Chrisovalantis Lakhiani

Vascular anatomy of the anterolateral thigh flap: a systematic review.

Background: The most untoward aspect of the anterolateral thigh is the complexity of the local vasculature. Failure to understand its variability can lead to vascular flap embarrassment and tissue loss. The authors present a comprehensive summary of the vascular anatomy of the anterolateral thigh. Methods: A MEDLINE search was performed for articles published between 1948 and 2012 on the anterolateral thigh flap. Two levels of screening and manual reference check identified 44 relevant studies. Results: The descending branch of the lateral circumflex femoral artery was variably found to originate from the deep femoral (6.25 to 13 percent) or common femoral artery (1 to 6 percent), instead of the lateral circumflex femoral artery. Dominant perforator supply to the anterolateral thigh was most commonly from the descending (57 to 100 percent), transverse (4 to 35 percent), oblique (14 to 43 percent), or ascending (2.6 to 14.5 percent) branch. Septocutaneous perforators were present in 19.8 percent (0 to 61.5 percent) of cases overall (n = 2486). No perforators were found in 1.8 percent of cases overall (n = 2895). The majority of perforators were found in the central third of the thigh. The previously undescribed musculoseptocutaneous perforator was observed in 21 to 52.3 percent of vascular mapping or anatomic studies, but not in clinical studies. Conclusions: As knowledge of pertinent vascular anatomy for the anterolateral thigh flap has increased, so has insight into the amount of existing variation. This systematic review summarizes the wide spectrum of normal and variant anatomy described in the literature to date. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Treatment of capsular contracture using complete implant coverage by acellular dermal matrix: a novel technique.

Background: Capsular contracture is a frequent complication of breast reconstruction that affects 2.8 to 15.9 percent of patients. Use of acellular dermal matrix has been reported for treatment of contracture, with a recurrence rate of 6.3 percent, but this was limited to partial implant coverage only. The authors describe a novel surgical technique using acellular dermal matrix to completely cover the implant anteriorly to treat and prevent capsular contracture. Methods: Charts were reviewed to identify patients who had received implant insertion with complete acellular dermal matrix coverage performed by a single surgeon. Patient demographic information, history of irradiation or capsular contracture, prior treatment, and postoperative complications were recorded. Results: Eleven patients (16 breasts) were identified. Mean age and body mass index were 52.3 ± 6.9 years and 23.6 ± 4.4 kg/m2, respectively. Four patients (five breasts) had a history of capsular contracture requiring previous capsulectomy and implant exchange. Ten cases were for correction of new-onset grade III (n = 2) or IV (n = 8) capsular contracture and one was to prevent future capsular contracture. Mean acellular dermal matrix size was 229.8 ± 46.5 cm2 (range, 144 to 256 cm2). Average follow-up was 9.2 months (range, 2.4 to 18.8 months). One patient (one breast) developed an infection requiring implant removal. No patients experienced recurrent capsular contracture. Conclusions: Capsular contracture may be treated successfully using complete acellular dermal matrix coverage. This technique may be a useful addition to therapies currently used to treat recalcitrant capsular contracture (early recurrence or refractory to standard therapy). CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The free descending branch muscle-sparing latissimus dorsi flap: vascular anatomy and clinical applications.

Background: Increasing focus on reducing morbidity from latissimus dorsi flaps has led to the evolution of muscle-sparing variants and perforator-based flaps. This study aimed to investigate the vascular anatomy of the muscle-sparing variant and to describe its application as a free flap based on the descending branch of the thoracodorsal artery. Methods: Twelve fresh cadavers underwent anatomical dissection and angiographic injection studies of the thoracodorsal arterial system. The musculocutaneous territories of the descending and transverse branches to the latissimus dorsi muscle were identified and assessed using three-dimensional reconstruction software of computed tomography imaging results. In the clinical study, five patients underwent reconstruction of a variety of defects using the free descending branch muscle-sparing latissimus dorsi flap. Results: Three- and four-dimensional (computed tomography) angiography demonstrated perfusion of the latissimus dorsi muscle by the transverse and descending branches, with overlap of vascular territories via cross-linking vessels. The descending branch supplied a slightly greater cutaneous area overlying the muscle, although differences between both branches were not significant (p = 0.76). In the clinical study, the free muscle-sparing latissimus dorsi flap provided excellent coverage with no flap complications or seroma. Conclusions: The free muscle-sparing latissimus dorsi flap based on the descending branch of the thoracodorsal artery is a viable reconstructive option. Significant collateral flow between vessels allows for larger flap harvest than would be expected. The flap is technically simple to harvest, provides a large perfusion area, and is a reliable variant of the full latissimus dorsi flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Timing of traumatic upper extremity free flap reconstruction: a systematic review and progress report.

