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.     

Breast reconstruction with deep inferior epigastric perforator flaps

INTRODUCTION

Approximately 45,000 women are diagnosed with breast cancer in the UK each year. The success of screening and the introduction of adjuvant therapies have meant that prognosis is improving and an increasing number of patients are seeking reconstruction following mastectomy. The purpose of this study was to evaluate the deep inferior epigastric perforator (DIEP) flap reconstructions performed in Stoke Mandeville Hospital and, through analysis of complications, detail the evolution of the current care pathway.

METHODS

A retrospective analysis was performed of all the DIEP flap reconstructions performed by the senior author (MT) between July 2003 and December 2010.

RESULTS

Overall, 159 flaps were performed on 141 patients (including 36 bilateral flaps). The average patient age was 49 years (range: 28–70 years) and 13% of flaps were risk reducing for BRCA1/2. Twenty-six per cent of patients suffered one or more complication post-operatively, including systemic complications (pulmonary embolism 2%) and flap specific complications (partial flap necrosis 9%, reanastomosis 3%, fat necrosis 9%). Seventy-four per cent had further elective operations including nipple reconstruction (72%), contralateral breast reduction (36%) and scar revision (21%).

CONCLUSIONS

DIEP flaps are a safe and reliable option for breast reconstructions. This series illustrates the significant leaning curve, with complications, operative time and ischaemic time reducing through the series and post-operative haemoglobin increasing. The complications experienced in this series of 159 flaps with no total flap loss provide the framework for the evolution of the current care pathway including pre-operative imaging, peri-operative deep vein thrombosis prophylaxis and analgesia.     

Preoperative imaging for deep inferior epigastric perforator flaps: a comparative study of computed tomographic angiography and magnetic resonance angiography

Background

Breast reconstruction with transverse rectus abdominis myocutaneous flap has evolved towards the intramuscular dissection of perforators of the deep inferior epigastric pedicle to reduce abdominal wall morbidity. We aimed to compare magnetic resonance angiography (MRA) and computed tomography angiography (CTA) findings for the identification of deep inferior epigastric perforators (DIEP) flap and to compare the results with intraoperative findings.

Methods

This was a prospective comparative study that was approved by the local ethics committee, and written informed consent was obtained. Ten patients underwent both MRA and CTA scans prior to DIEP flap breast reconstruction. The perforators that were identified by MRA, CTA and surgery were projected on a scaled grid. The contrast ratios between the vessels and surrounding tissues were calculated and compared using a bilateral t test.

Results

Totals of 67 and 59 perforators were found with MRA mapping and CTA, respectively. Fifty-six perforators were found with both techniques. All 70 perforators identified (MRA and CTA) were found during surgery. The estimated sensitivities for CTA and MRA were 84 and 96?%, respectively. Both techniques showed specificities of 100?%. The contrast analysis showed a better contrast of the fat-surrounded vessels with CTA (p?=?0.007) compared with MRA. However, a better contrast of the muscle-surrounded vessels was observed with MRA (p?=?0.001) compared with CTA.

Conclusions

Our study found a higher sensitivity with MRA in identifying perforators compared with CTA. This difference can be explained by a higher contrast of vessels in muscles that facilitates identification, especially in cases in which perforators are within aponeuroses.

Level of Evidence

Level II: Diagnostic study     

Peritoneo‐cutaneous perforators in deep inferior epigastric perforator flaps: A cadaveric dissection and computed tomographic angiography study

Background: Cutaneous perforators that do not originate from the deep inferior epigastric artery (DIEA) are rare, but may significantly affect operative outcome. Peritoneal‐cutaneous perforators have been described as a source for augmenting the blood flow to a deep inferior epigastric perforator (DIEP) flap, however if unrecognized, may compromise flap survival. Methods: We reviewed 375 DIEA perforator (DIEP) flaps (325 with preoperative CTA and 50 cadaveric dissections) to investigate the incidence of this anomaly. Results: We detected this variation in 3/325 (1%) of DIEP flaps following preoperative computed tomography. In 1/50 (2%) of the cadaveric specimens, a peritoneal‐cutaneous perforator was found and injected with lead oxide contrast. It was shown to fill the cutaneous veins of the majority of the lower abdominal integument. Conclusion: Peritoneal‐cutaneous perforators are rare anatomical variations (4/375: 1.1%) that may have significant ramifications for surgery utilizing the vasculature of the abdominal wall. CTA was significantly able to detect this anomaly and aid operative planning. Preoperative CTA helps to safely identify individual vascular anatomy including rare variations. © 2008 Wiley‐Liss, Inc. Microsurgery, 2009.     

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.     

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.     

腹壁下动脉穿支分布特点及扩张穿支皮瓣临床应用

目的 探讨腹壁下动脉穿支的体表分布特点,及应用扩张后腹壁下动脉穿支皮瓣修复手部、前臂大面积瘢痕的I临床效果.方法 随机选取20例健康成人,应用多普勒血流探测仪探测双侧腹壁下动脉穿支,分析其在体表分布规律.临床应用扩张后腹壁下动脉穿支皮瓣治疗10例爪形手、前臂瘢痕挛缩畸形患者.结果 20例成人,探测范围包括脐上至剑突的下1/3区域、脐下至耻骨联合的上2/3区域,探测出穿支点共425个,其中80%的点位于腹正中线旁1.1～5.8 cm垂线之间.按照Rand分区法:Ⅰ、Ⅱ、Ⅲ区穿支点所占百分比分别为26%、43%、30%.Ⅳ区穿支点罕见.近脐水平线穿支点较其他部位密集,左右两腹部穿支点排列不对称.临床应用10例,1例皮瓣远端出现血运障碍,经换药后愈合;余9例皮瓣全部成活良好.结论 应用扩张后腹壁下动脉穿支皮瓣治疗手部大面积瘢痕,皮瓣切取面积大,较薄、不显臃肿,外观美观,是修复手部及前臂大面积瘢痕的一种较好的方法.     

