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.     

Supermicrosurgical free sensate superficial circumflex iliac artery perforator flap for reconstruction of a soft tissue defect of the ankle in a 1‐year‐old child

Although a superficial circumflex iliac artery perforator (SCIP) flap has recently been widely used owing to its various advantages, reports on its use in the pediatric population are limited. A case of a supermicrosurgical reconstruction of a soft tissue defect of the ankle associated with the congenital deficiency of the tibia using a free sensate SCIP flap in a 1‐year‐old child has been presented. The correction of the valgus deformity of the ankle resulted in a soft tissue defect, which required flap coverage. The lateral cutaneous branch of the intercostal nerve of the flap was coapted with the deep peroneal nerve for sensory recovery. Postoperative course was uneventful and the flap completely survived. The patient was able to ambulate independently at 7 months after surgery. To the best of our knowledge, this is the youngest case of a SCIP flap transfer in literature. This case showed that young age is not a contraindication for SCIP flap transfer. It is believed that the SCIP flap procedure may be a useful option for free flap reconstruction in children. © 2015 Wiley Periodicals, Inc. Microsurgery 36:254–258, 2016.     

Sensate hypothenar perforator free flap for resurfacing large volar surface defect of the digit

In this report we present a case of large sized volar surface defect of a digit reconstructed by hypothenar perforator free flap coverage. A 57‐year‐old male patient presented with a 5 × 2 cm sized avulsive injury on his left little finger involving near total loss of the volar surface. The perforator arteries of the hypothenar area were identified around 5–15% on the x‐axis and 25–50% on the y‐axis (y‐axis: a line from the pisiform base to the metacarpophalangeal joint, x‐axis: a line perpendicular to the y‐axis.) The hypothenar free flap was designed centered on the anticipated location of the perforator artery. Upon dissection, the perforator artery was found as predicted and a superficial palmar vein was saved for venous drainage. In addition, a neighboring cutaneous branch of the ulnar nerve was also saved. The flap survived with satisfactory flap contour, durability, skin color and texture. Five months of follow‐up showed acceptable range of motion for joints of the affected digit and nearly full range of motion for the hand. The sensate hypothenar perforator free flap could be considered as a useful surgical option for large sized volar side defects of finger.     

The use of innervated radial artery superficial palmar branch perforator free flap for complex digital injuries reconstruction

Loco-regional flaps have been widely used for the reconstruction of digital injuries without requiring microvascular anastomosis, however, they result in scarring and compromised functional outcomes. This study demonstrates our experience utilizing the innervated radial artery superficial palmar branch (RASPB) perforator free flap for complex digital injury reconstruction. From May 2007 to March 2014, the innervated RASPB perforator free flap was used to reconstruct 79 distal complex hand and digital soft tissue defects of which 14 were used to re-vascularise the distal digit in a flow-through fashion. All free flaps were innervated by the palmar cutaneous branch of the median nerve. All 79 free flaps survived and all 14 digits re-vascularized successfully. One flow-through free flap developed distal skin necrosis which healed uneventfully without further procedure. The average follow-up was 21.5 months. Measurement of two-point discrimination ranged from 7 to 13?mm. All patients were satisfied with the aesthetic results. The innervated RASPB perforator free flap is a feasible and effective option for the reconstruction of complex digital defects and the flow-through concept, when utilized in cases with compromised vascularity, provides reliable re-vascularization. Level III, therapeutic study.     

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.     

The anatomical and neurophysiological basis of the sensate free TRAM and DIEP flaps.