Background: The recommendations on the timing of microsurgical extremity reconstruction are as variable and numerous as the flaps described for such reconstruction. Original articles suggested that reconstruction should take place within 72 hours of injury. However, significant changes in perioperative and intraoperative management have occurred in this field, which may allow for more flexibility in the timing of reconstruction. This article aims to review current literature on timing of upper extremity reconstruction to provide the microsurgeon with up-to-date recommendations. Methods: A structured literature search including Spanish and English language articles published between January of 1995 and December of 2011 was performed using the MEDLINE and Scopus databases. The search strategy was conducted using groups of key words, and articles were subsequently reviewed for relevance. Bibliographies of selected articles were further reviewed for additional relevant publications. Rates of total flap loss, infection, hospital stay, and bony nonunion were recorded and analyzed according to emergent (<24 hours), early (<5 days), primary (6 to 21 days), or delayed (>21 days) reconstruction. Results: Fifteen articles met inclusion criteria. There was no significant association between timing of reconstruction and rates of flap loss, infection, or bony nonunion. Linear regression analysis displayed a significant association between length of hospital stay and timing of reconstruction. Conclusions: No conclusive evidence exists to suggest that emergent, early, primary, or delayed reconstruction will eliminate or decrease complications associated with posttraumatic upper extremity reconstruction. Earlier reconstruction may decrease length of hospital stay and limit associated medical costs.

Free tissue transfer to the traumatized upper extremity: Risk factors for postoperative complications in 282 cases

BACKGROUND Complex traumatic upper extremity injuries frequently possess compromised local vasculature or extensive defects that are not amenable to local flap reconstruction. Free tissue transfer is required to provide adequate soft tissue coverage. The present study aimed to evaluate risk factors that contribute to postoperative complications and flap loss in complex upper extremity reconstruction. METHODS Retrospective chart review was performed for all patients undergoing free tissue transfer for upper extremity reconstruction from 1976 to 2001. Data collected included patient demographic characteristics, timing of reconstruction, location of injury, fracture characteristics, operative interventions, and postoperative complications. Statistical analysis was performed using χ(2) and Fisher exact tests. RESULTS In total, 238 patients underwent 285 free tissue transfers and met inclusion criteria, from which 3 were excluded because of inadequate information (n = 282). Extremities were repaired within 24 h (75 cases; 27%), in days 2-7 (32 cases; 12%), or after day 7 (172 cases; 62%). Timing of reconstruction did not significantly affect postoperative outcomes. Proximal location of injury was significantly associated with superficial (relative risk [RR], 6.5; P < .01) and deep infection (RR, 5.3; P < .01), and osteomyelitis (RR, 4.0; P < .01), although not with flap failure (P = .30). Presence of an open fracture was significantly associated with developing superficial (RR, 3.1; P = .01) and deep (RR, 1.9; P < .01) infection, as well as osteomyelitis (RR, 1.6; P < .01). Having a closed fracture did not negatively influence postoperative outcomes. CONCLUSIONS This study supports the safety of early free tissue transfer for reconstruction of traumatized upper extremities. Injuries proximal to the elbow and open fracture were associated with a significantly higher infection rate. Gustilo grade IIIC fractures, need for interpositional vein grafts, and anastomotic revision at index operation resulted in significantly higher risk of flap loss, whereas the presence of fracture, fracture fixation, and injury location were not predictors of flap failure.

Vascular anatomy of the deep inferior epigastric artery perforator flap: a systematic review.

Background: The deep inferior epigastric artery perforator (DIEP) flap is one of the most commonly used perforator flaps for reconstruction. The anatomy of the flap varies considerably between patients and even within patients. The authors conducted a comprehensive review to fully describe the vascular anatomy of the DIEP flap. Methods: The authors performed MEDLINE, Ovid, and PubMed searches for articles published between 1993 and 2012 on the vascular anatomy of the DIEP flap. Abstracts were screened first, then entire articles, followed by manual reference check. A total of 60 relevant articles were identified and reviewed in their entirety. The authors synthesized all descriptions of DIEP flap vascular anatomy. Results: The perforators originating from the deep inferior epigastric artery can be categorized as musculocutaneous or extramuscular. Musculocutaneous perforators are the most common (33 to 100 percent), followed by extramuscular (0 to 67.6 percent). Of the musculocutaneous perforators, a short intramuscular course (<4 cm) is most common (61 to 80 percent), followed by a long intramuscular course (>4 cm; 9 to 26 percent) and a perpendicular course (3 to 26 percent). Two subfascial patterns have been described, with direct fascial penetration more common than a subfascial course. The two extramuscular perforator types, paramedian (<46.4 percent) and tendinous (<67.6 percent), are the most desirable for dissection. Conclusions: The vascular anatomy of the DIEP flap shows significant variability. Despite this, several patterns of musculocutaneous and extramuscular-type perforators have been found. A greater understanding of these patterns will improve knowledge of the anatomical variation and will enhance the use of evidence-based perforator selection.

