

The thoracodorsal artery perforator (TDAP) flap has contributed to the efficient reconstruction of tissue defects that require a large amount of cutaneous tissue. The optimal reconstruction method should provide thin, and well-vascularized tissue with minimal donor-site morbidity. The indications for the use of this particular flap with other flaps are discussed in this article.

Materials and Methods:

Thirteen patients underwent soft tissue reconstruction using TDAP flaps between 2009 and 2011. Of those, there were four cases of antecubital burn contracture, three cases of axillary burn contracture, two cases of giant hair cell nevus of upper extremity, two cases of axillary reconstruction following severe recurrent hidradenitis, and two cases of crush injury. All patients were male and their ages ranged from 20 to 23 (average, 21 years). The mean follow-up period was 8 months (range, 4-22 months).

Results:

All reconstructive procedures were completed without any major complications. Minor complications related to transfered flaps were wound dehiscence in one case, transient venous congestion in two cases. Minor complication related to the donor site was seroma in one case. The success rate was 100%, with satisfactory cosmetic results.

Conclusions:

The TDAP flap is a safe and extremely versatile flap that offers significant advantages in acute and delayed reconstruction. Although the vascular anatomy may be variable, free and pedicled TDAP flap is a versatile alternative for soft tissue defects. It adapts very well to the soft tissue defects with acceptable donor site scar.KEY WORDS: Burn contracture, hidradenitis suppurativa, soft tissue defects, the thoracodorsal artery perforator, thoracodorsal artery perforator flap     

Immediate nipple reconstruction utilizing the DIEP flap in areola‐sparing mastectomy

The surgical treatment of breast cancer has dramatically evolved over the past decade toward an approach combining oncologic safety with aesthetic outcomes. The skin‐sparing mastectomy initiated this paradigm shift amongst breast surgeons and can be oncologically safe, in some cases sparing both the areola and the nipple. In accordance with the emphasis on aesthetics, some general surgeons have adopted new methods of resecting only the nipple, sparing the areola in select patients. The superior aesthetic results, durability, and decreased donor site morbidity of perforator flaps have brought autologous reconstruction back to the forefront of breast reconstruction with the deep inferior epigastric artery perforator (DIEP) flap as the gold standard. We describe a technique utilizing the DIEP flap skin paddle for immediate nipple reconstruction at the time of mastectomy and reconstruction, eliminating the need for delayed reconstruction and limiting donor site morbidity by concealing the donor site below the mastectomy skin flaps. In the six cases described performed between 2010 and 2012 (mean with 53 years; range 46–59 years), there have been no complications to the flap or the nipple postoperatively, nor has there been a need for further nipple revisions for 6 months. The nipple position relative to the flap breast mound has remained unchanged for up to 6 months. The immediate nipple reconstruction does not significantly lengthen operative time, requiring approximately 30 additional operative minutes per nipple. Immediate nipple reconstruction utilizing the DIEP flap can be a cost‐effective and feasible technique for recreating a natural‐appearing and aesthetic nipple in select patients. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

Perforator flaps: evolution,classification, and applications

In this article, the authors review the literature regarding perforator flaps. Musculocutaneous perforator flaps have evolved from musculocutaneous flaps and offer several distinct advantages. By sparing muscle tissue, thus reducing donor site morbidity and functional loss, perforator flaps are indicated for a number of clinical problems. The versatility of the perforator flap makes it ideal for the reconstruction of three-dimensional defects such as breast reconstruction or as a thin flap for resurfacing shallow wounds when bulk is considered a disadvantage. The authors review the historical development of the perforator flap and discuss the advantages and disadvantages of perforator flaps compared with free and pedicled musculocutaneous flaps. The nomenclature traditionally used for perforator flaps is confusing and lacks a standardized anatomic basis. The authors present a method to describe all perforator flaps according to their artery of origin.     

A safe approach to sparing the rectus muscle in abdominal-based microvascular breast reconstruction—TRAM, MS-TRAM, DIEP or SIEA?

There has been an international drive towards the use of abdominal-based perforator (deep inferior epigastric perforator (DIEP) or superficial inferior epigastric artery (SIEA)) flaps for breast reconstruction as they provide the ideal tissue whilst minimizing donor site morbidity, post-operative pain and recovery times. Ultimately, what is desired is a safe and reliable reconstruction. We retrospectively reviewed 245 consecutive abdominal-based free flaps performed by three surgeons at a single institution between January 2002 and March 2008. Primary breast reconstructions were planned as DIEPs, but a safe, flexible approach to flap selection was adopted with the most appropriate flap performed depending on the perforator anatomy at the time of surgery. Chest wall resurfacing procedures for extensive recurrent disease, inflammatory breast carcinoma or following radionecrosis were planned as transverse rectus abdominis myocutaneous (TRAM) flaps. The incidence of flap complications was compared including total and partial flap loss, returns to operating room, seroma, abdominal hernia/bulge, fat necrosis and delayed wound healing. Patient age, body mass index (BMI), smoking status, co-morbidity and pre- and post-operative radiotherapy were recorded. Two hundred patients, mean age 48?years (range, 26–74?years), underwent a total of 245 abdominal-based microvascular breast reconstructions. Twelve salvage TRAM flaps were performed for chest wall resurfacing. Of the remaining 233 flaps, 151 (65%) were immediate and 82 (35%) were delayed reconstructions. Flaps included 171 DIEPs, 38 muscle-sparing (MS)-TRAMs, 2 TRAMs and 22 SIEA flaps. Of the 233 reconstructions, 39 flaps (16.7%) in 31 patients received radiotherapy. Mean follow-up was 2.6?years. There were three (1.3%) complete flap losses and three (1.3%) partial flap losses. Rates of fat necrosis were 3.0% and abdominal hernia/bulge 1.7%. We present an algorithm to aid decision-making in autologous breast reconstruction that reflects our safe flexible approach. We have achieved excellent success rates in autologous breast reconstruction and conclude that in order to minimize complications, a safe flexible approach towards muscle harvest must be maintained in our drive to use perforator flaps.     

