Breast reconstruction using perforator flaps

BACKGROUND: Perforator flaps allow the transfer of the patient's own skin and fat in a reliable manner with minimal donor-site morbidity. The deep inferior epigastric artery (DIEP) and superficial inferior epigastric artery (SIEA) flaps transfer the same tissue from the abdomen to the chest for breast reconstruction as the TRAM flap without sacrificing the rectus muscle or fascia. Gluteal artery perforator (GAP) flaps allow transfer of tissue from the buttock, also with minimal donor-site morbidity. INDICATIONS: Most women requiring tissue transfer to the chest for breast reconstruction or other reasons are candidates for perforator flaps. Absolute contraindications to perforator flap breast reconstruction include history of previous liposuction of the donor site or active smoking (within 1 month prior to surgery). ANATOMY AND TECHNIQUE: The DIEP flap is supplied by intramuscular perforators from the deep inferior epigastric artery and vein. The SIEA flap is based on the SIEA and vein, which arise from the common femoral artery and saphenous bulb. GAP flaps are based on perforators from either the superior or inferior gluteal artery. During flap harvest, these perforators are meticulously dissected free from the surrounding muscle which is spread in the direction of the muscle fibers and preserved intact. The pedicle is anastomosed to recipient vessels in the chest and the donor site is closed without the use of mesh or other materials. CONCLUSIONS: Perforator flaps allow the safe and reliable transfer of abdominal tissue for breast reconstruction.     

Choice of flaps for breast reconstruction

The optimal method for breast reconstruction should be safe, reliable, and accessible for every patient, and it should display little or no donor-site morbidity. After comparing mammary implants it has been found that autogenous breast reconstruction can create a ptotic, soft, symmetrical breast mound. The transverse rectus abdominis musculocutaneous flap (TRAM) remains the most popular method for autogenous reconstruction. Modern trends in breast reconstruction using the TRAM flap have promoted adequate blood supply to the flap while minimizing donor-site defects in the anterior abdominal wall. The pedicled TRAM flap remains one of the most frequently used flaps, but the indirect blood supply in this flap has required many modifications and refinements. Such modifications have included the bipedicled TRAM flap, the free TRAM flap, and the supercharged TRAM flap. To avoid donor-site morbidities, the muscle-sparing free TRAM, deep inferior epigastric perforator flap (DIEP), and superficial inferior epigastric artery (SIEA) flap were introduced. The DIEP perforator flap requires meticulous technique but offers proven reliability and a low rate of complications. As surgeons become more comfortable with harvesting DIEP flaps, the frequency of usage seems likely to increase. The latissimus dorsi musculocutaneous flap, gluteus maximus musculocutaneous flap, and others may be selected when these modifications of free TRAM flap are unavailable or unusable.     

带蒂穿支皮瓣在乳房再造术中的应用

与游离穿支皮瓣相比,带蒂穿支皮瓣分离技术更加简单,安全系数更高,而且供区畸形更小。近年来,应用带蒂穿支皮瓣技术已经成为乳房再造手术一种新的选择, 甚至是一些患者的首选方案。常用的带蒂穿支皮瓣有胸背动脉穿支皮瓣、肋间动脉穿支皮瓣(外侧肋间动脉穿支皮瓣、前侧肋间动脉穿支皮瓣)等,其他可用的选择包括前锯肌动脉穿支皮瓣,腹壁上动脉穿支皮瓣,胸外侧动脉穿支皮瓣等。为了提高手术设计的精确性,术前需要评估穿支血管的质量,并对其定位穿支。皮瓣的设计相比游离皮瓣手术而言,显得更加重要。虽然带蒂穿支皮瓣在乳房再造领域的作用尚不能取代游离皮瓣的金标准地位,但随着“损伤最小化”重建概念的日渐推广,带蒂穿支皮瓣将会成为乳房再造领域里的一种新的趋势。     

