Shannon Colohan

The role of fat grafting in reconstructive and cosmetic breast surgery: a review of the literature.

The technique of autologous fat transplantation has been dramatically improved since its first introduction in 1893. This surgical approach has more recently been used in both the reconstructive and cosmetic setting, and has subsequently been the subject of much controversy. We sought to compose a detailed and systematic literature review of recent literature on the topic in order to provide surgeons with the data in an organized and easily accessible manner. We selected 19 studies and systematically documented trends in their methods, follow-up procedures, and outcomes, paying particular attention to complications. We chose to include studies that analyzed the outcomes of the surgical procedure in both reconstructive and cosmetic cases. Most authors reported satisfactory or greater results, and we concluded that it appears as though autologous fat transplantation to the breast is a safe option for patients seeking both reconstructive and cosmetic surgery.

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.

Free tissue transfers and replantation.

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the indications and contraindications for free flap reconstruction. 2. Describe the indications, anatomy, harvest technique, and advantages and disadvantages of the workhorse free flaps. 3. Describe the indications and contraindications for extremity replantation. 4. Describe the techniques and management for extremity replantation. Summary: Microsurgical free flap reconstruction uses a multitude of surgical flaps available to meet the needs of the recipient site. These include cutaneous, muscle, bone, fascia, or some combination of these as available options. Furthermore, sophisticated reconstruction has been enhanced by the development of perforator flaps, enabling multicomponent reconstruction to be performed with reduced donor-site morbidity. It is mandatory that proper débridement of the defect be performed before reconstruction, and that the anastomosis is performed without tension or twisting outside of the zone of injury. There are indications for both musculocutaneous and perforator flaps, and selection is dependent on recipient-site characteristics in addition to function and aesthetics of both the recipient and donor sites. Muscle flaps provide well-vascularized pliable tissue and are used for deep space obliteration, whereas fasciocutaneous flaps are used for flatter, more superficial wounds. Microsurgical replantation of an amputated extremity offers a result that is usually superior to any other type of reconstruction. However, replantation of extremities involves more than microsurgery, as repair of bony and tendon injury must be undertaken as well. This article focuses on the indications, technique, and results of free flap reconstruction and replantation.

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.

Discussion: are pfannenstiel scars a boon or a curse for DIEP flap breast reconstructions?

T identification of preoperative and perioperative risk factors in autologous breast reconstruction has been at the forefront of the flap literature for the past several years. In an effort to reduce flap complications, emphasis has been placed on everything from preoperative evaluation with computed tomography angiography and ultrasound, to perioperative perfusion assessment and postoperative methods of monitoring. Certainly, any risk factors identified preoperatively, which may alter the patient’s surgical anatomy, will provide additional support to maximizing preoperative evaluation in an effort to reduce morbidity. In their article, Dr. Mahajan et al. present a retrospective cohort study examining the impact of a Pfannenstiel incision on surgical anatomy and outcomes in deep inferior epigastric perforator (DIEP) breast reconstruction. This study was intended to provide scientific evidence supporting their clinical observation that lower abdominal scars do not affect DIEP breast reconstruction negatively. Although there are several published articles looking at abdominal scars in breast reconstruction, the majority of them focus on vertical midline scars.1–5 This is the first to specifically look at the Pfannenstiel incision. In the current study, 36 women with Pfannenstiel incisions were compared with an equal number of matched controls retrospectively. Anatomic factors, including perforator “bundle” size, number of perforators, and location of perforators relative to the umbilicus, were reported based on preoperative computed tomography angiography. In addition, demographic data and outcome data (flap loss, fat necrosis, wound problems, abdominal wall laxity, etc.) were collected. The results demonstrate a slightly greater average number of perforators among those without an abdominal incision (9.14 versus 8.3), with a similar periumbilical distribution of perforators in both groups. When looking at size, the control group appeared to have a greater number of smaller diameter perforator “bundles” (i.e., artery vein) on computed tomography angiography compared with those in the study group having a greater proportion of 4to 5-mm diameter bundles (p 0.04). There was no difference in postoperative complications between both groups. The authors conclude that the presence of a Pfannenstiel incision is associated with a significant change in the dimension of the perforators and propose a mechanism of “ischemic preconditioning” (or delay) as a possible benefit of the scar. Unfortunately, although it is plausible, the design of this study does not allow for such a causal relationship to be established. The true causal relationship would perhaps be better explored in a preimaging and postimaging study that looks at perforator anatomy before and after the creation of a lower abdominal incision. Although one cannot predict which patients with a Pfannenstiel incision will later require autologous breast reconstruction, one could consider a delay study in which the lower portion of the DIEP incision is created in the first stage and then flap elevation is completed several weeks later in a second stage. To date, there has only been one DIEP surgical delay study published.6 Several factors regarding study design warrant discussion. First, there is no mention of a power calculation to determine an appropriate cohort size that would provide results bearing statistical significance. This would need to be based on a combination of factors, including what is deemed to be a “clinically relevant” difference when it comes to perforator size and number. It would also be important to establish normal anatomic varia-

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.