Bilateral autogenous breast reconstruction using perforator free flaps: a single center's experience

The authors present a single center's experience in bilateral breast reconstruction using perforator free flaps. The aim of this study was to show their indications, surgical technique, and results. A series of 53 patients underwent this procedure between February of 1996 and October of 2002. The surgical procedures were performed on patients with bilateral breast cancer (11 patients), patients with unilateral breast cancer and contralateral prophylactic mastectomy (22 patients), patients who had undergone bilateral prophylactic mastectomy (18 patients), a patient with Poland's syndrome, and a patient whose aesthetic breast augmentation had failed. Primary and secondary bilateral breast reconstructions were done in 18 and four patients, respectively. Eighteen patients who had earlier undergone breast reconstruction with implants had a tertiary breast reconstruction. Combined reconstruction (primary with secondary and primary with tertiary reconstruction) was done in 13 patients. Ninety-eight deep inferior epigastric perforator flaps and eight superior gluteal artery perforator flaps were used. The average operative time was 10 hours (range, 8 to 14.5 hours) for the simultaneous bilateral reconstruction. Total flap necrosis occurred in two cases (one deep inferior epigastric perforator flap and one superior gluteal artery perforator flap). Partial flap necrosis was not encountered, and fat necrosis was found in one deep inferior epigastric perforator flap (1 percent). Two pulmonary infections, one deep vein thrombosis, and one cardiac arrhythmia occurred as postoperative complications. The mean hospital stay was 9 days (range, 6 to 20 days). Abdominal bulging was reported in one patient. There were no recurrent disease or cancer manifestations, with an average follow-up of 3.5 years. This series clearly shows that perforator flaps are reliable and useful tools for bilateral breast reconstruction. This technique decreases the donor-site morbidity and offers an excellent aesthetic and long-term outcome and high patient satisfaction.     

The value of preoperative Doppler sonography for planning free perforator flaps

The individual perforating vessels have a high degree of anatomical variation, therefore it is desirable to conduct a careful examination of them before undertaking a perforator flap operation. Because locating the vessels beforehand makes performing the operative procedure much easier, the aim of the present study was to assess the value of using simple acoustic Doppler sonography to plan a perforator flap operation. The vessel examinations were carried out before taking 46 free microvascular flaps from either the lower abdominal wall or the buttock for reconstructive breast surgery. The perforating vessels located were marked, and their position relative to the umbilicus or the most cranial point of the rima ani recorded using a coordinate system. In 40 patients, a perforator flap operation (deep inferior epigastric perforator flap, n = 32; superior gluteal artery perforator flap, n = 8) was actually carried out; in six of these patients, a myocutaneous flap was used because of the insufficient availability of perforating vessels. Before the operation, perforating vessels were marked for each patient, with an average of 7.3 for the deep inferior epigastric perforator flap and 6.5 for the superior gluteal artery perforator flap. Out of 286 vessels marked for later perforator flaps, 162 were identified during the operation. A preoperatively marked vessel was used in 37 of 40 patients. In the remaining patients, a vessel was used that had not been previously marked. The vertical and horizontal distance between the perforating vessels identified during the operation and the preoperative marks averaged 0.8 cm. The results show preoperative Doppler sonography to be useful for locating the position of individual perforating vessels, making it much easier to find them during the operation.     

A 10-year retrospective review of 758 DIEP flaps for breast reconstruction

This study examined 758 deep inferior epigastric perforator flaps for breast reconstruction, with respect to risk factors and associated complications. Risk factors that demonstrated significant association with any breast or abdominal complication included smoking (p = 0.0000), postreconstruction radiotherapy (p = 0.0000), and hypertension (p = 0.0370). Ninety-eight flaps (12.9 percent) developed fat necrosis. Associated risk factors were smoking (p = 0.0226) and postreconstruction radiotherapy (p = 0.0000). Interestingly, as the number of perforators increased, so did the incidence of fat necrosis. There were only 19 cases (2.5 percent) of partial flap loss and four cases (0.5 percent) of total flap loss. Patients with 45 flaps (5.9 percent) were returned to the operating room before the second-stage procedure. Patients with 29 flaps (3.8 percent) were returned to the operating room because of venous congestion. Venous congestion and any complication were observed to be statistically unrelated to the number of venous anastomoses. Overall, postoperative abdominal hernia or bulge occurred after only five reconstructions (0.7 percent). Complication rates in this large series were comparable to those in retrospective reviews of pedicle and free transverse rectus abdominis musculocutaneous flaps. Previous studies of the free transverse rectus abdominis musculocutaneous flap described breast complication rates ranging from 8 to 13 percent and abdominal complication rates ranging from 0 to 82 percent. It was noted that, with experience in microsurgical techniques and perforator selection, the deep inferior epigastric perforator flap offers distinct advantages to patients, in terms of decreased donor-site morbidity and shorter recovery periods. Mastery of this flap provides reconstructive surgeons with more extensive options for the treatment of postmastectomy patients.     

