Breast reconstruction with gluteal artery perforator flaps.

BACKGROUND: Several alternatives exist for breast cancer reconstruction with perforator flaps. For those patients in whom the buttock is the best choice as a source for autologous tissue, the IGAP and SGAP flaps are an excellent option. These flaps allow the reliable transfer of skin and soft tissue from the buttock without the associated donor site morbidity of a muscle flap. INDICATIONS: Most women requiring tissue transfer to the chest from the buttock for breast reconstruction or other reasons are candidates for IGAP or SGAP flaps. Do to an improved donor site contour and scar, we now prefer to use the IGAP to the SGAP flap. Absolute contraindications specific to perforator flap breast reconstruction in our practice include history of previous liposuction of the donor site or active smoking (within 1 month prior to surgery). ANATOMY AND TECHNIQUE: IGAP and SGAP flaps are based on perforators from either the superior or inferior gluteal artery. These perforators are carefully dissected free from the surrounding gluteus maximus muscle, which is spread in the direction of the muscle fibres and safely preserved. The vascular pedicle is anastomosed to recipient vessels in the chest and the donor site closed primarily. CONCLUSIONS: IGAP and SGAP flaps allow the safe and reliable transfer of tissue from the buttock for breast reconstruction as an alternative to soft tissue transfer from an abdominal donor site or even as a first choice in selected patients.     

Simultaneous bilateral breast reconstruction with superior gluteal artery perforator (SGAP) flaps

The superior gluteal artery perforator (SGAP) flap is a useful technique for restoration of the breast after mastectomy. If appropriately planned, the soft-tissue envelope supplied by the superior gluteal artery perforator vessels can be harvested with minimal donor site morbidity and often results in a highly esthetic restoration of the breasts. Dissection of the flap is performed with complete preservation of gluteus maximus muscle function. The resulting vascular pedicle obtained via dissection through the muscle is longer than that of gluteal musculocutaneous flaps and affords the surgeon the luxury of avoiding vein grafts in the anastomotic phase of surgery.Despite these advantages, use of the SGAP flap is not popular among reconstructive surgeons. Many practitioners are not familiar with the vascular anatomy of the gluteal area and may not be comfortable with the dissection of the parent vessels or lack the desire to practice microsurgery. On the other hand, our group has reported the largest experience to date with this method of breast reconstruction and has found the SGAP flap to be a reliable and safe method of autologous breast restoration in unilateral absence of the breast. Although the indications to perform single-stage gluteal tissue transplantation for bilateral breast restoration are uncommon, they do occasionally arise in clinical practice. We have carried out concurrent bilateral breast reconstruction using SGAP flaps on 6 patients with acceptable overall morbidity. All flaps went on to survive and resulted in highly esthetic restorations of the breast. Though a challenging undertaking, in-unison transfer of bilateral SGAP flaps serves as a useful option for a subset of patients desiring 1-stage bilateral breast reconstruction.     

