Guillermo Artero

Propeller thoracodorsal artery perforator flap for breast reconstruction

BACKGROUND The thoracodorsal artery perforator (TDAP) flap has been described for breast reconstruction. This flap requires intramuscular dissection of the pedicle. A modification of the conventional TDAP surgical technique for breast reconstruction is described, utilizing instead a propeller TDAP flap. The authors present their clinical experience with the propeller TDAP flap in breast reconstruction alone or in combination with expanders or permanent implants. METHODS From January 2009 to February 2013, sixteen patients had breast reconstruction utilizing a propeller TDAP flap. Retrospective analysis of patient characteristics, clinical indications, procedure and outcomes were performed. The follow-up period ranged from 4 to 48 months. RESULTS Sixteen patients had breast reconstruction using a TDAP flap with or without simultaneous insertion of an expander or implant. All flaps survived, while two cases required minimal resection due to distal flap necrosis, healing by second intention. There were not donor-site seromas, while minimal wound dehiscence was detected in two cases. CONCLUSIONS The propeller TDAP flap appears to be safe and effective for breast reconstruction, resulting in minimal donor site morbidity. The use of this propeller flap emerges as a true alternative to the traditional TDAP flap.

Stacked Thoracodorsal Artery Perforator Flaps for Unilateral Breast Reconstruction.

Summary: The thoracodorsal artery perforator flap is reliable and safe for breast reconstruction, but stacking bilateral thoracodorsal artery perforator flaps for unilateral reconstruction to achieve greater volumes has not been reported. To create a stacked thoracodorsal artery perforator flap, the ipsilateral flap is transferred as an island, and the contralateral flap is transferred as a microvascular free flap. In this article, the authors present their 8-year 14- patient experience with stacked thoracodorsal artery perforator flaps for unilateral breast reconstruction. Patients’ ages ranged from 33 to 72 years (mean, 52.6 years). Mean follow-up time was 48.1 months (range, 1 to 98 months). Flaps measured between 22 × 6 cm and 32 × 8 cm and weighed between 110 and 550 g. Two of the island flaps had steatofibrosis of the distal 3 cm, which was resected and closed directly. The rest of the island flaps and all 14 free flaps healed uneventfully. At the time of follow-up, all flaps appeared healthy, and the reconstructed breast had a similar appearance and volume as the contralateral side. The donor areas had almost no functional deficit, and the final scar was aesthetically acceptable, especially when the ascending oblique design was used. This represents the first description of stacked thoracodorsal artery perforator flaps for unilateral breast reconstruction. This novel addition to the reconstructive surgeon’s selection of methods is a safe and reliable option for large-volume unilateral breast reconstruction. It allows for symmetry without requiring prostheses or reduction of the contralateral side.

Reconstruction of thoracic burn sequelae by scar release and flap resurfacing.

INTRODUCTION In the USA, 450,000 thermal burns receive medical treatment annually. Burn scars are commonly excised and covered with skin grafts. Long-term, these treatments commonly leave patients with discomfort, reduced total lung capacity and forced vital capacity, and restriction of thoracic expansion and shoulder joint mobility. In this article, we present our experience with using scar release and immediate flap reconstruction to treat thoracic restriction due to burn sequelae. METHODS From 1998 to 2014, we enrolled 16 patients with anterior thoracic burn sequelae that had previously been treated conservatively or with skin grafts that eventually recidivated. Preoperatively, we measured thoracic circumference in expiration and inspiration, %FVC, %FEV1, and shoulder mobility. All patients underwent anterior thoracic scar release and immediate flap resurfacing. RESULTS At 2 weeks to 3 months postoperatively (mean, 2.6 months), mean thoracic circumference upon inspiration increased from 83.6 cm±5.7 to 86.5 cm±5.8 (p<0.0000000001). Mean %FVC improved from 76.0%±2.64% to 88.2%±4.69% (p<0.0000001). Mean %FEV1 improved from 79.2%±3.85 to 87.8%±2.98 (p<0.000001). All 14 patients who had restricted shoulder mobility preoperatively no longer had restricted shoulder mobility postoperatively. The mean patient-reported satisfaction was 4.6/5 (range, 3-5). At a mean follow up of 2.5 years, none of the contractures recidivated. Complications included 2 cases of tissue necrosis of the distal end of the flap. In one case, the flap was restored; in the other case, the patient eventually had to receive a new flap. Additional complications included two local infections that were successfully treated with oral and local antibiotics and two hematomas that were drained and eventually healed without tissue loss. CONCLUSIONS Scar releases and flaps provide a safe and effective method for the correction of restricted thoracic expansion, respiratory restriction, decreased range of shoulder motion, and discomfort from thoracic burn sequelae.