Recent developments in autogenous breast reconstruction using the rectus abdominis myocutaneous free flap include attempts to reinnervate the flap tissue. We have carried out anatomical studies to determine the nature of abdominal-wall cutaneous innervation, with particular emphasis on the harvesting of sensate flaps. Dissections were performed on four embalmed and 12 fresh human cadavers (32 sides). The lowest five intercostal nerve trunks were identified and traced to the lateral border of the rectus sheath. A detailed dissection of the intramuscular course of the nerves and associated vasculature was performed. The relationship of the nerves to the vascular perforators used for rectus abdominis myocutaneous flaps was determined visually, and confirmed histologically. In contrast to previous studies, we show that nerves supplying cutaneous sensation can travel with both medial and lateral vascular perforators. In order to confirm clinically useful innervation, the abdominal flap skin of five patients undergoing TRAM flap reconstruction was stimulated electrically, and sensory recordings were made directly from the related intercostal nerve just prior to flap harvest. These studies represent, to our knowledge, the first clinical application of neurophysiological techniques to outline the perforator neurosomes of flaps based on the deep inferior epigastric vascular axis. We provide the first comprehensive study of abdominal-wall innervation with regard to sensate free-flap harvest. Our dissections show complex patterns of abdominal skin innervation that have not been previously described. The implications for sensate free TRAM and DIEP flap reconstructions, as well as the potential for more accurate inclusion of innervated flap skin, are discussed.     

Upper extremity reconstruction using free SCIA/SIEA flap

The most suitable free flap alternative in upper extremity reconstruction has adequate and quality of tissue with consistent vascular pedicle. Free flap must provide convenient tissue texture to reconstruct aesthetic and functional units of upper extremity. Furthermore, minimal donor site morbidity is preferred features in free flap election. In our efforts to obtain the best possible outcome for patients, we chose, as a first priority, the free superficial circumflex inferior artery (SCIA)/superficial inferior epigastric artery (SIEA) flap over other free flap options for the soft‐tissue reconstruction of upper extremities. The authors retrospectively report the results of 20 free SCIA/SIEA flaps for upper extremity reconstruction during the past 3 years. Nineteen of 20 flaps were successful (95%): three required emergent postoperative reexploration of the anastomosis and one failed. Flap thinning (n = 4) was performed during the flap harvest, whereas some flaps were thinned with secondary debulking (n = 4). The functional and aesthetic results were evaluated as acceptable by all patients. Based on our results, a free SCIA/SIEA flap has the following advantages in soft‐tissue reconstruction of the upper extremity: (1) if necessary, flap thinning may be performed safely at the time of flap elevation and (2) flaps are harvested using a lower abdominal incision so that it causes minimal donor site scar. © 2009 Wiley‐Liss, Inc. Microsurgery, 2010.     

A novel model for supermicrosurgery training: the superficial inferior epigastric artery flap in rats

The purpose of this study was to determine the usefulness of a new flap model, the superficial inferior epigastric artery (SIEA) flap for supermicrosurgical training. Experimental groups were randomly divided into three groups of 10 rats each. In each group SIEA flaps were elevated and then returned to their original locations with or without vascular anastomosis of the superficial inferior epigastric vessels. Group 1: free SIEA flap, group 2: free SIEA flap with 1 hour ischemia time, group 3: free SIEA flap with 4 hours ischemia time, group 4: SIEA flap without vascular anastomosis. The viability rate was 80% with group 1, 50% with group 2, and 40% with group 3. All nonvascularized flaps (group 4) underwent complete necrosis. These findings suggest that preservation of blood flow in a flap has a beneficial effect on the prevention of microthrombosis in the subcutaneous capillary network of the skin and increases the flap survival rate. The SIEA flap with preserved circulation is an ideal model for developing supermicrosurgical skills.     

不同穿支蒂的足内侧皮瓣修复手指皮肤缺损

目的 总结不同穿支蒂的足内侧皮瓣修复手指皮肤软组织缺损的选择及临床应用疗效.方法 对29例手指皮肤软组织缺损,分别采用以足底内侧动脉深支内侧深支皮支为供血动脉的足内侧皮瓣修复指腹及指侧方缺损5例;以足内侧动脉浅支为供血动脉的足内侧皮瓣修复手指掌侧皮肤缺损及指侧方皮肤缺损10例;以内踝前动脉为供血动脉的足内侧皮瓣修复指背皮肤缺损及指侧方皮肤缺损11例;以多皮支动脉供血的足内侧皮瓣修复手指中节、近节环形缺损3例.结果 术后29例皮瓣全部存活,术后23例获得6～13个月的随访.皮肤弹性、色泽良好,两点分辨觉6～9mm.结论 足内侧供区隐蔽,皮瓣切取方便,不损伤动脉主干,皮肤质地与手指相近,应用不同皮穿支的足内侧皮瓣移植是一种修复手指皮肤软组织缺损较理想的方法.     