Post-Mastectomy Breast Reconstruction: A History in Evolution

Although the need for mastectomy has been evident for many years, postmastectomy reconstruction has been recognized as an achievable outcome for only a little over a century. A review of the evolution of both autologous and prosthetic options for reconstruction was undertaken. The earliest attempts at reconstruction used autologous techniques that were either unsuccessful, not reproducible, or were associated with significant morbidity. Prosthetic techniques became sought after, with silicone prostheses widely used until concerns about potential adverse effects led to the investigation of alternate options. With these concerns shown to be unfounded, silicone and saline prostheses evolved with successive generations of implants. Concurrent advances in reconstructive surgery led to a revival in autologous techniques for breast reconstruction, with microsurgical free-tissue transfer potentiating a new range of potential donor sites. The abdominal wall became the donor site of choice, and with the advent of perforator flaps, morbidity associated with flap harvest was minimized. In cases where the abdominal wall is unsuitable, flaps such as the superior and inferior gluteal artery perforator flaps, the musculocutaneous gracilis flap, and the “stacked” deep inferior epigastric artery perforator flap are frequently used options. The development of minimally invasive techniques for implant placement and flap harvest, such as endoscopy, continue to evolve, and research in tissue engineering offers a vision for a future without the need for a donor site.     

Recent advances in microvascular autologous breast reconstruction after ablative tumor surgery

Breast cancer is a ubiquitous disease and one of the leading causes of death in women in western societies. With overall increasing survival rates, the number of patients who need post-mastectomy reconstruction is on the rise. Especially since its psychological benefits have been broadly recognized, breast reconstruction has become a key component of breast cancer treatment. Evolving from the early beginnings of breast reconstruction with synthetic implants in the 1960s, microsurgical tissue transfer is on the way to become the gold standard for post oncology restoration of the breast. Particularly since the advent of perforator based free flap surgery, free tissue transfer has become as safe option for breast reconstruction with low morbidity. The lower abdominal skin and subcutaneous fat tissue typically offer enough volume to create an aesthetically satisfying breast mound. Nowadays, the most commonly used flap from this donor site is the deep inferior epigastric artery perforator flap. If the lower abdomen is not available as a donor site, the gluteal area and thigh provide a number of flaps suitable for breast reconstruction. If the required breast volume is small, and there is enough tissue available on the upper medial thigh, then a transverse upper gracilis flap may be a practicable method to reconstruct the breast. In case of a higher amount of required volume, a gluteal artery perforator flap is the best choice. However, what is crucial in addition to selecting the best flap option for the individual patient is the timing of the operation. In patients with confirmed post-mastectomy radiation therapy, it is advisable to perform microvascular breast reconstruction only in a delayed fashion.     

Microvascular reconstruction of the breast

The growth of microsurgical procedures has led to significant technological, scientific, and clinical advances that have made these procedures safe, reliable, reproducible, and routine in most major medical centers. In many instances, free flap reconstruction has become the primary reconstructive method for many major defects, including breast reconstruction. The advantages of free flap breast reconstruction include better flap vascularity, broader patient selection, easier insetting of the flap, and decreased donor site morbidity. Free flap breast reconstruction can occur either at the time that the mastectomy is performed or as a delayed reconstruction following a previous mastectomy. Immediate reconstructions have the advantage of avoiding scar contracture and fibrosis within the mastectomy flaps and at the recipient vessel site. The most common recipient vessel sites are the thoracodorsal vessels and the internal mammary vessels. The thoracodorsal vessels are most frequently used in immediate reconstruction because they are partially exposed during the mastectomy procedure. The internal mammary vessels are used more frequently in delayed reconstructions, to avoid repeat surgery in the axilla. This recipient site also allows more medial placement of the reconstruction. Flap selections for free autogenous breast reconstruction include the transverse rectus abdominis myocutaneous (TRAM) flap, the superior gluteal myocutaneous flap, the inferior gluteal myocutaneous flap, the lateral thigh flap, and the deep circumflex iliac soft tissue flap (Rubens). The TRAM flap is most commonly used in free flap breast reconstruction. For patients with inadequate abdominal tissue or prior abdominal surgery, the superior gluteal flap is typically used. Both the TRAM flap and the superior gluteal flap can be designed as perforator flaps, preserving all of the involved muscle and, in the TRAM perforator, all the rectus fascia. These flaps are more technically demanding, with minimal impact on donor site function. The other flaps are less frequently used and limited to special patient circumstances. Free flap autogenous breast reconstruction provides a natural, long-lasting result with a high degree of patient satisfaction. Semin. Surg. Oncol. 19:264-271, 2000.     