Fat necrosis in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps

A series of 310 breasts reconstructed by a single surgeon using free transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps was reviewed to see if there were any differences in the incidence of fat necrosis and/or partial flap loss between the two techniques. During the study period, 279 breasts were reconstructed with free TRAM flaps and 31 breasts were reconstructed with DIEP flaps. In the breasts reconstructed with free TRAM flaps, the incidence of partial flap loss was 2.2 percent and the incidence of fat necrosis was 12.9 percent. The DIEP flaps were divided into two groups. For the first eight flaps, patients were selected using the same criteria normally used to choose patients for free TRAM flaps. In this unselected early group, the incidence of partial flap loss was 37.5 percent and the incidence of fat necrosis was 62.5 percent. Because of the high incidence of partial flap loss and fat necrosis in the first eight flaps, subsequent selection was modified to limit the use of DIEP flaps to patients who had at least one sufficiently large perforator in each flap (a palpable pulse and a vein at least 1 mm in diameter) and who did not require more than 70 percent of the flap to create a breast of adequate size. In this later (selected) group, fat necrosis (17.4 percent) and partial flap loss (8.7 percent) were reduced to a level only moderately higher than that found in the free TRAM flap group. From these data, it can be concluded that the incidence of partial flap loss and fat necrosis is higher in DIEP flaps than in free TRAM flaps, probably because the blood flow to the former flap is less robust. This difficulty can be circumvented to some extent, however, by careful patient selection. Factors that should be considered include tobacco use, size of the perforators (especially the vein), and (in unilateral reconstructions) the amount of flap tissue across the midline needed to create an adequately sized breast. If these factors are properly considered when planning the operation, fat necrosis and partial flap loss can be reduced to an acceptable level. For selected patients, the DIEP flap is an excellent technique that can obtain a successful, autologous tissue breast reconstruction with minimal donor-site morbidity. For patients who are not good candidates for reconstruction with this flap, the free TRAM flap remains a good alternative.     

Perforator flap breast reconstruction using internal mammary perforator branches as a recipient site: an anatomical and clinical analysis

A variety of useful recipient sites exist for breast reconstruction with free flaps, and correct selection remains a significant decision for the surgeon. Among the main pedicles, the disadvantages of the internal mammary vessels are the necessity of costal cartilage resection and the impairment of future cardiac bypass. This study was designed to reduce morbidity and to seek alternative recipient vessels. In the anatomical part of the study, 32 parasternal regions from 16 fresh cadavers were used. The locations and components of internal mammary perforator branches were measured and a histomorphometric analysis was performed. In the clinical part of the study, 36 patients underwent 38 deep inferior epigastric perforator (DIEP) flap and two superior gluteal artery perforator flap breast reconstructions (31 immediate and four bilateral). The recipient vessels were evaluated. In the anatomical study, there were 22 perforating vessels, with 14 (63.6 percent) on the second intercostal space and 11 (50 percent) with one artery and vein. The average (+/-SD) internal and external perforator artery diameters were 598.48 +/- 176.68 microm and 848.97 +/- 276.68 microm, respectively. In the clinical study, 13 successful anastomoses (32.5 percent) were performed at the internal mammary perforator branches (second and third intercostal spaces) with 12 DIEP flaps and one superior gluteal artery perforator flap (all performed as immediate reconstructions). One case of intraoperative vein thrombosis and one case of pedicle avulsion during flap molding were observed. The anatomic and clinical studies demonstrated that the internal mammary perforator branch as a recipient site is a further refinement to free flap breast reconstruction. However, it is neither a reproducible technique nor potentially applicable in all patients. Preoperative planning between the general surgeon and the plastic surgeon is crucial to preserve the main perforator branches during mastectomy. The procedure was not demonstrable in late reconstructions. The main advantages of internal mammary perforator branches used as recipient sites are sparing of the internal mammary vessels for a possible future cardiac surgery, prevention of thoracic deformities, and reduction of the operative time by limited dissection. Despite this, limited surgical exposure, caliber incompatibility, and technical difficulties have to be considered as the main restrictions.     