Breast reconstruction with gluteal artery perforator (GAP) flaps: a critical analysis of 142 cases

Fujino was the first to introduce gluteal tissue as a free flap for breast reconstruction. The use of the musculocutaneous flap from the buttock in breast reconstruction has been championed by Shaw. Despite the initial enthusiasm for this area as a donor site, few other large series exist on the subject. Two decades of experience with this region as a donor site led to recognition of advantages and drawbacks. Furthermore, use of both the superior and inferior gluteal musculocutaneous flap was associated with certain important donor site complications and the use of vein grafts to allow for microvascular anastomosis. The evolution of free tissue transfer has progressed to the level of the perforator flap. This reconstructive technique allows elevation of tissue from any region consisting only of fat and skin. This minimizes donor site morbidity by allowing preservation of the underlying muscle and coverage of important structures in the region such as nerves. The superior and inferior gluteal perforator flaps have been used at our institution for breast reconstruction since 1993. The superior gluteal artery perforator (S-GAP) flap is our preferred method of breast reconstruction when the abdomen is not available or preferable. We report the result of this flap over the past 9 years and point out important surgical refinements, advantages, disadvantages, and lessons learned during this time.     

Thoracodorsal artery perforator flap: a versatile alternative for various soft tissue defects

Thoracodorsal artery perforator (TDAP) flap is a relatively new member of the perforator flap family. The objective of this study is to describe the use of pedicled and free TDAP flaps for various soft tissue defects. Fifteen patients underwent soft tissue reconstruction using 16 TDAP flaps. Twelve pedicled flaps were used for axillary, breast, and shoulder regions. Four free flaps were used for cheek, popliteal, hand, and foot reconstruction. The flaps were harvested based on the perforators, which were preoperatively located at or close to a point 8 cm below the posterior axillary fold and 2 cm behind the lateral border of the latissimus dorsi muscle. Early, late, major, and minor complications were documented. In 13 of the 16 flaps, perforators from the thoracodorsal artery were found in the circle 3 cm in diameter, centered on the anatomic landmark. Three other perforators were found outside this circle. One flap loss was considered the only major complication. Minor complications occurred in 12.5% of flaps. Although the vascular anatomy can be variable, free and pedicled TDAP flap is a versatile option in soft tissue reconstruction.     

Latissimus dorsi flaps oriented on the lateral intercostal artery perforators: anatomical study and application in autologous breast reconstruction

Autologous breast reconstruction with the latissimus dorsi (LD) musculocutaneous flap has several problems including scarcity of tissue and postoperative atrophy of muscles. We report a modification of the flap based on a re-evaluation of the intramuscular and perforating vascular anatomy focused on the intercostal vascular system. Our anatomical study confirmed the following technical improvements: splitting of the muscle oriented along the 10(th) posterior intercostal artery; siting the axis of the flap on the centre of the 10(th) lateral intercostal artery perforator to obtain ample subcutaneous fat cranial to the iliac crest; and enclosing the dermoadipofascial flap around the split muscular pedicle. These flaps were used in 12 patients who required reconstruction without implants. The results showed a consistent volume of tissue and shape, and less donor site morbidity. Our modifications can be used to improve the three-dimensional potential of the LD flap in autologous breast reconstruction.     

The “limited rectus sheath incisions” technique for DIEP flaps using preoperative CT angiography

The abdominal wall donor site has become popularized for autologous breast reconstruction, with low donor site morbidity one of its key attributes. Further improvements in donor site outcomes have been facilitated through muscle sparing techniques, such as the use of the deep inferior epigastric artery (DIEA) perforator (DIEP) flap, and the use of modifications to closing the rectus sheath following muscular dissection, such as the use of endoscopic techniques and the use of mesh. We describe a new and unique method for potentially minimizing donor site damage during DIEP flap harvest: the “limited rectus sheath incisions” technique. This approach is only possible in select cases, the choice of which can be aided with the use of preoperative computed tomography angiography (CTA). In select patients, there may be an extended segment of DIEA that does not give any musculocutaneous perforators, and thus does not require open exposure. In such cases, limited incision to the rectus sheath may be made: one to access the periumbilical perforators and a separate incision to access the pedicle near its origin on the external iliac artery. This incision may then be made in a muscle‐splitting fashion, in the line of external oblique fibers. This approach may reduce damage to the anterior rectus sheath, and may contribute to improving donor site morbidity. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

Deep inferior epigastric perforator flap: a modification that simplifies elevation

The deep inferior epigastric perforator flap is accepted worldwide as a reliable and relatively safe technique for autologous breast reconstruction. Preserving the continuity of the rectus muscle, it reduces donor site morbidity, allowing less postoperative pain, a faster recovery, and a reduced hospital stay. Nevertheless, the more complex nature of this type of surgery leads to increased operating time and a demand for more tedious microsurgical dissection. The authors present a modification of the deep inferior epigastric perforator flap harvesting technique that allows a more safe, simple, and faster elevation of the flap. They have used it successfully for breast reconstruction in 3 patients.