Surgical therapy of vulvar cancer: how to choose the correct reconstruction?

ObjectiveTo create a comprehensive algorithmic approach to reconstruction after vulvar cancer ablative surgery, which includes both traditional and perforator flaps, evaluating anatomical subunits and shape of the defect.MethodsWe retrospectively reviewed 80 cases of reconstruction after vulvar cancer ablative surgery, performed between June 2006 and January 2016, transferring 101 flaps. We registered the possibility to achieve the complete wound closure, even in presence of very complex defects, and the postoperative complications. On the basis of these experience, analyzing the choices made and considering the complications, we developed an algorithm to help with the selection of the flap in vulvoperineal reconstruction after oncologic ablative surgery for vulvar cancer.ResultsWe employed eight types of different flaps, including 54 traditional fasciocutaneous V-Y flaps, 23 rectus abdominis myocutaneous flaps, 11 anterolateral thigh flaps, three V-Y gracilis myocutaneous flaps, three free style perforators V-Y flaps from the inner thigh, two Limberg flaps, two lotus flaps, two deep inferior epigastric artery perforator flap, and one superficial circumflex iliac artery perforator flap. The structures most frequently involved in resection were vulva, perineum, mons pubis, groins, vagina, urethra and, more rarely, rectum, bladder, and lower abdominal wall.ConclusionThe algorithm we implemented can be a useful tool to help flap selection. The key points in the decision-making process are: anatomical subunits to be covered, overall shape and symmetry of the defect and some patient features such as skin laxity or previous radiotherapy. Perforator flaps, when feasible, must be considered standard in vulvoperineal reconstruction, although in some cases traditional flaps remain the best choice.     

Free muscle transfer with split thickness skin graft coverage in head and neck reconstructive surgery

Sixteen patients (eight females and eight males) who underwent microsurgical free tissue transfers for head and neck reconstruction are reviewed. In this series, the flap reconstruction was completed on eleven patients with extra-oral defects and five with intra-oral defects. Split thickness skin graft coverage was used in all cases. The rectus abdominis free muscle flap was used in nine patients and the latissimus dorsi free muscle flap in seven patients. The choice of tissue reconstruction was decided by the size of the surgical defect. There were no failures of the tissue transfers and skin grafts. In skilled hands, free tissue transfer provides a reliable method of head and neck reconstruction, with a low incidence of recipient and donor site complications. In extra-oral defects, coverage of free muscle transfer with split thickness skin grafts, results in a better colour match than musculocutaneous flaps, and complements the appearance and pliability of the free muscle flap.     

Assessment of the perforators of anterolateral thigh flaps using 64-section multidetector computed tomographic angiography in head and neck cancer reconstruction

Background

The anterolateral thigh (ALT) flap is a frequent choice for free flap transfer in head and neck cancer reconstruction because of its versatility. Preoperative mapping of the perforator pedicles of an ALT flap is still a challenge because of variations in vasculature. Although computed tomographic angiography (CTA) is used increasingly to evaluate the peripheral vasculature, the use of this method for evaluating the perforators of an ALT flap has not been described in detail.