Congenital breast deformity reconstruction using perforator flaps

BACKGROUND: Congenital breast deformities such as Poland syndrome, unilateral congenital hypoplasia, tuberous breast anomaly, and amastia pose a challenging plastic surgical dilemma. The majority of patients are young, healthy individuals who seek esthetic restoration of their breast deformities. Currently, both implant and autologous reconstructive techniques are used. This study focuses on our experience with congenital breast deformity patients who underwent reconstruction using a perforator flap. METHODS: From 1994 to 2005, a retrospective chart review was performed on women who underwent breast reconstruction using perforator flaps to correct congenital breast deformities and asymmetry. Patient age, breast deformity type, perforator flap type, flap volume, recipient vessels, postoperative complications, revisions, and esthetic results were determined. RESULTS: Over an 11-year period, 12 perforator flaps were performed. All cases were for unilateral breast deformities. The patients ranged from 16 to 43 years of age. Six patients had undergone previous correctional surgeries. Eight (n = 8) flaps were used for correction of Poland syndrome and its associated chest wall deformities. Four (n = 4) flaps were used for correction of unilateral breast hypoplasia. In all cases, the internal mammary vessels were the recipient vessels of choice. No flaps were lost. No vein grafts were used. All patients were discharged on the fourth postoperative day. Complications encountered included seroma, hematoma, and nipple malposition. Revisional surgery was performed in 30% of the cases. Esthetic results varied from poor to excellent. CONCLUSIONS: Perforator flaps are an acceptable choice for patients with congenital breast deformities seeking autologous breast reconstruction. Deep inferior epigastric artery (DIEP) or superficial inferior epigastric artery (SIEA) flaps are performed when adequate abdominal tissue is available; however, many young patients have inadequate abdominal tissue, thus a GAP flap can be used. Perforator flaps are a safe, reliable surgical technique. In the properly selected patient, donor-site morbidity and functional compromise are minimized, improved self-esteem is noted, postoperative pain is decreased, and excellent long-term esthetic results can be achieved.     

螺旋CT血管造影在腹壁下动脉穿支皮瓣乳房再造术前评价中的应用

目的 评价多层螺旋CT(multidetector-row computed tomography,MDCT)血管造影对腹部穿支皮瓣乳房再造术前血管评估的意义.方法 2006年12月至2009年6月,利用MDCT血管造影对34例乳房再造患者行术前腹部穿支血管探测,根据探测结果拟定乳房再造的手术方式,并作术中实际情况和术前探测的对比.选取该时间段之前未行螺旋CT血管造影的22例腹部游离皮瓣乳房再造的病例设立对照组,比较两组间手术方式改变率,手术时间差异,以及术后皮瓣坏死的发生率.结果 实验组术前手术方式改变率为23.53%,对照组为0(P=0.00),实验组术中手术方式改变率为0,对照组为13.64%(P=0.00);实验组切取皮瓣的平均手术时间为(2.51±0.64)h,对照组为(4.42±0.21)h(P＜0.05).实验组皮瓣并发症发率为6.12%,对照组为12.5%(P=0.017).结论 MDCT是一种准确、简便的方法,有助于更合理地制定乳房再造的手术方式,节约手术时间,降低手术风险.     

Spontaneous reinnervation of deep inferior epigastric artery perforator flaps after secondary breast reconstruction.

The deep inferior epigastric artery perforator (DIEAP) flap is the gold standard of free flaps in breast reconstruction. However, until now little attention has been paid to reinnervation of the flap. The aim of this study was to examine the spontaneous reinnervation of the DIEAP flap after breast reconstruction. The study was cross-sectional, and included 29 women who had all previously had secondary reconstruction with a DIEAP flap after mastectomy for breast cancer. Pressure thresholds were analysed on the skin island of the flap using Semmes-Weinstein monofilaments. The measurements showed measurable sensation in 29 of the 30 flaps. Nine patients had normal or diminished light touch in one or more areas. We also found significant better pressure sensitivity when the medial was compared to the lateral side and the inferior to the superior side of the flap. Our data showed that DIEAP flaps reinnervate after breast reconstruction although there is no sensory nerve repair. We suggest that nerve ingrowth takes place from the sides and this seems to be more pronounced in the inferomedial part of the flap.     

Patient-reported outcomes after breast reconstruction with deep inferior epigastric perforator flaps

We assessed patient-reported outcomes in 34 women who had had their breasts reconstructed with a deep inferior epigastric perforator (DIEP) flap, and compared them with those of 24 patients who were waiting for breast reconstruction. Both groups completed the Short Form 36 (SF-36) questionnaire. The DIEP flap group also assessed their preoperative conditions retrospectively and completed a study-specific questionnaire. The DIEP group reported higher SF-36 mental health scores after the operation than before, but no difference on other SF-36 scales. There was no difference on any SF-36 scale between patients who had had DIEP flaps and those waiting for reconstruction. Most of the DIEP group was satisfied with their bodies, the appearance of their breasts after reconstruction, and would have chosen operation again. In conclusion, there was little improvement in generic health-related quality of life after reconstruction with a DIEP flap. However, patients’ satisfaction was high after the procedure.     

