Breast reconstruction with free flaps from the abdominal donor site: TRAM, DIEAP, and SIEA flaps

Multiple types of free flap can be elevated from the lower abdominal region for use in breast reconstruction. These include the free transverse rectus abdominis myocutaneous flap, the deep inferior epigastric artery perforator flap, and the superficial inferior epigastric artery flap. This sequence of flaps represents an evolution in the protection of the donor site. However, the decision as to which flap may be most appropriate for an individual patient is complex. This article serves to review pertinent surgical anatomy, preoperative planning, intraoperative decision making in flap elevation, and reported outcomes.     

Banking a hemi‐abdominal DIEP flap: A pilot report of indications,technique, and utility

We present a pilot report of “banking” the contralateral hemi‐abdominal deep inferior epigastric perforator (DIEP) flap under the abdominal closure in patients undergoing unilateral autologous breast reconstruction when a hemi‐abdominal flap suffices. Four patients undergoing unilateral autologous breast reconstruction with a hemi‐abdominal DIEP or superficial inferior epigastric artery flap had their contralateral hemi‐abdominal flap left in position, or “banked,” under their abdominal closure to be used in case of failure. This novel method may be of assistance when a free microvascular hemi‐abdominal flap is felt to be threatened or suspect. It provides a life‐boat for the younger and experienced surgeon alike, and most importantly, for the breast cancer survivor. Economic analysis of the technique reveals that the contralateral hemi‐abdominal flap should be banked more often than intuition alone would suggest. © 2009 Wiley‐Liss, Inc. Microsurgery 2009.     

Sensate superficial inferior epigastric artery flap innervated by the iliohypogastric nerve for reconstruction of a finger soft tissue defect

In the era of perforator flaps, lower‐abdominal/inguinal perforator flaps such as superficial circumflex iliac artery perforator (SCIP) flap and superficial inferior epigastric artery (SIEA) perforator flap are becoming popular with its longer vascular pedicle and usefulness in various reconstructions. SIEA flap's region is innervated by the T12 nerve and the iliohypogastric nerve (IHN), but no sensate SIEA flap has been reported so far. In this report, we present a case in which a sensate SIEA flap innervated by the IHN was used for reconstruction of a finger soft tissue defect. A 55‐year‐old male suffering from the volar skin necrosis of the right ring finger underwent the volar soft tissue reconstruction using a free sensate SIEA flap because of hypoplastic SCIA. The SIEA flap included the IHN anterior branch, and neuroraphy was performed between the IHN and the third common digital nerve in an end‐to‐side manner after vascular anastomoses. The reconstructed volar skin could sensate 14 weeks after the surgery. At postoperative 6 months, Semmes‐Weinstein test and moving 2‐point discrimination revealed 3.64 and 8 mm in the proximal portion of the SIEA flap where the IHN was supposed to innervate. The IHN may be included in a SIEA flap, and a sensate SIEA flap may be a useful option when a SCIP flap is not available. Further anatomical and clinical studies are required to clarify anatomy and clinical usefulness of the IHN. © 2014 Wiley Periodicals, Inc. Microsurgery 35:324–327, 2015.     

Superficial inferior epigastric artery‐supercharged deep inferior epigastric artery perforator flap‐based breast reconstruction for a thin patient: A case report