Cost-based comparison between perforator flaps and TRAM flaps for breast reconstruction

More women than ever before are undergoing mastectomies secondary to increased awareness and screening. This increase has also caused a corresponding increase in the number of breast reconstructions requested each year. The increased demand for reconstruction has fueled recent advances in new techniques. Aside from foreign-body reconstruction such as implants, the methods now being used are related to autogenous donations and reconstruction. Transverse rectus abdominis myocutaneous (TRAM) flaps and perforator flaps are currently being used for autogenous breast reconstruction. This study will compare these two techniques on the basis of cost and length of stay. A retrospective study of 49 patients undergoing a total of 64 perforator flap breast reconstructions at Memorial Medical Center in New Orleans, Louisiana, during the 1997 calendar year was used. There were 59 deep inferior epigastric perforator and five gluteal artery perforator breast reconstructions. All patients underwent some form of breast reconstruction and differed only in respect to whether a mastectomy was performed and whether the reconstruction was unilateral or bilateral. Those patients who underwent a mastectomy with immediate perforator flap reconstruction (n = 26) were then compared with patients undergoing mastectomy with immediate TRAM flap reconstruction (n = 154) at the University of Texas M. D. Anderson Cancer Center. The data from the Anderson Study were obtained from material published in Plastic and Reconstructive Surgery in 1996. Comparison of patients was limited to those who underwent mastectomy with immediate breast reconstruction because this was the design of the M. D. Anderson study. This approach allowed a cost and length of stay comparison while keeping other variables relatively similar. Patients in the perforator flap series enjoyed a marginally shorter operating time and a much shorter length of stay. On average, the operative time for all perforator flap reconstructions was approximately 2 hours shorter than for all TRAM flaps. As for length of stay, perforator flap patients were discharged, on average, 3 days after the initial reconstruction. In contrast, TRAM flap patients remained in the hospital for an average of approximately 7 days after the initial reconstruction. The overall total, average cost for the perforator flap reconstruction in this study is $9625, whereas the average cost of all TRAM flaps performed in the Anderson study is $18,070.     

Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps

Breast reconstruction using the lower abdominal free superficial inferior epigastric artery (SIEA) flap has the potential to virtually eliminate abdominal donor-site morbidity because the rectus abdominis fascia and muscle are not incised or excised. However, despite its advantages, the free SIEA flap for breast reconstruction is rarely used. A prospective study was conducted of the reliability and outcomes of the use of SIEA flaps for breast reconstruction compared with transverse rectus abdominis musculocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps. Breast reconstruction with an SIEA flap was attempted in 47 consecutive free autologous tissue breast reconstructions between August of 2001 and November of 2002. The average patient age was 49 years, and the average body mass index was 27 kg/m. The SIEA flap was used in 14 (30 percent) of these breast reconstructions in 12 patients. An SIEA flap was not used in the remaining 33 cases because the SIEA was absent or was deemed too small. The mean superficial inferior epigastric vessel pedicle length was approximately 7 cm. The internal mammary vessels were used as recipients in all SIEA flap cases so that the flap could be positioned sufficiently medially on the chest wall. The average hospital stay was significantly shorter for patients who underwent unilateral breast reconstruction with SIEA flaps than it was for those who underwent reconstruction with TRAM or DIEP flaps. Of the 47 free flaps, one SIEA flap was lost because of arterial thrombosis. Medium-size and large breasts were reconstructed with hemi-lower abdominal SIEA flaps, with aesthetic results similar to those obtained with TRAM and DIEP flaps. The free SIEA flap is an attractive option for autologous tissue breast reconstruction. Harvest of this flap does not injure the anterior rectus fascia or underlying rectus abdominis muscle. This can potentially eliminate abdominal donor-site complications such as bulge and hernia formation, and decrease weakness, discomfort, and hospital stay compared with TRAM and DIEP flaps. The disadvantages of an SIEA flap are a smaller pedicle diameter and shorter pedicle length than TRAM and DIEP flaps and the absence or inadequacy of an arterial pedicle in most patients. Nevertheless, in selected patients, the SIEA flap offers advantages over the TRAM and DIEP flaps for breast reconstruction.     