Contrast-enhanced magnetic resonance angiography for preoperative imaging of deep inferior epigastric artery perforator flaps: advantages and disadvantages compared with computed tomography angiography: a United Kingdom perspective

The anatomy of the anterior abdominal wall is highly variable and leads to uncertainty when harvesting a deep inferior epigastric artery perforator flap. Presurgical imaging has been shown to reduce the operating time, as well as reduce the rates of flap and donor site complications. The importance of imaging of the venous system has also been recognized for reducing the risk of venous congestion. The modalities currently available for presurgical imaging include handheld Doppler ultrasound, duplex ultrasound, computed tomographic angiography (CTA), and contrast-enhanced magnetic resonance angiography (CE-MRA). Of these, the most promising are CTA and CE-MRA, and advantages and disadvantages exist for both modalities. In this article, we review the use of CE-MRA for preoperative flap imaging and report our experience with its use in deep inferior epigastric artery perforator flap harvest, as well as compare it with CTA. We also explore the future directions for presurgical flap imaging.     

腹壁下动脉穿支分布特点及扩张穿支皮瓣临床应用

Objective To'explore the distribution of deep inferior epignstric perforator vessel and application of the expanded perforator flap for large sear on hand and forearm. Methods 20 healthy adults were selected to detect the distribution of deep inferior epignstrie perforator vessel. 10 cases with eieatricial constriction on hand and forearm were treated with expanded perforator flap. Results 425 perforator paints were detected on the skin surface of abdomen in 20 adults. 80% of the points are located within the area which is 1.1 ～5.8 cm far from the mid-line of abdomen. According to the Rand method, the percentage of the paints in zone Ⅰ, Ⅱ, Ⅲ were 26%, 43%, and 30%, respectively. There were few points in zone Ⅳ. The area around navel had a high density of points. The paints were distributed asymmetrically at the two sides of abdomen, 10 cases were treated. Vascular deficiency happened at the distal end of one flap. All the other 9 flaps survived. Conclusions The expanded deep inferior epigastric perforator flap is thin and has a large size. It is very suitable for large sear on forearm or hand.     

CT血管成像技术在腹壁下动脉穿支皮瓣术前设计中的应用

目的 探讨CT血管成像(computed tomography angiography,CTA)技术在腹壁下动脉穿支(deep inferior epigastrie artery perforator,DIEAP)皮瓣术前设计中的应用. 方法 2007年1月至2008年3月,对13例拟行DIEAP皮瓣手术的患者术前应用CTA技术对腹壁下动脉进行检查,包括5例阴道先天性缺如、4例阴茎阴囊Paget's病、4例乳腺癌术后乳房缺损的患者,将获得的数据进行处理,包括多平面重组、最大密度投影以及容积显示.观察腹壁下动脉的走行、分支以及穿支位置,并将CTA图像结果与术中情况进行比较. 结果 CTA图像提供腹壁下动脉在肌肉内走行和穿支位置等有效信息,指导DIEAP皮瓣的术前设计,并在手术中得到验证. 结论 术前对腹壁下动脉进行CTA检查,可以有效地指导DIEAP皮瓣的术前设计.     

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.     

Preoperative planning of deep inferior epigastric artery perforator flap reconstruction with multislice-CT angiography: imaging findings and initial experience.

BACKGROUND: Autologous breast reconstruction with abdominal tissue is one of the best options after mastectomy. Reconstruction with deep inferior epigastric perforator (DIEAP) flaps requires a precise location and preoperative evaluation of perforating vessels. The objective of this report is to demonstrate the usefulness of multislice-CT (MSCT) angiography for preoperative planning in patients undergoing DIEAP flap reconstruction. METHODS: Six consecutive women were considered for breast reconstruction with DIEAP flaps after previous mastectomy for breast cancer. Preoperative MSCT angiography was performed to localise the arterial perforators. Axial images, multiplanar reconstructions (MPR) and 3D volume-rendered images were analysed. Findings were correlated with surgery. Initial experience and imaging findings will be described. RESULTS: Accurate identification of the main perforators was achieved in all six patients with a very satisfactory concordance between MSCT angiography and surgical findings. No unreported vessels were found. Location, course, anatomical variations and relations of the superficial inferior epigastric artery were reported. The very small perforators, were equally evaluated and described. CONCLUSIONS: Preoperative evaluation of perforator arteries with MSCT angiography is feasible in patients undergoing breast reconstruction. This technique provides a noninvasive global approach of the vascular anatomy and the entire anterior abdominal wall. However, more patients need to be evaluated in order to clarify the potential aspects pointed in this report.     

Breast reconstruction using deep inferior epigastric perforator flaps in EEC syndrome.

Ectrodactyly, ectodermal dysplasia, cleft lip/palate (EEC) syndrome is a rare condition that may result in failure of breast development. Breast reconstruction in these patients may pose a challenging problem, as they are young and reconstructive options should have minimal long-term complications. The use of deep inferior epigastric perforator (DIEP) flaps in breast reconstruction following breast cancer has been well described with good results. The use of DIEP flaps in breast augmentation, however, is far less common. We present the case of a young patient with EEC syndrome and mammary hypoplasia who underwent DIEP flap reconstruction for breast augmentation. The outcome was satisfactory to both patient and surgeon.