David T. Greenspun

Perforator Flaps: Recent Experience, Current Trends, and Future Directions Based on 3974 Microsurgical Breast Reconstructions

Summary: Perforator flap breast reconstruction is an accepted surgical option for breast cancer patients electing to restore their body image after mastectomy. Since the introduction of the deep inferior epigastric perforator flap, microsurgical techniques have evolved to support a 99 percent success rate for a variety of flaps with donor sites that include the abdomen, buttock, thigh, and trunk. Recent experience highlights the perforator flap as a proven solution for patients who have experienced failed breast implant–based reconstructions or those requiring irradiation. Current trends suggest an application of these techniques in patients previously felt to be unacceptable surgical candidates with a focus on safety, aesthetics, and increased sensitization. Future challenges include the propagation of these reconstructive techniques into the hands of future plastic surgeons with a focus on the development of septocutaneous flaps and vascularized lymph node transfers for the treatment of lymphedema.

A technique of brachioplasty.

Various techniques for the management of upper extremity contour deformities have been suggested since aesthetic brachioplasty was first described. Such deformities are commonplace with aging, after normal weight loss, and especially after massive weight loss such as is seen following bariatric surgery. Despite the multiplicity of procedures described for the correction of these deformities, there are still problems associated with current brachioplasty techniques, including incorrectly placed incisions, widened hypertrophic scars, and postoperative contour deformities. In addition, postoperative skin laxity and ptosis in the axillary region are frequently encountered in the more extreme deformities. The authors present their technique for upper extremity brachioplasty. This technique is suitable for patients with severe brachial ptosis and skin laxity, with relatively little lipomatous tissue, which may extend from the olecranon to the chest wall. The described surgical approach provides excellent overall extremity contour with favorable scars while simultaneously addressing axillary contour deformities.

Anatomic imaging of abdominal perforator flaps without ionizing radiation: Seeing is believing with magnetic resonance imaging angiography

The tremendous variability of the inferior epigastric arterial system makes accurate imaging of the vasculature of the anterior abdominal wall an essential component of optimal perforator selection. Preoperative imaging of the abdominal vasculature allows for preoperative perforator selection, resulting in improved operative efficiency and flap design. Abdominal wall perforators of 1-mm diameter can be reliably visualized without exposing patients to ionizing radiation or iodinated intravenous contrast through advances in magnetic resonance imaging angiography (MRA). In this study, MRA imaging was performed on 31 patients who underwent 50 abdominal flaps. For each flap, the location, relative to the umbilicus, of the three largest perforators on both the left and right sides of the abdomen was determined with MRA. Vessel diameter and anatomic course were also evaluated. Postoperatively, a survey was completed by the surgeon to assess the accuracy of the MRA with respect to the intraoperative findings. All perforators visualized on MRA were found at surgery (0% false-positive). In 2 of 50 flaps, the surgeon transferred a flap based upon a vessel not visualized on the MRA (4% false-negative). This article details our experience with MRA as a reliable preoperative imaging technique for abdominal perforator flap breast reconstruction.

Perforator flap magnetic resonance angiography for reconstructive breast surgery: A review of 25 deep inferior epigastric and gluteal perforator artery flap patients

To evaluate the accuracy of magnetic resonance angiography (MRA) for preoperative mapping of rectus and gluteal muscle perforating arteries prior to autologous flap breast reconstruction.

Anatomic imaging of gluteal perforator flaps without ionizing radiation: seeing is believing with magnetic resonance angiography.

Preoperative imaging is essential for abdominal perforator flap breast reconstruction because it allows for preoperative perforator selection, resulting in improved operative efficiency and flap design. The benefits of visualizing the vasculature preoperatively also extend to gluteal artery perforator flaps. Initially, our practice used computed tomography angiography (CTA) to image the gluteal vessels. However, with advances in magnetic resonance imaging angiography (MRA), perforating vessels of 1-mm diameter can reliably be visualized without exposing patients to ionizing radiation or iodinated intravenous contrast. In our original MRA protocol to image abdominal flaps, we found the accuracy of MRA compared favorably with CTA. With our increased experience with MRA, we decided to use MRA to image gluteal flaps. Technical changes were made to the MRA protocol to improve image quality and extend the field of view. Using our new MRA protocol, we can image the vasculature of the buttock, abdomen, and upper thigh in one study. We have found that the spatial resolution of MRA is sufficient to accurately map gluteal perforating vessels, as well as provide information on vessel caliber and course. This article details our experience with preoperative imaging for gluteal perforator flap breast reconstruction.

