Munique Maia

Modifications to extend the transverse upper gracilis flap in breast reconstruction: Clinical series and results

Background: The transverse myocutaneous gracilis flap has traditionally been used to reconstruct smaller breasts. The authors have been performing autologous breast reconstruction utilizing the flap with two types of modifications to increase flap volume: an extended and a vertical extended flap. In this article, they discuss the different operative techniques and present a clinical series of both flap types. Methods: A retrospective review of all patients undergoing either flap modification under the senior author (M.S.-C.) was performed. Data collated included pedicle artery and vein diameters, flap weight, and patient complications. Results: Twenty-four transverse myocutaneous gracilis flaps were performed: 12 extended (seven patients) and 12 vertical flaps (six patients). The vertical group trended to have greater flap weights than the extended group. Mean flap weight was 385.75 g (range, 181 to 750 g) for the extended group and 469.75 g (range, 380 to 605 g) for the vertical group (p = 0.06). Mean arterial diameter of the medial circumflex artery was 1.9 mm (range, 1.5 to 2.0 mm), mean venous diameter was 2.4 mm (range, 2.0 to 3.5 mm), and mean pedicle length was 6.8 cm (range, 6.0 to 7.0 cm). All donor sites were closed primarily. Complications included seroma (n = 1), wound dehiscence (n = 2), and partial flap loss (n = 2). Conclusions: Modifications of the transverse myocutaneous gracilis flap increase flap volume and can be useful in patients who do not wish to have abdomen, buttock, or back scars. Donor-site scars can be concealed, and patients have the added benefit of a thigh lift. Complications are comparable to those found with other reconstructive options. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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.

The short- and ultrashort-pedicle deep inferior epigastric artery perforator flap in breast reconstruction

Background: Breast reconstruction using the deep inferior epigastric perforator (DIEP) flap is becoming more common and can help reduce donor site morbidity. The authors proposed that dissection of the deep inferior epigastric artery (DIEA) and vein (DIEV) to their external iliac source may not be required for safe flap transfer. Methods: Sixteen whole fresh cadaveric hemiabdomens were used to dissect transverse abdominal-based flaps. Latex injection of the DIEA system was carried out, and the diameters of the DIEA/DIEV vessels were assessed at various points along the course of the pedicle from the origin to the perforator. A clinical study of 26 patients who underwent a short and ultrashort pedicle DIEP flaps was carried out. Results: The average DIEA and DIEV vessel diameters were relatively similar from the external iliac origin to a point just caudal to the bifurcation. At the lateral rectus edge, the average DIEA diameter was 3.2 mm, and the DIEV diameter was 3.1 mm. The average pedicle length obtained with classic DIEP dissection was 16.9 cm, short-pedicle DIEP dissection 10.4 cm, ultrashort technique 8.1 cm, and free TRAM technique 6.5 cm. Venous injection study demonstrated rich venous interconnections between both venae comitantes. In their clinical study, the authors were able to achieve average pedicle lengths of 11.0 cm when transecting cranial to the lateral edge of the rectus, with average diameters of 2.5 mm (artery) and 2.9 mm (vein). Conclusion: Transection of the DIEA/DIEV pedicle at the lateral rectus edge or more proximally is safe and can help reduce operative time and donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Aesthetic subunit of the breast: An analysis of women's preference and clinical implications

Patient satisfaction in breast surgery is dependent on achieving a balance among all aesthetic subunits. The purpose of this study is to identify which subunit of the breast women consider important and correlate this clinically to improve patient satisfaction following breast surgery.A total of 313 subjects (ages, 20–80) were surveyed using a 25-point survey instrument collected via a telemedicine form. The data was analyzed to determine clinical significance.Of the subjects, 63% selected the upper inner quadrant as the most important subunit. Furthermore, 66% of the subjects indicated defects located in this region would lead them to seek operative intervention and this was consistent for all subgroups. Based on these results, defects in the upper inner quadrant of the breast are more likely to cause patient dissatisfaction. Patient outcomes following surgery can be enhanced by restoring volume and minimizing scars in this upper medial subunit of the breast.

Anterior chest wall reconstruction with a low skin paddle pedicled latissimus dorsi flap: a novel flap design.

Distal anterior chest wall defects remain a challenge for the reconstructive surgeon. To reconstruct this region, the most commonly used flaps are the pectoralis and rectus abdominis flaps.1,2 When these flaps cannot be used, the pedicled latissimus dorsi flap and the omentum flap are suitable options.3,4 The use of the pedicled latissimus dorsi flap for chest wall reconstruction was first described by Tansini5 in 1906 and was subsequently popularized by Olivari in 1976.6 Since then, the latissimus dorsi flap has gradually evolved, with many modifications and refinements described in the literature.7–10 In the traditional pedicled latissimus dorsi flap, the skin paddle is typically placed in the mid to upper back region. With this location, the arc of rotation and reach of the skin paddle can make it difficult to cover anterior chest wall defects. Thus, when the latissimus dorsi flap is used for coverage of the anterior chest wall, skin grafting over the muscle is often required, resulting in less than optimal cosmetic results. To provide a latissimus dorsi flap with a wider arc of rotation and increased skin paddle reach to and past the chest anterior midline, we designed the low skin paddle pedicled latissimus dorsi flap. The preoperative design and vascular basis of the flap are discussed and a case report is presented.

Secondary techniques in breast reconstruction refinement: the periareolar advancement flap.

Background: Techniques in breast reconstruction have vastly improved with natural feeling, aesthetically pleasing breasts created through transfer of free or pedicled tissue. Traditional flap designs incorporate a skin paddle that leaves a “patch,” which can be fairly large on the nouveau breast, clearly delineating the boundaries between the reconstruction and the native skin. In this article, the authors discuss the operative technique and present a clinical series of patients undergoing the periareolar advancement flap procedure. This technique reduces the skin paddle either to a circumferential areola-size area onto which the nipple can be simultaneously reconstructed (type I) or a single linear scar (type II) across the breast mound, thus enhancing the aesthetic appearance of the reconstructed breast. Methods: A retrospective review of all patients between 2007 and 2009 undergoing periareolar advancement flaps under the care of the senior author (M.S.C.) was performed. Type of reconstruction, staging of procedures, additional operations, and complications were recorded. Results: Fifteen patients had a type I procedure and six patients had a type II procedure. There were no major complications. One patient had minor nipple scabbing that resolved. All type I patients had concomitant nipple reconstructions at the time of their periareolar advancement flap. Conclusions: The periareolar advancement flap is a useful technique to include in the range of secondary revision procedures for further refinement of autologous breast reconstruction. It results in a sensate, more aesthetically pleasing breast. It has low complication rates and can be performed at the same time as a nipple reconstruction in type I patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Extended Transverse Musculocutaneous Gracilis (TMG) Flap: 3D CT Angiography and Clinical Series

INTRODUCTION: The transverse musculocutaneous gracilis (TMG) flap has been utilized in autologous breast reconstruction, but disadvantages include a small volume, compared to abdominal-based flaps. The vascular territory of this flap is investigated, with the possibility of extending its dimensions. We present two types of modifications to increase the bulk of TMG flaps, along with a case series for each modification.