Reconstruction of lower extremity with perforator free flaps by free style approach in pediatric patients

Pediatric reconstruction using microsurgery is accepted normal practice, and the use of perforator flaps is slowly increasing. This study presents clinical work using various perforator free flaps by free style approach to reconstruct lower extremity soft tissue defects in pediatric patients and evaluates its efficacy. Between June 2002 and February 2011, 32 cases (mean age: 10.1 years) were reconstructed with free style perforator free flaps. Retrospective evaluations for flap survival, growth character, and other associated morbidities were performed. Flaps used in this series are anterolateral thigh (ALT) perforator, superficial circumflex iliac artery perforator (SCIP), upper medial thigh perforator, and posterior interosseous perforator free flaps. The free style approach for pedicle dissection was successful in all cases. Early postoperative complications were 15.6% from hematoma collection to partial loss of flap. Although there was no total loss in this series, one case needed additional flap coverage to cover the partial loss of the flap. The long-term follow-up showed contracture along the margin, with 16% needing a releasing procedure. Bone growth was not affected by flap contracture. The overall results show perforator flaps using the free style approach to be a reliable and feasible approach for lower extremity reconstruction in the pediatric population.     

游离胸背动脉穿支皮瓣桥式移植修复小腿软组织缺损

目的总结游离胸背动脉穿支皮瓣或肌瓣桥式移植修复小腿软组织缺损的临床应用效果。方法自2006年9月至2009年1月,应用游离胸背动脉穿支皮瓣或肌瓣桥式移植修复小腿软组织缺损11例,缺损范围4cm×8cm至8cm×22cm。皮瓣切取连带肩胛下与旋肩胛血管,血管蒂呈T形,与健侧小腿胫后动脉行端端吻合,血管蒂用中厚网状游离植皮覆盖。结果除1例术后皮瓣远端发生小的表浅感染,经换药后愈合外,本组皮瓣全部成活。术后随访9个月至3.6年(平均2.9年),没有发现明显的供区功能障碍,供区与受区外形较好,健侧小腿经临床观察与Doppler检查,胫后动脉通畅。结论本方法适用于修复四肢软组织缺损后,患者仅存1条主要动脉者;行桥式游离胸背动脉穿支皮瓣或肌瓣移植不损伤健侧小腿胫后动脉,降低了对供区的损伤。     

小腿前踝上-足背部串联皮瓣移植修复手部软组织缺损

目的　探讨小腿前踝上 足背部串联皮瓣移植 ,修复手部软组织缺损的手术方法。方法　在解剖学基础上 ,设计以胫前 足背动脉为蒂的小腿前踝上 足背串联皮瓣移植修复手掌、背和手指软组织缺损 8例。结果　 8例皮瓣全部成活 ,供区植皮Ⅰ期愈合。术后 4～ 8个月随访 ,移植皮瓣无明显臃肿 ,皮瓣质地、色泽良好 ,厚度适中。 4例修复神经的移植皮瓣 ,两点分辨觉达 6mm～ 10mm。另 4例皮瓣恢复了实体感觉。结论　应用以胫前 足背动脉为血管蒂的小腿前踝上 足背部串联皮瓣移植 ,血供可靠 ,手术简便、实用 ,是修复手掌、背和手指软组织缺损的良好供区。     

桡动脉浅支皮瓣修复手指皮肤缺损

目的：探讨应用桡动脉浅支皮瓣修复手指皮肤缺损的方法及临床疗效。方法2008年8月-2012年1月,采用游离桡动脉浅支皮瓣修复手部皮肤缺损伴骨或肌腱外露30例,以桡动脉浅支走行于腕掌侧设计皮瓣,其中20例于皮瓣近端切取正中神经掌皮支重建感觉。皮肤缺损范围为1.5 cm×2.5 cm～2.0 cm×3.5 cm。结果本组30例皮瓣全部成活,未发生血管危象。术后随访6～12个月,皮瓣质地血运良好,外形满意,两点辨别觉为5～7 mm,供区无并发症。结论游离桡动脉浅支皮瓣切取方便,供区损伤小,是修复手指皮肤缺损较为理想的方法。     