Gadofosveset trisodium-enhanced abdominal perforator MRA.

To compare image quality including the number of perforators visualized, vessel contrast ratios, and vessel sharpness with blood pool and extracellular contrast agents in abdominal perforator flap magnetic resonance angiography (MRA).

Autologous Breast Reconstruction: Preoperative Magnetic Resonance Angiography for Perforator Flap Vessel Mapping

BACKGROUND Selection of a vascular pedicle for autologous breast reconstruction is time consuming and depends on visual evaluation during the surgery. Preoperative imaging of donor site for mapping the perforator artery anatomy greatly improves the efficiency of perforator selection and significantly reduces the operative time. In this article, we present our experience with magnetic resonance angiography (MRA) for perforator vessel mapping including MRA technique and interpretation. METHODS We have performed over 400 MRA examinations from August 2008 to August 2013 at our institution for preoperative imaging of donor site for mapping the perforator vessel anatomy. Using our optimized imaging protocol with blood pool magnetic resonance imaging contrast agents, multiple donor sites can be imaged in a single MRA examination. Following imaging using the postprocessing and reporting tool, we estimated incidence of commonly used perforators for autologous breast reconstruction. RESULTS In our practice, anterior abdominal wall tissue is the most commonly used donor site for perforator flap breast reconstruction and deep inferior epigastric artery perforators are the most commonly used vascular pedicle. A thigh flap, based on the profunda femoral artery perforator has become the second most used flap at our institution. In addition, MRA imaging also showed evidence of metastatic disease in 4% of our patient subset. CONCLUSION Our MRA technique allows the surgeons to confidently assess multiple donor sites for the best perforator and flap design. In conclusion, a well-performed MRA with specific postprocessing provides an accurate method for mapping perforator vessel, at the same time avoiding ionizing radiation.

Breast Tissue Expanders with Magnetic Ports: Clinical Experience at 1.5 T.

Background: The purpose of this study was to evaluate breast tissue expanders with magnetic ports for safety in patients undergoing abdominal/pelvic magnetic resonance angiography before autologous breast reconstruction. Methods: Magnetic resonance angiography of the abdomen and pelvis at 1.5 T was performed in 71 patients in prone position with tissue expanders with magnetic ports labeled “MR Unsafe” from July of 2012 to May of 2014. Patients were monitored during magnetic resonance angiography for tissue expander–related symptoms, and the chest wall tissue adjacent to the tissue expander was examined for injury at the time of tissue expander removal for breast reconstruction. Retrospective review of these patients’ clinical records was performed. T2-weighted fast spin echo, steady-state free precession and gadolinium-enhanced spoiled gradient echo sequences were assessed for image artifacts. Results: No patient had tissue expander or magnetic port migration during the magnetic resonance examination and none reported pain during scanning. On tissue expander removal (71 patients, 112 implants), the surgeons reported no evidence of tissue damage, and there were no operative complications at those sites of breast reconstruction. Conclusion: Magnetic resonance angiography of the abdomen and pelvis in patients with certain breast tissue expanders containing magnetic ports can be performed safely at 1.5 T for pre–autologous flap breast reconstruction perforator vessel mapping. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Abstract: The Impact of Implementing a Standardized Postoperative Pathway on Underserved Patients Undergoing Microsurgical Breast Reconstruction

PURPOSE: There is paucity of knowledge regarding the impact of variation in postoperative care for microsurgical breast reconstruction patients. Currently, both optimizing patient outcomes and decreasing the cost of healthcare are of prime concern. Caring for underserved populations presents greater challenges in this realm for many reasons. Our aim was to understand the impact of initiating a standardized postoperative pathway for underserved patients undergoing microsurgical reconstruction.