Methods

From September 2008 to March 2009, 32 patients underwent preoperative CTA before free ALT flap transfer for head and neck cancer reconstruction. The perforators were marked on a 64-section multidetector CT image for each patient. The preoperatively mapped perforators were compared with the actual intraoperative findings. Flap success rates and associated morbidity and complications were recorded.

Results

Preoperative CTA identified major variations in perforators. Eighty-four were found by preoperative CTA; 64 of these were mapped to be explored during the operation, and 13 additional perforators were identified during surgery. The accuracy rate of identifying the branching origin of the ALT perforators was 98% (63/64). All of the ALT flaps survived except for one with necrosis (survival rate 97%). There was no donor site morbidity.

Conclusions

Preoperative mapping of perforators by CTA proved valuable in free ALT flap transfer and shortened the operation time significantly. This modality provides useful information for head and neck cancer reconstruction in difficult cases, especially in patients with large or through-and-through defects that might need multiple perforators in flap design.     

应用游离股前外侧皮瓣修复头颈部软组织缺损

背景与目的：股前外侧皮瓣（ALT）对供区创伤小,有独特优点,但目前临床应用还不常见。本文探讨应用ALT皮瓣修复头颈部软组织缺损的临床价值。方法：回顾2004年11月至2008年5月期间于中山大学肿瘤医治中心20例应用ALT皮瓣修复重建头颈部软组织缺损的病例资料。总结皮瓣切取的技术细节。报告术中解剖和成功率。结果：20例游离股前外侧皮瓣修复头颈部软组织缺损均获成功。ALT皮瓣血管蒂长介于5～14cm,平均9．9cm。切取的面积介于（4～9cm）×（6～16cm）。皮肤穿支的解剖类型分为肌间隔穿支4例（占20％）,肌皮穿支16例（占80％）。股前外侧皮瓣用于修复的头颈部缺损包括口腔内黏膜缺损14例（其中修复舌体及口底9例、口颊黏膜3例、硬腭1例、以及磨牙后区黏膜1例）．面部及颈部皮肤缺损6例。皮瓣供区除1例以外均可一期缝合。结论：股前外侧皮瓣是头颈部各种软组织缺损修复重建中一个很有价值和应用潜力的供区,具有成功率高,对供区影响小的特点。     

旋髂浅动脉穿支皮瓣的临床解剖学研究及其在舌癌缺损修复中的应用*

目的:探讨旋髂浅动脉穿支皮瓣的解剖学特点及其在舌癌术后修复中的应用。方法:2014年1 月至2015年1 月，解剖制备15例旋髂浅动脉穿支皮瓣，成功修复9 例舌癌根治术后缺损，术前及术后3 个月评价舌部功能及供区状况。结果:切取旋髂浅动脉穿支皮瓣面积27～110 cm2，平均厚度为（1.2 ± 0.3）cm，旋髂浅动脉从股动脉起始处的平均管径为（0.7 ± 0.2）cm，旋髂浅静脉为（1.2 ± 0.2）cm。旋髂浅动脉与旋髂深动脉和腹壁浅动脉的关系可以分为5 型:Ⅰ型（8/ 15），Ⅱ型（2/ 15），Ⅲ型（2/ 15），Ⅳ型（2/ 15），Ⅴ型（1/ 15）。 术后随访4～16个月，受区局部外形丰满，语言及吞咽功能恢复满意。供区均拉拢缝合，瘢痕隐蔽，无功能障碍。结论:旋髂浅动脉穿支皮瓣质地柔软，穿支血管蒂较长，供区瘢痕隐蔽，术后患者语音及咀嚼功能恢复良好，是修复舌癌术后缺损的良好选择。      

Severe atherosclerosis of the radial artery in a free radial forearm flap precluding its use

The free radial forearm flap is the most frequently used free flap for head and neck reconstructions. Survival of free flaps is dependent on adequate blood supply. A 69-year old woman was scheduled for excision of a T3N0M0 oropharyngeal carcinoma, neck dissections and reconstruction with a free vascularized radial forearm flap. During the operation it appeared that the entire radial artery was almost completely obstructed by atherosclerotic plaques precluding microvascular anastomosis. Despite systemic risk factors certain artery types are more prone to develop clinically manifest atherosclerosis. There are no reports on the pathology of the radial artery in free flap reconstructions. In head and neck cancer patients severe atherosclerosis of the radial artery is very rare, but if present makes free radial forearm flap reconstruction impossible. Therefore, in patients with risk factors for peripheral vascular disease screening for radial artery stenosis should be considered.     

