Liliana Barone-Adesi

Planning Breast Reconstruction with Deep Inferior Epigastric Artery Perforating Vessels: Multidetector CT Angiography versus Color Doppler US

PURPOSE To evaluate the accuracy of multidetector computed tomographic (CT) angiography versus color Doppler ultrasonography (US) for perforating artery identification, intramuscular course of perforator vessel assessment, and superficial venous communication detection before a deep inferior epigastric perforator (DIEP) procedure for breast reconstruction. MATERIALS AND METHODS Informed consent and institutional review board approval were obtained. Forty-five patients underwent multidetector CT angiography and color Doppler US to identify the DIEP vessel prior to breast reconstruction surgery. Findings at surgery were used as a reference for accuracy evaluations. RESULTS The accuracy for identifying dominant perforator arteries was 97% for color Doppler US and 91% for CT angiography. Perforator arteries suitable for surgery were identified in 90% of cases with color Doppler US and in 95% of cases with CT angiography. For measurement of perforator calibers, surgical findings were similar to color Doppler US measurements (P = .33) but were significantly different than CT measurements (P < .0001). The accuracies for intramuscular course of perforator vessel assessment and superficial venous communication detection were 95% and 97% for CT and 84% and 80% for color Doppler US, respectively. In our population, the absence of superficial venous communication was associated with a risk for flap morbidity (P = .009). CONCLUSION Both color Doppler US and CT angiography resulted in accurate DIEP mapping. Color Doppler US was superior for measuring perforator artery calibers, and CT angiography was superior for estimating the intramuscular course of the perforator vessel and identifying superficial venous communications. Considering x-ray exposure and results of this study, employing multidetector CT angiography is suggested only in selected cases.

Flap algorithm in vulvar reconstruction after radical, extensive vulvectomy

The objective of this study was to assess the reconstructive options after radical, extensive vulvectomy; relate them to tumor characteristics; and select a choice of flaps able to correct every remaining defect. This study is a retrospective review of a 4-year experience with 31 flaps in 20 consecutive vulvar reconstructions. Three of the 31 flaps presented nonsignificant delayed healing at their tips and 3 other flaps developed a major breakdown related to an infection or an error in flap planning. According to the authors, the size of the defect is the main issue that must be taken into consideration during the establishment of reconstructive needs. Closure of vulvar defects is preferably performed using fasciocutaneous flaps, which are very reliable flaps and can be raised with different techniques to meet different needs. A flap is then chosen with the fewest potential complications. An algorithm has been thus established: Small to medium-size defects are closed with island V-Y flaps, island gluteal fold flaps, or pedicled pudendal thigh flaps. Among them, the island V-Y flap is the workhorse flap for vulvar reconstruction because of its versatility, reliability, and technical simplicity compared with its very low complication rate. If the vulvar defect is large and/or reaches the vulva–crural fold, V-Y flaps are also preferred to close these large and posteriorly extended excisions. If the vulvar defect is very large, extending both anteriorly and posteriorly, the use of a distally based, vertically oriented rectus abdominis muscle flap is recommended. Using this algorithm, immediate vulvar reconstruction with pedicled local or regional flaps can be performed easily and reliably.

Use of the Thoracodorsal Artery Perforator (TDAP) Flap With Implant in Breast Reconstruction

The latissimus dorsi (LD) musculocutaneous flap with implant has been widely used for breast reconstruction. This technique, which is safe and reliable, results in the sacrifice of the largest muscle in the body with high seroma incidence in the donor site. The thoracodorsal artery perforator (TDAP) flap spares the LD muscle. However, the TDAP has never been used together with implant for breast reconstruction. We present our strategies in sparing the LD muscle by using the TDAP flap with an implant beneath. The perforator was always mapped preoperatively. The TDAP flap was designed with the perforator located at the proximal part. Modifications to the flap should be done when multiple small perforators are found or when the perforator enters the subcutaneous tissue in the middle of the flap. A small segment of the muscle is included in the flap behind the perforator (LD-muscle sparing TDAP type I) to protect perforator compression by the implant. In very thin patients, a larger segment of the LD is needed to cover the implant (LD muscle-sparing TDAP type II). In both situations, the rest of the LD muscle is spared with its motor innervation. We present 4 patients who underwent a TDAP flap with implant for breast reconstruction. The flaps were transferred successfully. No seroma formation occurred. Combining a TDAP flap with an implant is feasible. Perforator mapping with correct flap design is the keystone in this technique. Reducing donor site morbidity and seroma rate are the ultimate goals of this technique. The TDAP flap should be modified to an LD muscle-sparing version in any case of unfavorable anatomic or clinical situations.