Dorsal branches of superficial radial nerve: an anatomic study with potential clinical applications

An anatomical study was performed to assess the course of the dorsal branches of superficial radial nerve and to investigate potential clinical applications in hand surgery. Eight upper extremities were dissected, using an operating microscope. All branching points of the superficial radial nerve were noted and the distances from the radial styloid process were recorded. Their proximity to neighboring vascular structures was noted. The superficial branches of the radial nerve can vascularize axial neurofasciocutaneous flaps via their paraneural arterial network. In addition, various reverse neurofasciocutaneous flaps may be harvested, based on dorsal branches of the superficial radial nerve. The nerve can be anastomosed with a suitable nerve in the recipient area. The dorsal branches of the superficial radial nerve can easily be added to the reverse first dorsal metacarpal artery flap and other reverse dorsal metacarpal artery flaps, thus making it possible to form a sensate flap. These branches may be anastomosed with nerves in the recipient site, such as dorsal branches of digital nerve stump, without significant donor site morbidity. A free sensate first dorsal artery flap can be prepared with a combination of dorsal branches of the superficial radial nerve and used with the same indications as a free digital artery flap. It has some advantages over the free digital artery flap, because the main neurovascular structures of the finger are kept intact. Finally, a dorsal nerve branch which accompanies the first dorsal metacarpal artery may be harvested with this artery and a subcutaneous dorsal vein as vascularized nerve graft. It can be used to repair a digital nerve defect in dense scar tissue. Received: 3 January 2000     

尺动脉近端穿支皮瓣修复指掌侧面皮肤软组织缺损

目的 探讨尺动脉近端穿支皮瓣修复指掌侧面皮肤软组织缺损的临床疗效。方法 回顾性分析2019年4月至2021年2月我院收治的11例指掌侧面皮肤软组织缺损病人的临床资料,其中男7例,女4例,年龄为20～52岁,平均31.2岁,均采用尺动脉近端穿支皮瓣修复指掌侧面皮肤软组织缺损。皮肤软组织缺损面积为2.4 cm×1.8 cm～5.8 cm×2.5 cm,平均4.2 cm×2.2 cm。皮瓣切取面积为2.9 cm×2.3 cm～6.3 cm×3.0 cm,平均4.7 cm×2.7 cm。参照美国手外科协会总主动活动度（total action movement,TAM）系统评定手指功能。结果 11例皮瓣均成活,外形满意,伤口均一期愈合。全部病例获得随访,随访时间为6～22个月,平均8.4个月。皮瓣肤色红润,质地良好,厚薄适中,指掌侧面外形佳,弧度可,两点辨别觉为3.3～5.2 mm,平均4.0 mm。供区仅留有线形疤痕,无明显障碍。按TAM系统评定手指功能：优9例,良2例,优良率为100%。结论 尺动脉近端穿支皮瓣能有效修复指掌侧面皮肤软组织缺损,是一种行之有效的方法。     

应用骨间后动脉单一穿支微型皮瓣修复手指皮肤缺损

目的 应用骨间后动脉单一穿支微型皮瓣对手部较小面积的皮肤软组织缺损进行精确的定点修复。方法 在前臂背侧中部，以骨间后动脉（骨间总动脉尺侧肌皮支）为轴线，用多普勒血流探测仪确定穿支部位后以此设计皮瓣。对24例手指皮肤软组织缺损的患者，应用单一穿支微型皮瓣进行修复，并对皮瓣的设计、切取、吻合、成活特点及治疗效果进行观察和探讨。结果 术后21例皮瓣顺利存活，3例皮瓣术后1—3d出现不同程度的水疱、暗紫、结痂，2例皮瓣脱痂后成活，1例坏死。术后17例获得5—17个月的随访，7例失访。皮瓣外形满意，手指修复后效果良好。3例缝合伴行神经、皮下神经者，Dellon试验达5—6mm。结论 骨间后动脉单一穿支微型皮瓣游离移植可对手部较小的皮肤软组织缺损进行精确的定点修复，并获得了较好的临床效果。     

Immediate autologous breast reconstruction using muscle-sparing TRAM flaps with superficial epigastric system turbocharging: a salvage option

