Joshua L. Levine

The In-the-crease Inferior Gluteal Artery Perforator Flap for Breast Reconstruction

Background: Perforator free flaps harvested from the abdomen or buttock are excellent options for breast reconstruction. They enable the reconstructive surgeon to recreate a breast with skin and fat while leaving muscle at the donor site undisturbed. The gluteal artery perforator free flap using buttock tissue was first introduced by the authors’ group in 1993. Of the 279 gluteal artery perforator flaps, the authors have performed for breast reconstruction, 220 have been based on the superior gluteal artery and 59 have been based on the inferior gluteal artery. The authors have found that for some women with excess tissue in the upper buttock and hip area, use of the gluteal artery perforator flap resulted in an improvement at the donor site, whereas for others the aesthetic unit of the buttock was clearly disrupted. Therefore, the authors have recently been placing the scar in the inferior buttock crease to improve donor-site aesthetics. Methods: The authors have now performed 31 in-the-crease inferior gluteal artery perforator free flaps for breast reconstruction and found that the results are very favorable. Results: The removal of tissue from the inferior buttock results in a tightened, lifted appearance. The resultant scar is well concealed within the infrabuttock crease, and exposure or injury of the sciatic nerve has not occurred. Extended beveling at this site is also possible, with less risk of causing an unsightly depression. The final aesthetic result of the scar lying within the inferior buttock crease is very favorable. All patients report satisfaction with the donor site. Complications included one total flap loss, two reoperations for venous congestion, one hematoma, two cases with delayed wound healing at the recipient site, and one with delayed wound healing at the buttock. Conclusion: The in-the-crease inferior gluteal artery perforator flap from the buttock is now the authors’ primary alternative to the deep inferior epigastric perforator flap from the abdomen for breast reconstruction.

Microlymphatic surgery for the treatment of iatrogenic lymphedema.

Lymphedema is a chronic and progressive condition that occurs after cancer treatment. Autologous lymph node transplant, or microsurgical vascularized lymph node transfer (ALNT), is a surgical treatment option that brings vascularized vascular endothelial growth factor-C-producing tissue into the operated field to promote lymphangiogenesis and bridge the distal obstructed lymphatic system with the proximal lymphatic system. Operative techniques for upper- and lower-extremity ALNT are described with 3 donor lymph node flaps (inguinal, thoracic, cervical). Surgical technique is described for the combination of ALNT with abdominal flaps and nonabdominal flaps. Imaging showing restoration of lymphatic drainage after ALNT is shown.

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.

Algorithm for autologous breast reconstruction for partial mastectomy defects

Background: The use of lateral thoracic skin and fat for breast reconstruction is advantageous because it does not require the use of muscle transfer, and the donor-site incision is well hidden under the arm. In patients with redundant skin at the thoracic flank, use of this tissue has the added benefit of removal of an unsightly roll. The lateral thoracic skin and fat flap can be harvested using microsurgical technique based on three different pedicles: the thoracodorsal artery perforators; a direct cutaneous branch of the thoracodorsal, axillary, or lateral thoracic arteries; and the lateral thoracic intercostal perforating vessel. Methods: The authors describe the techniques for harvest of lateral thoracic tissue based on each of the pedicle options. A case is then presented to illustrate each option, and an algorithm is suggested for deciding which pedicle to use. Results: The authors have used lateral thoracic tissue for partial breast reconstruction for a variety of defects. In this report, the authors review the results of three illustrative cases. Conclusions: Partial breast reconstruction may be required for patients after breast-conserving therapy or after breast reconstruction by other methods. Lateral thoracic tissue can be safely transferred to correct defects in treated or reconstructed breast, or to obtain symmetry. Knowledge of the vascular anatomy to this region is helpful in understanding the pedicle options when harvesting this tissue. The authors present an algorithm for determining which pedicle is most appropriate for the transfer of lateral thoracic tissue for partial breast reconstruction.

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.

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.

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.

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.