New microsurgical breast reconstruction using free paraumbilical perforator adiposal flaps

Pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps have generally been used for bilateral breast losses. The major disadvantages of this method are the total or partial loss of the rectus abdominis muscles and various resulting postoperative complications, such as abdominal bulging and lumbar pain. With the recent development of perforator flaps and supermicrosurgery with anastomosis of 0.5-mm caliber vessels, these serious complications can be overcome with a paraumbilical perforator adiposal flap, without sacrificing the rectus abdominis muscle. The breasts of a 57-year-old woman who had undergone a bilateral subcutaneous mastectomy, including silicone prostheses, were repaired simultaneously with this new method using free paraumbilical perforator adiposal flaps. This new method of breast augmentation with a vascularized adiposal flap and without any muscle component is minimally invasive; its advantages are the preservation of the rectus abdominis muscles and the short time elevation for the adiposal flap.     

A comparison of outcomes using three different methods of breast reconstruction.

In a review of 325 postmastectomy breast reconstructions, the aesthetic quality of the result and the risk of unsuccessful outcome were compared for three techniques: tissue expansion (105 breasts), latissimus dorsi myocutaneous flap (47 breasts), and TRAM flap (173 breasts). The aesthetic successes achievable with the three methods were similar, and some excellent results were achieved with each of them. The failure rate after tissue expansion (21 percent) was significantly higher than those observed with the TRAM (3 percent) and latissimus (9 percent) flaps. Tissue expansion also was not as aesthetically successful as other techniques in obese patients. For immediate breast reconstruction, the TRAM flap was the most aesthetically successful technique. Although tissue expansion has advantages and may be the best choice for some patients, methods that used autogenous tissue provided more consistent success.     

A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity

Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.     

Symmetrical breast reconstruction: is there a role for three-dimensional digital photography?

Clinical applications of three-dimensional digital photography include assessments of breast volume and contour. It was hypothesized that knowledge of preoperative and postoperative breast volumes might facilitate obtaining symmetry after reconstructions with autologous tissue or implants. Breast reconstruction was performed for 382 women during a 4-year period. Of those women, 334 completed all phases of the reconstruction and underwent symmetry analysis. Reconstructive procedures included the use of pedicle transverse rectus abdominis musculocutaneous flaps, free transverse rectus abdominis musculocutaneous flaps, deep inferior epigastric perforator flaps, superior gluteal artery perforator flaps, or latissimus dorsi flaps or expanders/implants. Three-dimensional digital photographic images were obtained for 33 women, whereas the remaining 301 women were not digitally photographed. The differences in symmetry after the initial reconstruction and after the secondary procedures were compared for all women and for the groups with and without three-dimensional photographic images. For the group with three-dimensional imaging, initial volume symmetry was obtained for 73 percent, initial contour symmetry was obtained for 27 percent, secondary procedures were necessary for 70 percent, final volume symmetry was obtained for 88 percent, and final contour symmetry was obtained for 79 percent. For the group without three-dimensional photographic images, initial volume symmetry was obtained for 57 percent, initial contour symmetry was obtained for 34 percent, secondary procedures were necessary for 50 percent, final volume symmetry was obtained for 80 percent, and final contour symmetry was obtained for 71 percent. The results demonstrated that there was no significant difference in final contour and volume symmetry between women who had or did not have three-dimensional digital photographic images taken. However, the results demonstrated that autologous tissue reconstructions resulted in improved contour and volume symmetry, compared with implant reconstructions.     