影像学评估腹壁下动脉穿支皮瓣血运的研究进展

应用不同影像学方法评估游离皮瓣的穿支血管走行及血供特性在乳房再造术中的重要作用腹壁下动脉穿支(leep inferior epigastric perforator, DIFP)皮瓣属穿支皮瓣, 穿支血管细小, 解剖变异大, 术前影像评估穿支血管的位置, 管径大小及其走行, 对提高手术成功率和安全性具有重要意义评估血管的方法包括手持多普勒、色彩双超声、数字减影血管造影、CT血管造影、核磁血管造影、多层螺旋CT以及吲哚菁绿激光辅助的血管造影等, 本文初步介绍不同检查方法评估DIEP皮瓣血管走行及血供特性的优缺点, 辅助乳腺癌乳房再造术中血管分布的评估。      

游离股前外侧皮瓣修复头颈部缺损术后供区功能调查

目的:评价股前外侧皮瓣(ALT)修复头颈部缺损术后供区的功能,为选择ALT皮瓣修复头颈部软组织缺损提供理论依据.方法:应用问卷调查的方法随访2004-11-2008-05于中山大学肿瘤防治中心应用ALT皮瓣修复头颈部缺损的14例患者,评价手术对供区外观满意度、感觉及运动功能的影响.结果:所有患者供区伤口均能一期拉拢缝合...     

乳腺癌改良根治术后即刻乳房再造不同方法的临床应用

目的：探讨乳腺癌改良根治术后即刻乳房再造不同方法的适应证、手术方法及优缺点。方法：本组37例乳腺癌患者,分别采用横形腹直肌肌皮瓣带蒂转移、腹壁下动脉穿支皮瓣吻合血管游离移植、背阔肌肌皮瓣带蒂转移、单纯乳房假体置入以及不同方法相结合进行术后即刻乳房再造。结果：除2例单纯TRAM皮瓣患者近腋窝皮瓣局部坏死,1例TRAM＋DIEP联合皮瓣患者下腹正中局部皮瓣脂肪液化外,余34例皮瓣全部成活,形态满意。随访5个月-10年,无腹部薄弱或腹壁疝等并发症,患者生活质量均得到提高。结论：乳腺癌术后即刻再造安全可行,不同的方法各有优缺点,应根据患者具体情况选择适合患者本人的方法进行乳房再造。     

Reconstruction of Combined Oral Mucosa-Mandibular Defects Using the Vascularized Myoosseous Iliac Crest Free Flap

The authors present five cases of combined oral mucosa-mandible defects reconstructed with thevascularized internal oblique-iliac crest myoosseous free flap. This technique has many advantages comparedto other conventional methods such as the radial flap, scapula flap, and fibula flap. Vascularized iliac crestflaps provide sufficient high-quality bone suitable for reconstructing segmental madibular defects. Althoughfibular flaps allow longer donor bone tissue to be harvested, the iliac crest can provide an esthetic shape formandibular body reconstruction and also provides sufficient bone height for dental implants. Conventionalvascularized iliac crest myoosseous flaps have excessive soft tissue bulk for reconstruction of intraoral softtissue defects. The modification discussed in the present article can reduce soft tissue volume, resulting inbetter functional reconstruction of the oral mucosa. Another advantage is that complete replacement of theoral mucosa is observed in as early as one month post-operation. The final mucosal texture is much betterthan that obtained with other skin paddle flaps, which is especially beneficial for the placement of dentalimplant prostheses. Donor site morbidity looks to be similar to, if not less than that observed for othermodalities in terms of function and esthetics. For combined oral mucosa-mandible defects, the vascularizedinternal oblique-iliac crest myoosseous free flap shows good results with respect to hard and soft tissuereconstruction.     