Microcirculatory evaluation of deep inferior epigastric artery perforator flaps with laser Doppler perfusion imaging in breast reconstruction

We have made a quantitative analysis of the microcirculation in the classic perfusion zones of the deep inferior epigastric artery perforator (DIEAP) flap on 10 consecutive women having breast reconstruction with a unilateral DIEAP. Laser Doppler perfusion imaging was used for operative scans. Data were recorded 10 minutes after successful microanastomosis. The mean (SD) perfusion for each perfusion zone was calculated. Zone I = 44.2 (6.2); zone II = 35.1 (10.3); zone III = 39.9 (9.2); and zone IV = 21.9 (10.0). There were significant differences between zones I, II, and III and zone IV (p < 0.001), and zones I and II (p = 0.02). However, there was no significance between zones I and III (p = 0.9), and zones II and III (p = 0.6). The perfusion of zone IV was significantly lower than those in all other zones, which is in keeping with clinical practice in which zone IV is normally discarded to avoid partial necrosis of the flap in unilateral breast reconstruction. Higher values are expected in zone I than zone III, and in zone II than zone III. However, we could not confirm this. We conclude that there are no differences in skin perfusion between zones I and III, and zones II and III. However, the perfusion of zone IV was significantly less than that in all other zones immediately after revascularisation of the DIEAP flap.     

Gluteal artery perforator flaps

Perforator flaps have allowed the transfer of a patient's own skin and fat in a reliable manner with minimal donor site morbidity for more than a decade. They represent the latest in the evolution of soft tissue flaps and provide the reconstructive microsurgeon with more freedom to select a donor site that matches the skin color, thickness, texture, and subcutaneous fat quality of the recipient site. More attention can be paid to the aesthetic quality of the reconstruction. This article focuses on buttock flaps for breast reconstruction and covers aspects such as patient evaluation, selection, preparation, surgical technique, and complications of superior gluteal artery perforator and inferior gluteal artery 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.     

Inferior gluteal artery perforator flap breast reconstruction

BACKGROUND: In thin patients or in those with prior surgery that precludes the use of abdominal tissue for autologous breast reconstruction, the skin and fat of the lower buttock, perfused by perforating branches of the inferior gluteal artery, has been proposed as an alternative. METHODS: This study reviewed 19 reconstructions based on the inferior gluteal artery that were performed between July 2001 and March 2007. Patient characteristics, cancer stage and treatment, indications for use of gluteal tissue, surgical time, length of hospitalization, and complications were recorded. RESULTS: Our average patient age was 49 years, with early stage breast cancer, and low body mass index. The average surgical time was 9 hours and 7 minutes, and the average hospitalization time was 4 days. Complications included 2 complete flap losses, seromas, and delayed donor site healing. CONCLUSIONS: We conclude that tissue from the lower buttock, perfused by branches of the inferior gluteal artery, is a useful alternative for autologous breast reconstruction.     

Patient-reported outcomes after breast reconstruction with deep inferior epigastric perforator flaps.

We assessed patient-reported outcomes in 34 women who had had their breasts reconstructed with a deep inferior epigastric perforator (DIEP) flap, and compared them with those of 24 patients who were waiting for breast reconstruction. Both groups completed the Short Form 36 (SF-36) questionnaire. The DIEP flap group also assessed their preoperative conditions retrospectively and completed a study-specific questionnaire. The DIEP group reported higher SF-36 mental health scores after the operation than before, but no difference on other SF-36 scales. There was no difference on any SF-36 scale between patients who had had DIEP flaps and those waiting for reconstruction. Most of the DIEP group was satisfied with their bodies, the appearance of their breasts after reconstruction, and would have chosen operation again. In conclusion, there was little improvement in generic health-related quality of life after reconstruction with a DIEP flap. However, patients' satisfaction was high after the procedure.     