No-drain DIEP Flap Donor-site Closure Using Barbed Progressive Tension Sutures.

Background: The use of progressive tension sutures has been shown to be comparable to the use of abdominal drains in abdominoplasty. However, the use of barbed progressive tension sutures (B-PTSs) in deep inferior epigastric artery perforator (DIEP) flap donor-site closure has not been investigated. Methods: A retrospective chart review was performed on patients with DIEP flap reconstruction in a 3-year period at 2 institutions by 2 surgeons. Patients were compared by method of DIEP donor-site closure. Group 1 had barbed running progressive tension sutures without drain placement. Group 2 had interrupted progressive tension closure with abdominal drain placement (PTS-AD). Group 3 had closure with only abdominal drain placement (AD). Data collected included demographics, perioperative data, and postoperative outcomes. Results: Seventy-five patients underwent DIEP reconstruction (25 B-PTS, 25 PTS-AD, and 25 AD). Patient characteristics—age, body mass index, comorbidities, smoking status, and chemotherapy—were not significantly different between groups. Rate of seroma was 1.3% (B-PTS = 0%, PTS-AD = 4%, AD = 0%), wound dehiscence 16% (B-PTS = 8%, PTS-AD = 16%, AD = 24%), and umbilical necrosis 5.3% (B-PTS = 0%, PTS-AD = 0%, AD = 16%). No hematomas were observed in any patients. No statistically significant difference was found between complication rates across groups. Conclusions: Use of B-PTSs for abdominal closure after DIEP flap harvest can obviate the need for abdominal drains. Complication rates following this technique are not significantly different from closure using progressive tension suture and abdominal drain placement. This practice can prevent the use of abdominal drains, which can promote patient mobility, increase independence upon discharge, and contribute to patient satisfaction.

In-vivo quantitative evaluation of perfusion zones and perfusion gradient in the deep inferior epigastric artery perforator flap

The selection of well-vascularized tissue during DIEP flap harvest remains controversial. While several studies have elucidated cross-midline perfusion, further characterization of perfusion to the ipsilateral hemiabdomen is necessary for minimizing rates of fat necrosis or partial fat necrosis in bilateral DIEP flaps. Eighteen patients (29 flaps) underwent DIEP flap harvest using a prospectively designed protocol. Perforators were marked and imaged with a novel system for quantitatively measuring tissue oxygenation, the Digital Light Hyperspectral Imager. Images were then analyzed to determine if perforator selection influenced ipsilateral flap perfusion. Flaps based on a single lateral row perforator (SLRP) were found to have a higher level of hemoglobin oxygenation in Zone I (mean %HbO2 = 76.1) compared to single medial row perforator (SMRP) flaps (%HbO2 = 71.6). Perfusion of Zone III relative to Zone I was similar between SLRP and SMRP flaps (97.4% vs. 97.9%, respectively). These differences were not statistically significant (p>0.05). Perfusion to the lateral edge of the flap was slightly greater for SLRP flaps compared SMRP flaps (92.1% vs. 89.5%, respectively). SMRP flaps had superior perfusion travelling inferiorly compared to SLRP flaps (88.8% vs. 83.9%, respectively). Overall, it was observed that flaps were better perfused in the lateral direction than inferiorly. Significant differences in perfusion gradients directed inferiorly or laterally were observed, and perforator selection influenced perfusion in the most distal or inferior aspects of the flap. This suggests broader clinical implications for flap design that merit further investigation.