Immediate breast reconstruction after skin- or nipple-sparing mastectomy for previously augmented patients: a personal technique.

BackgroundBreast reconstruction for previously augmented patients differs from breast reconstruction for nonaugmented patients. Many surgeons regard conservation therapy as not feasible for these patients because of implant complications, whether radiotherapy-induced or not. Despite this, most authors agree that mastectomy with immediate breast reconstruction is the most suitable choice, ensuring both a good cosmetic result and a low complication rate. Implant retention or removal remains a controversial topic in addition to the best available surgical technique. This study reviewed the authors’ experience with immediate breast reconstruction after skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) with anatomically definitive implants.MethodsThe retrospective records of 12 patients were examined (group A). These patients were among 254 patients who underwent SSM or NSM for breast carcinoma. The control group comprised 12 of the 254 patients submitted to SSM or NSM (group B) who best matched the 12 patients in the studied group. All of them underwent immediate breast reconstruction, with an anatomically definitive implant placed in a submuscular–subfascial pocket. The demographic, technical, and oncologic data of the two groups were compared as well as the aesthetic outcomes using the Breast Q score. The proportion of complications, the type of implant, the axillary lymph node procedure, and the histology were compared between the two groups using Fisher’s exact test. Student’s t test was used to compare the scores for the procedure-specific modules of the breast Q questionnaire in the two groups.ResultsA validated patient satisfaction score was obtained using the breast Q questionnaire after breast reconstruction. The demographic, technical, and oncologic characteristics were not significantly different between the two groups. The previously augmented patients reported a significantly higher level of satisfaction with their breast than the control patients. The scores for the other procedure-specific modules were similar in the two groups.ConclusionA valid immediate one-stage implant reconstruction can be obtained for previously augmented patients by placing the implant in a submuscular–subfascial pocket reinforced by the periprosthetic capsule of the previous prosthesis.

Update on one-stage immediate breast reconstruction with definitive prosthesis after sparing mastectomies

Immediate breast reconstruction after skin and nipple-sparing mastectomies is commonly performed as a two-stage procedure; to overcome the paradox of traditional two-stage tissue expander/implant reconstruction used to create a tight muscular pocket that needs expansion to produce lower pole fullness, while losing the laxity of the mastectomy skin flaps, the authors conceived a subpectoral-subfascial pocket by elevating the major pectoral muscle in continuity with the superficial pectoralis fascia up to the inframammary fold. This alteration allowed for the immediate insertion of the definitive implant. The authors present their experience in 220 cases of immediate one-stage breast reconstructions with definitive prostheses in sparing mastectomies. Immediate and long-term local complications were evaluated. Immediate breast reconstruction with definitive anatomical silicone-filled implants can produce excellent cosmetic results (78.6%) with a low rate of complications (17.7%); these results allow for agreement between oncologic, aesthetic and economic purposes.

The Retrograde Limb of Internal Mammary Vessels as Reliable Recipient Vessels in DIEP Flap Breast Reconstruction: A Clinical and Radiological Study

AbstractFor many microsurgeons, antegrade internal mammary vessels (AIMVs) represent the recipients of choice in autogenous breast reconstruction. For the past few years, the retrograde internal mammary vessels (RIMVs) have been demonstrated to be a further reliable option when needed, according to many papers focusing more on the vein than on the artery. Besides the clinical evidence, the hemodynamic features of the retrograde system have been very seldom analyzed.In this article, we report our clinical experience with deep inferior epigastric perforator (DIEP) flaps anastomosed to RIMVs, along with a perioperative radiological follow-up to study RIMVs’ hemodynamics and to further support the reliability of the retrograde system with particular focus on the retrograde internal mammary artery.Prospective, preoperative, and postoperative (3 days, 21 days, and 3 months, respectively) color Doppler sonographies of the internal mammary artery (IMA) and DIEPs have been performed to collect the velocity of flow (v) and resistive index (RI) data. Twenty-two patients agreed to undergo this protocol, of which 10 unipedicle flaps were anastomosed to AIMVs (“control” group), 10 bipedicle DIEPs to both AIMVs and RIMVs (“study” group), and 2 DIEPs anastomosed to retrograde internal mammary artery and antegrade internal mammary vein (not statistically analyzed for their paucity). Student t test was performed to compare the “control” and “study” groups.All the flaps survived, and no re-exploration was needed. Internal mammary artery and perforators v showed similar but speculate trend, whereas IMA and perforators RI looked stable during that time. Significant differences have been found in the “study” group for IMA v at 3-day period, for perforator v at 21- and 90-day periods, and for perforator RI at 90-day period, without any clinical implication for flap viability.Retrograde internal mammary vessels can be considered reliable vessels for both arterial flap input and venous flap outflows, either as additional or the sole recipients. However, further and larger studies would be useful to better understand the hemodynamics of the retrograde system.