Delay in unipedicled TRAM flap reconstruction of the breast: a review of 76 consecutive cases

Since its introduction in 1982, the transverse rectus abdominis musculocutaneous (TRAM) flap has become the standard therapy in autogenous breast reconstruction. A lower rate of partial flap (fat) necrosis is associated with microvascular free-flap transfer compared with the conventional (unipedicled) TRAM flap because of its potentially improved blood supply. A TRAM flap delay before flap transfer has been advocated, especially in a high-risk patient population (obesity, history of cigarette smoking, radiation therapy, or abdominal scar). The authors reviewed a series of 76 consecutive delayed unipedicled TRAM flap breast reconstructions during a 5-year period. Data were analyzed with respect to type of procedure and time of delay, overall outcome, general surgical complications, flap-related (specific) complications (partial or complete flap loss), and patient satisfaction. Seventy-six unilateral breast reconstructions using the unipedicled TRAM flap were performed between 1995 and 2000 in 76 patients (mean age, 47.4 years). Fifty-four flaps were performed as immediate reconstructions, and 22 as secondary procedures. Seventy-two flaps were based on the contralateral pedicle, and four flaps were based on an ipsilateral pedicle. In all cases, a flap delay consisted of ligature of both deep inferior epigastric arteries and veins, accessed from an inferior flap incision down to the fascia, with a mean of 13.9 days before the flap transfer. No acute flap take-back procedure had to be performed. There was no complete flap loss, and breast reconstruction was achieved in all cases. In five cases (6.6 percent), a partial (fat) flap necrosis occurred. Interestingly, the majority of these cases (four of five) were secondary breast reconstructions. In addition, of the five patients who had partial flap necrosis, four had a history of smoking, two received radiation therapy, three received chemotherapy, and three patients were obese (body mass index greater than or equal to 30) or overweight (body mass index greater than or equal to 25). In three cases, an early surgical complication (two wound infections at the flap interface and one at the donor site) occurred. One patient developed a deep vein thrombosis. Five patients developed secondary ventral hernias necessitating repair (6.6 percent). Forty-one patients underwent secondary nipple-areola reconstruction. In 19 patients of this group, a secondary procedure (e.g., scar revision, limited liposuction, and/or excision of contour deformities) was simultaneously performed. A survey of patient satisfaction was performed using a modified SF-36 questionnaire. Fifty-one patients participated (67 percent). The overall satisfaction was very high and 51 patients reported that they would recommend the procedure to others (100 percent). Multiple factors such as patient selection, surgical expertise, and preoperative and postoperative management contribute to the success of any type of autogenous breast reconstruction. However, rare partial and absent complete flap necrosis in the authors' series may be attributable to the flap delay. A low morbidity rate and short hospital stay may become increasingly relevant, with limited structural and financial resources in the future. Therefore, the delayed unipedicled TRAM flap should be regarded as a valuable option in attempted breast reconstruction using autogenous tissue in both a high-risk and the general patient population.     

The deep inferior epigastric perforator flap for breast reconstruction in overweight and obese patients

The authors retrospectively reviewed the computerized records of 71 women undergoing 80 deep inferior epigastric perforator (DIEP) flap reconstructions after mastectomy over a 1-year period. There were 33 normal, 26 overweight, and 12 obese patients. No statistically significant difference in flap complications was found between groups. Overall fat necrosis rates were 11.4 percent for the normal-weight patients, 6.7 percent for the overweight patients, and 6.7 percent for the obese patients. Postoperative hospital time was similar for all groups. The occurrence of abdominal wall fascial laxity was uncommon and similar for all groups. Large (>900 g) reconstructions were completed without prohibitive complications in the reconstruction flap. The DIEP flap represents a significant advance in autologous breast tissue reconstruction. Although concerns regarding fat necrosis rates in DIEP flaps have been voiced, the authors did not see an increasing rate of fat necrosis in their overweight and obese patients, and their overall rate of fat necrosis is comparable to rates reported for free transverse rectus abdominis myocutaneous (TRAM) flaps. Also, increasing body mass index did not seem to affect the rate of delayed complications of the abdominal wall, such as abdominal wall hernia or bulging. Although it was not statistically significant, the authors did observe a trend toward increased wound-healing complications with increasing body mass index. Their data also support the claim that the complete sparing of the rectus abdominis muscles afforded by the DIEP flap avoids abdominal wall fascial bulging or defects often seen in obese TRAM reconstruction patients. Because flap and wound complication rates are similar or superior to those of other autologous tissue reconstruction techniques and the occurrence of abdominal wall defects is all but eliminated, the DIEP flap likely represents the preferred autologous breast reconstruction technique for overweight and obese patients.     