Although a bipedicled deep inferior epigastric artery perforator (DIEP) flap is widely accepted for slim patients with large breasts, we suggest DIEP flap‐based breast reconstruction in which the superficial inferior epigastric artery (SIEA) is supercharged to the branch of thoracodorsal vessel as an alternative, which has not previously been well described. We report the case of a 48‐year‐old breast cancer patient who had a normal body mass index of 23.01 and relatively thin abdominal tissue, with large and ptotic (grade II ptosis) breasts. The mastectomy specimen weighed ~890 g, and the harvested abdominal tissue weighed ~700 g with a size of 32 × 12 cm². The elliptical‐shaped flap was inset with a 90° counterclockwise rotation, and the lower one‐third of the flap was folded to create a projection. Perfusion of flap was augmented by microvascular anastomosis between the contralateral SIEA and the serratus branch of a thoracodorsal vessel. With a supercharged DIEP flap, nearly the whole lower abdominal tissue (696 g, 99.4% of the elevated flap) could be transferred to obtain a symmetric contour, and there were no complications such as vascular obstruction, flap necrosis, and delayed wound healing during the postoperative course. Using the SIEA pedicle for contralateral abdominal perfusion with elongated branch of the thoracodorsal vessel, aesthetic inset and contouring of the reconstructed breast could be technically enhanced. The DIEP flap with the contralateral SIEA supercharged to the serratus branch of thoracodorsal vessel may be a feasible option for large ptotic breast reconstruction in thin patients.     

Anterolateral thigh flap salvage following failed deep inferior epigastric artery perforator breast reconstruction

The deep inferior epigastric artery perforator flap is an option for women desiring autologous tissue breast reconstruction. If this reconstruction fails, other autologous tissue flaps, including the gluteal artery perforator and latissimus dorsi flaps, may be used for salvage. The anterolateral thigh (ALT) flap offers adequate tissue volume for breast reconstruction, acceptable fat quality and a long vascular pedicle. Other advantages include obviating the need for intraoperative position changes and harvesting tissue outside of the radiation field. Two cases involving ALT flaps used in the setting of deep inferior epigastric artery perforator failure are presented with favourable results. A review of the anatomy of the ALT flap is included.     

腹壁浅动脉蒂游离腹壁皮瓣乳房再造术的初步临床应用

目的 探讨采用腹壁浅动脉(superficial inferior epigastric artery,SIEA)蒂游离腹壁皮瓣乳房再造术方法 、特点及适应证.方法 术前采用多层螺旋CT(multipledetector-row computed tomography,MDCT)三维血管造影及多普勒血流探测仪检查SIEA的直径、走行及分布,于脐与阴阜上缘之间设计皮瓣,采用单蒂或双蒂SIEA,与胸廓内动,静脉吻合,腹部供区直接拉拢缝合.结果 4例乳房再造病例皮瓣全部存活,皮瓣和腹部供区无脂肪液化、坏死、切口裂开、腹壁薄弱及腹壁疝等并发症的出现,再造乳房外形效果满意.结论 SIEA蒂游离腹壁皮瓣与腹壁下动脉穿支皮瓣(DIEP),横行腹支肌肌(TRAM)皮瓣乳房再造术提供同样的腹部皮肤和组织量,但却减轻了对腹部功能和形态的损害,在做好充分的术前血管评估、严格把握适应证和熟练掌握显微外科技术的前提下,是一种可供选择的乳房再造方法.     

腹壁浅动脉蒂游离腹壁皮瓣乳房再造术的初步临床应用

目的 探讨采用腹壁浅动脉（superficial inferior epigastric artery,SIEA）蒂游离腹壁皮瓣乳房再造术方法 、特点及适应证.方法 术前采用多层螺旋CT（multipledetector-row computed tomography,MDCT）三维血管造影及多普勒血流探测仪检查SIEA的直径、走行及分布,于脐与阴阜上缘之间设计皮瓣,采用单蒂或双蒂SIEA,与胸廓内动,静脉吻合,腹部供区直接拉拢缝合.结果 4例乳房再造病例皮瓣全部存活,皮瓣和腹部供区无脂肪液化、坏死、切口裂开、腹壁薄弱及腹壁疝等并发症的出现,再造乳房外形效果满意.结论 SIEA蒂游离腹壁皮瓣与腹壁下动脉穿支皮瓣（DIEP）,横行腹支肌肌（TRAM）皮瓣乳房再造术提供同样的腹部皮肤和组织量,但却减轻了对腹部功能和形态的损害,在做好充分的术前血管评估、严格把握适应证和熟练掌握显微外科技术的前提下,是一种可供选择的乳房再造方法.     