Current breast reconstruction trends favor the use of muscle-sparing abdominal flaps to minimize abdominal morbidity. When compared to the transverse rectus abdominis myocutaneous (TRAM) flap, the muscle-sparing deep inferior epigastric perforator (DIEP) flap and the superficial inferior epigastric artery (SIEA) flap are common options that minimize donor-site morbidity. For patients with inadequate flap perfusion via either system, alternative surgical options that permit preservation of the abdominal musculature are limited. Using both the DIEP and SIEA systems, the authors describe a turbocharged construct that also facilitates flap perfusion without the need for violation of the anterior rectus sheath. This turbocharged system can provide adequate blood supply in a flap with questionable DIEP or SIEA perfusion alone.     

Post‐traumatic lymphedema treatment with superficial circumflex iliac artery perforator lymphatic free flap: A case report

Post‐traumatic lymphedema is poorly understood. It is rarely considered in limb reconstruction decision‐making approach. We report a case of a 41‐year‐old female who presented with right upper extremity lymphedema after degloving injury and split thickness skin graft, successfully treated with a superficial circumflex iliac artery perforator (SCIP) free flap restoring the lymphatic drainage. Right upper extremity had an excess of 258.7 mL or an excess volume of 27.86% compared to the healthy contralateral limb. A SCIP free flap including lymphatic vessels (SCIP‐L) was performed to replace the skin graft in order to restore the lymphatic flow. Flap size was 19 × 8 cm and pedicle length was 4 cm. No lymph nodes were included and no lymphatic or lymphovenous anastomoses were performed. The surgery was uneventful, and there were no postoperative complications. Fourteen days after free tissue transfer, lymphedema showed clear improvement. At a 4‐month follow‐up, 55.6% reduction of excess volume was obtained. Indocyanine green lymphography performed at that time showed a restitution of lymph flow through the flap. Lymphedema improvements persisted at a 6‐month follow‐up. A successful treatment of post‐traumatic lymphedema can be performed by using the SCIP‐L free flap for soft tissue reconstruction of critical lymphatic drainage areas.     

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.     

The versatility of the SIEA flap: a clinical assessment of the vascular territory of the superficial epigastric inferior artery.

Following the TRAM and the DIEP the SIEA flap is the next logical step to reduce the donor site morbidity in autologous breast reconstruction. The vascular axis of the SIEA flap, however, is completely different from the deep epigastric pedicle, on which previous lower abdominal flaps were based. Therefore, a mapping of the vascular territory, which can be reliably harvested on this pedicle, seems mandatory before this new technique can become established. AIM: To chart the angiosome of the superficial inferior epigastric artery with regard to breast reconstruction and to evaluate the random extension of the vascular territory, which can be reliably raised on this pedicle. STUDY DESIGN: Clinical, prospective study in a university-affiliated department of plastic surgery. PATIENTS: Ten patients undergoing autologous breast reconstruction with the superficial inferior epigastric perforator flap and five patients undergoing aesthetic abdominoplasty with isolation of the abdominal flap on the superficial epigastric vessels. MATERIAL AND METHODS: After isolation of the abdominal panniculus on a single superficial inferior epigastric artery pedicle, the flap was divided in the four conventional zones according to Hartrampf. Perfusion in each of the four zones was measured on the table using the technique of dynamic laser-fluorescence videoangiography. RESULTS: Perfusion of Hartrampf Zone III occurred first (25s post-injection) and the perfusion index amounted median 89% of reference. Perfusion of Zone I occurred median 5s later and the relative perfusion was 80%. Perfusion of the contralateral zones II and IV was dramatically reduced to 8% and zero, respectively, and this reduction was statistically significant (p<0.0001). CONCLUSION: The true angiosome of the superficial epigastric artery is located laterally on the ipsilateral hemiabdomen. Its random extension is unreliable and ranges most frequently only to the midline. Based on the results of this study, survival of the skin and subcutaneous fat taken laterally to the border of the contralateral rectus sheath seems questionable. Therefore, the versatility of the SIEA flap for autologous breast reconstruction seems limited when compared with the conventional methods based on the deep inferior epigastric system.