Single perforator based anterolateral thigh flap for reconstruction of large composite defects of oral cavity

Composite defects of oral cavity are a reconstructive challenge. Anterolateral thigh flap provides large and pliable tissue for reconstruction of these defects. However, wide variations in the vascular anatomy, variable perforator number and location are reported. The aim of this study was to evaluate the reliability of single perforator based large anterolateral thigh for reconstruction of complex oral cavity defects following ablative surgery. We report a series of 25 consecutive patients who underwent reconstruction of oral cavity defects with anterolateral thigh flap based on single perforator between August 2009 and August 2010. The mean flap dimension was 261cm(2) (range 80-540cm(2)). In 21 patients the flap was bi-paddled and used for inner and outer lining for cheek. None of the flaps developed perforator insufficiency. Two flaps were lost due to delayed neck wound sepsis after 7th post operative day. This study establishes safety and reliability of using a large and/or bi-paddled anterolateral thigh flap based on single perforator for reconstruction of complex oral cavity defects.     

Oral squamous cell cancer: early detection and the role of alcohol and smoking

Defects in head and neck after tumor resection often provide significant functional and cosmetic deformity. The challenge for reconstruction is not only the aesthetic result, but the functional repair. Cancer may involve composite elements and the in sano resection may lead to an extensive tissue defect. No prospective randomized controlled studies for comparison of different free flaps are available. There are many options to cover defects and restore function in the head and neck area, however we conclude from experience that nearly all defects in head and neck can be closed by 5 different free flaps: radial forearm flap, free fibula flap, anterior lateral thigh flap, lateral arm flap and parascapular flap.     

Primary and secondary reconstruction after surgery of the irradiated pelvis using a gracilis muscle flap transposition.

INTRODUCTION: The aim of this study is to describe our experience with reconstruction of pelvic defects after surgery for previously irradiated malignancies using a gracilis muscle flap transposition. PATIENTS AND METHODS: Between 1993 and 2002, 25 patients were treated by primary (n=7) or secondary reconstruction (n=18) using a gracilis muscle transfer. All patients were previously irradiated with a median dosage of 50 Gy. RESULTS: Direct reconstruction following resection of the tumour was accompanied with minor complications in three patients and without major complications. Median time to complete healing of the donor site and perineal defect was 11 and 46 days, respectively. Reconstruction of persistent perineal infections resulted in minor complications at the donor site (n=3) and at the perineal wound (n=11). Three patients experienced a major complication. Median time to complete healing of the donor site and perineal defect was, respectively, 17 and 190 days. Necrosis of the gracilis muscle flaps was not observed. CONCLUSION: Direct reconstruction with a gracilis transfer resulted in primary wound healing with low morbidity, hereby preventing potentially disabling persistent defects. After debridement of persistent wounds, indirect reconstruction with gracilis muscle resulted in the majority of patients in healing of the defects with acceptable morbidity.     

影像学评估在腹壁下动脉穿支皮瓣乳房重建中的应用进展

腹壁下动脉穿支皮瓣自体乳房重建手术中,一个关键步骤是腹部皮瓣穿支的选择。计算机断层血管造影、磁共振血管造影、彩色多普勒超声和动态红外热像仪等影像学技术可帮助外科医生在术前进行穿支血管的定位及筛选,在术中可以评估血流灌注,并且节约手术时间,术后还可以监测皮瓣灌流状况。随着技术的发展这些影像学手段本身的精确度进一步提升,应用范围也更加广泛,能帮助医生做出更加精准和个性化的临床决策,提高患者在各方面的获益。