腹壁浅动脉蒂游离腹壁皮瓣乳房再造术的初步临床应用

目的 探讨采用腹壁浅动脉(superficial inferior epigastric artery,SIEA)蒂游离腹壁皮瓣乳房再造术方法 、特点及适应证.方法 术前采用多层螺旋CT(multipledetector-row computed tomography,MDCT)三维血管造影及多普勒血流探测仪检查SIEA的直径、走行及分布,于脐与阴阜上缘之间设计皮瓣,采用单蒂或双蒂SIEA,与胸廓内动,静脉吻合,腹部供区直接拉拢缝合.结果 4例乳房再造病例皮瓣全部存活,皮瓣和腹部供区无脂肪液化、坏死、切口裂开、腹壁薄弱及腹壁疝等并发症的出现,再造乳房外形效果满意.结论 SIEA蒂游离腹壁皮瓣与腹壁下动脉穿支皮瓣(DIEP),横行腹支肌肌(TRAM)皮瓣乳房再造术提供同样的腹部皮肤和组织量,但却减轻了对腹部功能和形态的损害,在做好充分的术前血管评估、严格把握适应证和熟练掌握显微外科技术的前提下,是一种可供选择的乳房再造方法.     

Contralateral unaffected breast augmentation using zone IV as a SIEA flap during unilateral DIEP flap breast reconstruction

BackgroundContralateral breast augmentation during unilateral breast reconstruction is a good option for women with small breasts. In patients with adequate lower abdominal tissues, the deep inferior epigastric perforator (DIEP) flap is often the first choice for unilateral autologous breast reconstruction. We use Zone IV, which is usually excised owing to its insufficient blood circulation, as a superficial inferior epigastric artery (SIEA) flap for contralateral breast augmentation.MethodsBetween October 2004 and January 2016, 32 patients underwent unilateral breast reconstruction using a DIEP flap and an attempted simultaneous contralateral breast augmentation with an SIEA flap. The unilateral DIEP flap attached to the contralateral SIEA flap was split into two separate flaps after indocyanine green angiography. In all patients, ipsilateral internal mammary vessels were used as recipient vessels for DIEP flap breast reconstruction. The SIEA flap pedicle was anastomosed to several branches of the deep inferior epigastric vessels. The SIEA flap was inset beneath the contralateral breast through the midline.ResultsOf 32 patients, 27 underwent DIEP flap breast reconstruction and simultaneous unaffected breast augmentation using 25 SIEA or 2 superficial circumflex iliac artery perforator (SCIP) flaps. All DIEP flaps survived, and total necrosis occurred in one SIEA flap. The mean weight of the final inset for DIEP flap reconstruction and SIEA or SCIP flap augmentation was 416 g and 112 g, respectively.ConclusionsUnilateral DIEP flap breast reconstruction and contralateral SIEA flap breast augmentation may be safely performed with satisfactory results.     

Profunda artery perforator based V‐Y rotation advancement flap for total vulvectomy defect reconstruction—A case report and literature review

Reconstruction of total vulvectomy defect represents a challenge, and reconstructive methods include skin graft, local skin flap, musculocutanous flap, and pedicled perforator flap. We report a case of a 63‐year‐old patient affected by extramammary Paget's disease of vulva who underwent total vulvectomy receiving reconstruction with bilateral profunda artery perforator based V‐Y rotation advancement flap. The literature about vulva reconstruction was reviewed. This innovative flap design combined the classic rotation flap and V‐Y advancement flap with inclusion of the profunda artery perforators to augment the flap blood supply. Besides, the internal pudendal nerve was preserved to maintain the sensation of the neo‐uvula. The flap survived completely without major post‐operative complications with 9‐months follow‐up. Profunda artery perforator based V‐Y rotation advancement flap may represent a valuable option in total vulvectomy defect reconstruction. © 2015 Wiley Periodicals, Inc. Microsurgery 35:668–671, 2015.     