Maximizing aesthetic outcome in autologous breast reconstruction with implants and lipofilling

BackgroundFree flap breast reconstruction is an option widely sought in postmastectomy breast reconstruction. However, the volume of autologous tissue from the patient is often not sufficient for symmetrical reconstruction. In these cases, flaps can be used in combination with implants or autologous fat injections to augment volume and achieve shape, symmetry, and contour.MethodsA retrospective chart review was performed on patients who underwent postmastectomy free flap reconstruction with secondary augmentation using autologous fat grafting or implant from 2008 to 2011.ResultsTwenty-four patients (39 breasts) received further augmentation of autologous tissue reconstruction during this period. Sixteen patients (26 breasts) had fat graft augmentation only, four patients (eight breasts) had implant augmentation only, and three patients (five breasts) had both procedures. Among patients who had fat grafting, operative intervention was required twice for fat necrosis. Contrastingly, of patients who received implants, one patient required operative intervention for implant malpositioning. These differences were not significant (P = 0.57). The group with both fat grafting and implant augmentation had significantly higher aesthetic scores regarding overall appearance, contour, and volume, but not projection, than the group with fat grafting only and the group with implant only.ConclusionsAutologous fat grafting offers several contouring aesthetic advantages, including selectively augmenting areas of hollowness to improve contour and maximize symmetry. However, implant augmentation generally allows for a larger increase in projection in a single procedure, with similar rates of postaugmentation complications. Use of both autologous fat grafting and implant augmentation may allow for superior aesthetic results.Level of Evidence: Level IV, therapeutic study.

Pedicle-to-Perforator Bypass Using Supermicrosurgical Technique for Deep Inferior Epigastric Artery Perforator Flap Salvage

1 Sir: A perforator selection is critical to successful deep inferior epigastric artery perforator flap harvest. Although the optimal number of perforators to be included is often debated, commitment to a single, dominant perforator simplifies dissection, reduces operative time, and minimizes donor-site morbidity when compared with multi-perforator flap designs.1 A potential drawback of this approach, however, relates to inadvertent perforator injury, which has a reported incidence as high as 4.3% and bears devastating prognostic implications.2 When discovered in-situ, conversion to a muscle-sparing alternative may facilitate flap salvage. However, the majority (71%) of these injuries are attributed to perforator mishandling (i.e., traction-induced) during flap transfer/ inset, rather than technical error of dissection, itself.2 As such, perforator-level injuries often go unnoticed until arterial insufficiency and/or venous congestion become evident following microvascular anastomosis. When this scenario is encountered intraoperatively, emergent microsurgical intervention offers the only reliable solution to avoid catastrophic flap loss. To this end, strategies that incorporate the superficial inferior epigastric artery/vein, with or without vein grafting and/or pedicle turbocharging, have been proposed to redirect flap inflow/outflow, respectively.3,4 These techniques, however, require preemptive planning and preservation of viable superficial inferior epigastric artery/vein, which are present in fewer than 30% of cases.5 In situations where the superficial system is inadequate/unavailable, segmental resection and anastomosis of the injured perforator to itself may aid in the reestablishment of nutritive perfusion.2 Although high success rates (83%) have been reported with this approach, perforator-to-perforator anastomosis in the setting of prior trauma can be technically challenging and increases the likelihood of thrombotic complications.2 A safer alternative to restore microcirculation involves interperforator bypass between previously ligated, nontraumatized perforators within the flap and preserved pedicle side branches (Fig. 1). After ligation/ division of the injured perforator, the undersurface of the flap and pedicle are each investigated to identify suitable perforator remnants. Donor/recipient perforators are preferentially selected on the basis of vessel caliber (0.3–0.5 mm diameter), length (4–6 mm), and absence of prior trauma (i.e., cauterization). Perforator dissection/anastomosis are performed under microscopic guidance utilizing meticulous supermicrosurgical technique with interrupted 10-0 nylon sutures (Fig. 2). After anastomotic patency is confirmed, the pedicle is sutured to the flap to avoid traction and/or accidental avulsion during inset. The advent of supermicrosurgical technique has expanded the indications and options available for salvage of perforator-level injuries. Successful pedicle-to-perforator bypass, as described herein, is dependent on the exclusion of injured vascular segments that pose unjustified thrombogenic risk. Preservation of perforator length during primary flap/pedicle dissection and use of hemoclip ligation optimize the quality/quantity of perforators available for anastomosis.3,4 In many cases, intraflap dissection and donor spatulation are required to lengthen the vascular cuff and improve size concordance between donor perforators and recipient pedicle side branches.5 It is our preference to incorporate perforators with accompanying venae comitans (VC), which simplifies the orientation of the arterial/venous pedicles supplying the flap. In the absence of reliable VC, the recipient venous pedicle can be separated along its length from the artery and transferred independently to an adjacent donor VC or the superficial inferior epigastric vein to facilitate flap outflow. Although described in the context of single-perforator deep inferiPedicle-to-Perforator Bypass Using Supermicrosurgical Technique for Deep Inferior Epigastric Artery Perforator Flap Salvage