The effect of liposuction on inferior epigastric perforator vessels. a prospective study with color doppler sonography.

The authors investigated the effect of abdominal liposuction performed by superficial subdermal liposuction technique on inferior epigastric perforators. We aimed to determine whether previous liposuction is a contraindication to the use of an abdominal flap. The perforators in the abdominal region in 6 patients were marked preoperatively by color and pulsed-wave Doppler sonography (CDS), which gave a morphologic and flowmetric representation. The parameters studied with CDS were the location of the perforators, the diameters of the arteries and veins, and the flow velocity. These parameters were evaluated by the same method preoperatively and 6 months postoperatively. The Student t test was employed to assess differences between pre- and postoperative values of variables. The results of our study led us to conclude that prior abdominal liposuction does no significant injury to most perforating vessels. However, CDS aimed to study the existence and the quality of perforators should be done before planning an abdominal flap.

Deep inferior epigastric artery perforator flap donor-site closure with cannula-assisted, limited undermining, and progressive high-tension sutures versus standard abdominoplasty: complications, sensitivity, and cosmetic outcomes.

Background: In deep inferior epigastric artery perforator (DIEP) flap breast reconstruction, abdominal donor-site cosmetic and sensibility outcomes and the closure technique have drawn little attention in the literature, with many surgeons still following the principles of standard abdominoplasty. In this article, the authors report their experience with the cannula-assisted, limited undermining, and progressive high-tension suture (“CALP”) technique of DIEP donor-site closure compared with standard abdominoplasty. Methods: Between December of 2008 and January of 2013, 137 consecutive women underwent DIEP flap breast reconstruction. Of these, 82 patients (between December of 2008 and November of 2011) underwent DIEP flap donor-site closure by means of standard abdominoplasty (control group) and 55 patients (from December of 2011 to January of 2013) by means of cannula-assisted, limited undermining, and progressive high-tension suture (study group). The abdominal drainage daily output, donor-site complications, abdominal skin sensitivity at 1-year follow-up, cosmetic outcomes, and patient satisfaction were recorded and analyzed statistically. Results: Daily drainage output was significantly lower in the study group. Donor-site complications were significantly higher in the control group (37.8 percent versus 9 percent). Seroma and wound healing problems were experienced in the control group. Abdominal skin sensibility was better preserved in the study group. Overall, abdominal wall aesthetic outcomes were similar in both groups, except for scar quality (better in the study group). Conclusion: According to the authors’ experience, cannula-assisted, limited undermining, and progressive high-tension suture should be always preferred to standard abdominoplasty for DIEP donor-site closure to reduce the complication rate to improve abdominal skin sensitivity and scar quality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Contralateral Breast Symmetrisation in Immediate Prosthetic Breast Reconstruction after Unilateral Nipple-Sparing Mastectomy: The Tailored Reduction/Augmentation Mammaplasty

Background In the literature on nipple-sparing mastectomy (NSM) with one-stage immediate implant reconstruction, contralateral symmetrisation has drawn little attention, with many surgeons still performing standard cosmetic mammaplasty procedures. However, standard implant-based mammaplasty usually does not result in proper symmetry with the mastectomy side, especially regarding breast projection, overall shape, and volume distribution. Methods We retrospectively reviewed 19 consecutive patients undergoing unilateral NSM with immediate prosthetic reconstruction and contralateral simultaneous symmetrisation by using the tailored reduction/augmentation mammaplasty technique between June 2012 and August 2013. Results The average follow-up time was 13 months (range, 10-24 months). No major complications, such as infection, haematoma, and nipple-areola complex necrosis, were experienced. Conclusions Our experience suggests that simultaneous contralateral symmetrisation with tailored reduction/augmentation mammaplasty after unilateral immediate implant reconstruction after NSM facilitates durable and pleasant symmetric outcomes.

A massive arterial thrombosis of a free anterolateral thigh flap in a patient with antiphospholipid syndrome.

The antiphospholipid syndrome is a pathological condition characterized by recurrent thrombotic manifestations in venous and/or arterial vascular systems and by peculiar laboratory findings as anticardiolipin antibodies and/or positive lupus anticoagulant. We present a case of massive pedicle thrombosis of a free anterolateral thigh perforator flap used for tongue reconstruction following hemiglossectomy in a patient with antiphospholipid syndrome, which compelled us to an immediate second reconstruction choice with a radial forearm free flap. This case is an example of how this syndrome, especially if unknown before surgery, can influence the outcome of microsurgical transfer of flaps.