Robotic‐assisted deep inferior epigastric artery perforator flap abdominal harvest for breast reconstruction: A case report

The deep inferior epigastric perforator (DIEP) flap is a mainstay of autologous breast reconstruction. The da Vinci robot has recently been adapted for an increasing number of reconstructive surgeries. The literature has yet to describe its use for the intra‐abdominal harvest of the deep inferior epigastric vessels (DIEV) during DIEP flap breast reconstruction. We show the use of the da Vinci robotic surgical system for the intra‐abdominal dissection of DIEV during delayed breast reconstruction with a DIEP flap in a 51‐year‐old female who had undergone a right modified radical mastectomy. After dissecting the flap from the anterior abdominal wall leaving only the targeted perforating vessels intact, a 1.5 cm fascial incision was made adjacent to the perforator and the vessels were dissected to below the level of the fascia. The intra‐abdominal robotic‐assisted dissection of the DIEV up to the perforator was then completed. The DIEV were divided at their origin using the robot and the flap removed from the abdomen for subsequent reconstruction. This technique enabled improved precision of flap harvest while also decreasing the donor‐site morbidity by minimizing the incision length of the anterior rectus sheath. The patient had an uneventful postoperative course and, at 9‐month follow‐up, exhibited no evidence of flap or donor‐site complications, specifically hernia or bulge. This novel approach for the harvest of a DIEP flap introduces an alternative technique to the conventional DIEP flap procedure in the appropriate patient population. Risks inherent to this technique as well as additional costs must be considered.     

Reconstruction of a full‐thickness,complex nasal defect that includes the nasal septum using a free,thin superficial inferior epigastric artery flap

Complex nasal defects present a surgical challenge, particularly in cases with a full‐thickness defect that extends into the nasal septum. Although the superficial inferior epigastric artery (SIEA) flap has been widely used as a bulky flap for soft tissue augmentation, reports on its use as a thin flap are limited. We present a case of complex nasal defect reconstruction using a free, thin SIEA flap. A 65‐year‐old man with a recurrent malignant peripheral nerve sheath tumor around the left nose and cheek underwent wide tumor resection, leaving a full‐thickness nasal defect that included portions of the nasal septum, nasal bone, and maxilla. A free, thin SIEA flap was elevated and primarily thinned by microdissecting the pedicle distally. The flap was then folded and inset to close the nasal septum and skin. The flap survived completely and complete closure of the nasal septum was observed. As the SIEA runs toward superficial layers as it is traced distally, primary thinning of the flap is possible. We believe that this method may represent an alternative to the superficial circumflex iliac artery perforator flap in cases in which the superficial circumflex iliac artery system is hypoplastic. © 2014 Wiley Periodicals, Inc. Microsurgery 36:66–69, 2016.     

Sitting on a gold mine: optimal autologous reconstruction of a significant cosmetic contour defect of the buttock using a deep inferior epigastric artery perforator free flap

The options for reconstruction of soft tissue defects of the buttock include custom prosthetic implants and autologous tissue transfer: fat transfer, local flaps, pedicled flaps and free flaps. Optimal reconstruction involves replacement of like-with-like tissue, sufficient padding and adequate contouring. We report a case of a female patient presenting with a significant cosmetic contour defect of her left buttock following previous excision of a malignant fibrous histiocytoma. The patient had autologous buttock reconstruction using a deep inferior epigastric artery perforator free flap with an excellent result. To our knowledge a deep inferior epigastric artery perforator free flap has not previously been described to reconstruct the buttock.     