双侧游离股后内侧穿支皮瓣再造一侧乳房

目的探讨双侧游离股后内侧穿支皮瓣再造一侧乳房的可行性。方法回顾性分析2018年10月至2019年6月湖南省肿瘤医院肿瘤整形外科收治的6例女性早期乳腺癌患者的临床资料。患者年龄31~47岁。肿瘤均为单侧,左侧3例,右侧3例;浸润性导管癌3例,浸润性小叶癌3例。对6例乳腺癌患者行一期或二期双侧游离股后内侧穿支皮瓣移植再造乳房。一期再造3例,乳腺肿块直径2.5~4.0 cm;二期再造3例。术后对皮瓣和供区的情况进行随访观察。结果6例患者手术过程顺利,切取皮瓣长(24.4±0.5)cm、宽(8.3±0.5)cm、厚(3.4±0.5)cm,血管蒂长度为(8.9±0.4)cm,动脉管径为(1.5±0.4)mm,静脉管径为(1.9±0.3)mm。皮瓣平均质量为235 g(165~345 g)。1例皮瓣供区术后1周出现淋巴漏,经持续负压吸引于2周后自行愈合。6例获5~8个月随访,平均5.5个月,所有皮瓣均成活,再造乳房外形可,弹性好,无皮瓣挛缩变形,供区仅遗留线性瘢痕,无下肢功能影响。6例效果均较满意,未发现乳腺癌复发。结论应用双侧游离股后内侧皮瓣移植再造一侧乳房效果较好,方法可行,可作为特殊情况下乳房再造的备选手术方案。     

The perforator angiosome: A new concept in the design of deep inferior epigastric artery perforator flaps for breast reconstruction

Background: The previously described “perfusion zones” of the abdominal wall vasculature are based on filling of the deep inferior epigastric artery (DIEA) and all its branches simultaneously. With the advent of the DIEA perforator flap, only a single or several perforators are included in supply to the flap. As such, a new model for abdominal wall perfusion has become necessary. The concept of a “perforator angiosome” is thus explored. Methods: A clinical and cadaveric study of 155 abdominal walls was undertaken. This comprised the use of 10 whole, unembalmed cadaveric abdominal walls for angiographic studies, and 145 abdominal wall computed tomographic angiograms (CTAs) in patients undergoing preoperative imaging of the abdominal wall vasculature. The evaluation of the subcutaneous branching pattern and zone of perfusion of individual DIEA perforators was explored, particularly exploring differences between medial and lateral row perforators. Results: Fundamental differences exist between medial row and lateral row perforators, with medial row perforators larger (1.3 mm vs. 1 mm) and more likely to ramify in the subcutaneous fat toward the contralateral hemiabdomen (98% of cases vs. 2% of cases). A model for the perfusion of the abdominal wall based on a single perforator is presented. Conclusion: The “perforator angiosome” is dependent on perforator location, and can mapped individually with the use of preoperative imaging. © 2009 Wiley‐Liss, Inc. Microsurgery, 2010.     

Penile reconstruction with bilateral superficial circumflex iliac artery perforator (SCIP) flaps

The free radial forearm flap is a very common material for penile reconstruction. Its major problems are donor-site morbidity with large depressive scar after skin grafting, urethral fistula due to insufficiency of suture line for the urethra, and need for microvascular anastomosis. A new method using combined bilateral island SCIP flaps for the urethra and penis is developed for gender identity disorder (GID) patients. The advantages of this method are minimal donor-site morbidity with a concealed donor scar, and possible one-stage reconstruction for a longer urethra of 22 cm in length without insufficiency, even for GID female-to-male patients. A disadvantage is poor sensory recovery.