Refining the extended circumflex scapular flap for neck burn reconstruction: A 30-year experience

INTRODUCTION Neck burn sequelae remain a major challenge for the reconstructive surgeon. To achieve satisfactory functional and aesthetic results, the anterior neck aesthetic unit must be covered as a single unit. In cases where free flaps are required, harvesting a flap of sufficient size can cause major donor site morbidity. In 1994, we published our favorable 6-year experience of reconstructing neck burn sequelae with an extended circumflex scapular flap (ECSF). Since then, we have made several modifications to the technique, resulting in improved long-term functional and aesthetic results. Herein, we present our 30-year, 150-patient experience with the ECSF flap for the treatment of anterior neck burn sequelae. METHODS We retrospectively reviewed the records of 150 consecutive patients who underwent ECSF procedure for neck resurfacing performed or supervised by the senior author from 1986 to 2015. All cases were assessed for function, aesthetics, satisfaction, and complications. RESULTS A total of 160 ECSFs were used in 150 patients. Ninety-nine patients were available for updated follow-up [1-30 years (mean, 15.3)]. At the last follow-up, 92 patients regained full range of motion, and 90 patients had acceptable cervicomental angle (<110°). The mean patient satisfaction score was 4.8/5. Nine flaps (5.6%) failed completely and were successfully replaced. Twenty-two patients (15%) had distal necrosis of the flap. Fifteen of these 22 patients underwent complementary flaps to replace the necrotic area, and all 15 patients regained full range of motion. CONCLUSIONS For neck burn sequelae, the ECSF provides safe and effective long-term functional and aesthetic results with minimal donor site morbidity.

Erratum to propeller thoracodorsal artery perforator flap for breast reconstruction

[This corrects the article on p. 174 in vol. 3, PMID: 25207210.].

Antegrade Peroneal Flap through the Interosseous Membrane for Knee and Distal Femur Coverage.

Background: Antegrade peroneal flaps can be rotated around the fibula to cover defects in the lower leg and lateral knee. However, these flaps cannot reliably cover the distal femur and anterior and medial knee. In the present article, the authors describe a novel technical modification that involves creating a tunnel through the interosseous membrane, through which the flap can be passed, circumventing the need to rotate around the fibula, allowing it to reach the entire knee and distal femur. Methods: An anatomical study was performed in five cadaveric specimens to measure the gain in pedicle reaching distance when the flap is tunneled compared to transferred around the fibula. A clinical study in 12 patients was also performed to measure the gain in pedicle reaching distance and the long-term viability of the tunneled interosseous flap. Results: In the anatomical study, the mean reaching distance was 7.4 ± 0.9 cm for the flaps rotated around the fibula and 17.0 ± 1.6 for the tunneled interosseous flaps (p < 0.001). In the clinical study, the mean reaching distance was 2.6 ± 1.4 cm for the flaps rotated around the fibula and 11.4 ± 2.4 for the tunneled interosseous flaps (p < 0.0000000001). Patients were followed for up to 4 years (mean, 2.5 years). All flaps survived completely, and there were no complications. Conclusion: By passing the antegrade peroneal flap through the interosseous membrane, instead of around the fibula, the flap reaching distance can be increased by approximately 8 cm, allowing for effective coverage of distal femur and knee defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.