Free prepuce perforator flap: Ultra‐thin superficial penile artery perforator flap for a dorsal finger defect

Dorsal skin defect of the hand/digit requires thin and pliable skin for coverage. The prepuce skin, the second thinnest skin, can be a reconstructive option, but there is no previous report of a free prepuce flap for the reconstruction of the hand/digit. We report the first successful case of a free prepuce flap based on the superficial penile artery perforator (SPAP) for the treatment of dorsal soft tissue defect of the hand/digit. A 68‐year‐old male presented with a 5 x 3 cm dorsal soft tissue defect of the left index finger with the extensor tendon exposure. A prepuce perforator flap was raised based on the SPAP. The flap was transferred to the recipient site, and the SPAP was supermicrosurgically anastomosed to the dorsal branch of the digital artery. The patient complained no postoperative discomfort of the donor penis, and was satisfied with functionally pleasing and esthetically acceptable results of the reconstructed finger and the donor site. Although only applicable for male patients without past history of penile trauma such as circumcision, a prepuce perforator flap may be an option for thin and pliable skin reconstruction with minimal donor site morbidity. © 2016 Wiley Periodicals, Inc. Microsurgery 37:252–255, 2017.     

Circummuscular Variant of the Deep Inferior Epigastric Perforator in Breast Reconstruction: Importance of Preoperative Multidetector Computed Tomographic Angiography

The deep inferior epigastric artery perforator is reliable and widely used in breast reconstruction. The anatomy and course of deep inferior epigastric vessels and their branches are relatively constant and well understood. However, some published cases with a direct perforating pattern and no intramuscular traveling were identified. A case involving a circummuscular variant of a deep inferior epigastric artery perforator is described as well as its clinical importance. This apprises clinicians who perform a transverse rectus abdominis muscle free flap procedure that there can be a rare circummuscular pedicle variant and that it is vulnerable to injury.     

Use of a 72‐cm‐long extended bilateral deep inferior epigastric artery perforator free flap for reconstruction of a lower leg with no suitable recipient vessel around the injury zone: A case report

In free‐flap reconstruction of the lower extremity, due either to trauma or pre‐existing vascular disease, healthy vessels may not be readily available in the proximity of the defect. A variety of options including a cross‐leg free flap, vein grafts, arteriovenous loops, and “bridging” flaps have been used to address the issue. The purpose of this report is to present a case in which a 72‐cm long extended bilateral deep inferior epigastric artery perforator (DIEP) free flap was used for coverage of a 20 × 25 cm soft tissue defect of the lower leg following a Gustilo grade IIIC fracture in a 29‐year‐old man. Because usable recipient vessels were far from the zone of injury, and to avoid complications accompanying long vein grafts, a long flap was necessary. The exposed tibia required coverage with a free flap, but peripheral portions of the defect with exposed muscles could be covered with a skin graft. Thus, a 72 × 12 cm flap was chosen. The flap was based on both bilateral DIEPs and on the superficial circumflex iliac artery (SCIA). The flap survived completely with no complications. After one debulking surgery, the flap and the donor site showed pleasing cosmesis, and the patient could walk without crutches at 18 months after the first surgery. In cases where no healthy recipient vessels can be found close to the defect, we believe that the use of an extended bilateral DIEP flap may be a feasible option which shortens or precludes vein grafts with no additional flap donor sites.     

Advances in the pre‐operative planning of deep inferior epigastric artery perforator flaps: Magnetic resonance angiography

Imaging of the abdominal wall vasculature prior to deep inferior epigastric artery (DIEA) perforator (DIEP) flaps has been shown to significantly improve surgical outcomes. Although computed tomography angiography (CTA) has been shown to be highly accurate, it is associated with radiation exposure, and as such modalities without radiation exposure have been sought. Magnetic resonance angiography (MRA) has been proposed as such an option. We conducted a pilot study comparing MRA with CTA and with operative findings in six consecutive patients undergoing DIEP flaps for breast reconstruction. The DIEA, superficial inferior epigastric artery (SIEA) and perforators were all assessed with each modality. We found that the DIEA and SIEA were accurately imaged with both CTA and MRA, but that while MRA could identify some major perforators, CTA was more accurate than MRA for perforator mapping. As such, while MRA does have a role in the imaging of DIEA perforators, CTA is still the preferred modality. On the basis of these findings, a larger study into the role for MRA in this setting is warranted. © 2008 Wiley‐Liss, Inc. Microsurgery, 2009.     

穿支皮瓣移植修复四肢软组织缺损108例

目的 探讨应用穿支皮瓣修复四肢皮肤软组织缺损的临床效果. 方法2007年7月至2009年5月,分别采用腹壁下动脉穿支皮瓣、股前外侧穿支皮瓣、胸背动脉穿支皮瓣、股外侧穿支皮瓣、骨间背侧动脉穿支皮瓣、桡侧副动脉穿支皮瓣、腓肠内侧动脉穿支皮瓣、胫后动脉穿支皮瓣、旋髂深动脉穿支皮瓣、腓动脉穿支皮瓣移植修复四肢皮肤软组织缺损108例(游离移植98例,带蒂转移10例),皮瓣切取面积最小4 cm×2 cm,最大44 cm×9 cm,皮瓣供区均直接缝合.结果 术后5例发生静脉危象,其中1例松解包扎后危象解除,4例再次手术探查,2例成活,2例坏死,其余103例顺利成活,皮瓣受区与供区创121愈合良好.术后随访6-24个月(平均10个月),皮瓣颜色、质地好,外形不臃肿;皮瓣供区遗留线性瘢痕,功能无影响. 结论穿支皮瓣不携带肌肉、深筋膜及运动神经,对皮瓣供区影响小,还具有血供可靠、质地薄、不需二期去脂整形的优点,是修复四肢浅表创面的首选方法.     

Revision breast and chest wall reconstruction in Poland and pectus excavatum following implant complication using free deep inferior epigastric perforator flap

This study aims to present the case of a female patient with Poland''s syndrome and pectus excavatum deformity who underwent breast and chest wall reconstruction with a pre-shaped free deep inferior epigastric perforator flap. A 57-year-old female patient with Poland''s syndrome and pectus excavatum presented with a Baker III capsular contracture following a previously performed implant-based right breast reconstruction. After a chest and abdominal CT angiography, she was staged as 2A1 chest wall deformity according to Park''s classification and underwent implant removal and capsulectomy, followed by a pre-shaped free abdominal flap transfer, providing both breast reconstruction and chest wall deformity correction in a single stage operation. Post-operative course was uneventful, and the aesthetic result remains highly satisfactory 24 months after surgery. Deep inferior epigastric free flap represents an interesting reconstructive solution when treating Poland''s syndrome female patients with chest wall and breast deformities.KEY WORDS: Deep inferior epigastric perforator flap, pectus excavatum, Poland''s syndrome     

Perineal and posterior vaginal wall reconstruction with a superior gluteal artery dual perforator‐pedicled propeller flap

Gluteal artery perforator flaps are a good option to reconstruct perineal and posterior vaginal wall defects after abdominoperineal resection. The bulkiness of the folded flap may compromise the results by obliterating the introitus and vaginal cavity. In this report, we present a case of the use of a superior gluteal artery dual perforator‐pedicled propeller flap to reconstruct the posterior vaginal wall and perineum in a 60‐year‐old female who had an abdominoperineal resection of a locally progressive anal squamous cell carcinoma. Two perforators were completely skeletonized through gluteus maximus muscle fibers. The vascularization of the skin flap was based on the first perforator, whereas the aponeurotic flap was vascularized by the second perforator. The vaginal defect was reconstructed with a gluteus maximus aponeurotic flap, and the perineal reconstruction was based on a superior gluteal artery perforator skin flap. No postoperative infection or necrosis occurred. Skin healing was completed in 3 weeks. Vaginal opening was controlled using lubricant and graduated vaginal dilators during 6 weeks. The patient began sexual intercourse 2 months postoperatively. No revision was needed. Perineal and posterior vaginal wall defects may be reconstructed with a gluteal artery perforator flap. The thickness of the flap allows a complete filling of the full perineal cavity. The gluteus maximus aponeurosis may be suitable for the reconstruction of the posterior vaginal wall. © 2014 Wiley Periodicals, Inc. Microsurgery 35:64–67, 2015.