Ex vivo intraoperative angiography for rectus abdominis musculocutaneous free flaps

In this study, the vascular architecture of rectus abdominis free flaps nourished by deep inferior epigastric vessels was investigated using an ex vivo intraoperative angiogram. Oblique rectus abdominis free flaps were elevated and isolated from the donor site. In 11 patients, the vascular architecture of these flaps was analyzed before the flap was thinned. Radiographic study identified an average of 2.1 large deep inferior epigastric arterial perforators in each flap. In nine of the 11 flaps, the axial artery was visible. In four flaps, the axial artery originated from the perforator of the lateral branch of the deep inferior epigastric artery; in five others, it originated from the medial branch. In each flap, the angle of the axial perforator from its anterior rectus sheath in the vertical plane was measured; its mean was 50.6 degrees. All flaps survived, although three showed partial necrosis in the distal portions. In two of these three flaps, the axial artery was not visible in the angiograms, and the third revealed a one-sided distribution of axial flap arteries. Using ex vivo intraoperative angiography, the architecture of the individual flap, its axial perforator, and its connecting axial flap vessel could be investigated. This information can help the surgeon safely thin and separate the flap.     

Delayed-immediate breast reconstruction

In patients with early-stage breast cancer who are scheduled to undergo mastectomy and desire breast reconstruction, the optimal timing of reconstruction depends on whether postmastectomy radiation therapy will be needed. Immediate reconstruction offers the best aesthetic outcomes if postmastectomy radiation therapy is not needed, but if postmastectomy radiation therapy is required, delayed reconstruction is preferable to avoid potential aesthetic and radiation-delivery problems. Unfortunately, the need for postmastectomy radiation therapy cannot be reliably determined until review of the permanent tissue sections. The authors recently implemented a two-stage approach, delayed-immediate breast reconstruction, to optimize reconstruction in patients at risk for requiring postmastectomy radiation therapy when the need for postmastectomy radiation therapy is not known at the time of mastectomy. Stage 1 consists of skin-sparing mastectomy with insertion of a completely filled textured saline tissue expander. After review of permanent sections, patients who did not require post-mastectomy radiation therapy underwent immediate reconstruction (stage 2) and patients who required postmastectomy radiation therapy completed postmastectomy radiation therapy and then underwent standard delayed reconstruction. In this study, the feasibility and outcomes of this approach were reviewed. Fourteen patients were treated with delayed-immediate reconstruction between May of 2002 and June of 2003. Twelve patients had unilateral reconstruction and two patients had bilateral reconstruction, for a total of 16 treated breasts. All patients completed stage 1. Tissue expanders were inserted subpectorally in 15 breasts and subcutaneously in one breast. The mean intraoperative expander fill volume was 475 cc (range, 250 to 750 cc). Three patients required postmastectomy radiation therapy and underwent delayed reconstruction. Eleven patients did not require postmastectomy radiation therapy. Nine patients had 11 breast reconstructions (stage 2), six with free transverse rectus abdominis musculocutaneous (TRAM) flaps, one with a superior gluteal artery perforator flap, and four with a latissimus dorsi flap plus an implant. The median interval between stages was 13 days (range, 11 to 22 days). Two patients who did not require postmastectomy radiation therapy have not yet had stage 2 reconstruction, one because she wished to delay reconstruction and the other because she required additional tissue expansion before permanent implant placement. Six complications occurred. The stage 1 complications involved two cases of mastectomy skin necrosis in patients who required post-mastectomy radiation therapy; one patient required removal of the subcutaneously placed expander before postmastectomy radiation therapy and the other patient had a subpectorally placed expander that only required local wound care. The stage 2 complications were a recipient-site seroma in a patient with a latissimus dorsi flap, a recipient-site hematoma in the patient with the superior gluteal artery perforator flap, and two arterial thromboses in patients with TRAM flaps. Both TRAM flaps were salvaged. Delayed-immediate reconstruction is technically feasible and safe in patients with early-stage breast cancer who may require postmastectomy radiation therapy. With this approach, patients who do not require postmastectomy radiation therapy can achieve aesthetic outcomes essentially the same as those with immediate reconstruction, and patients who require postmastectomy radiation therapy can avoid the aesthetic and radiation-delivery problems that can occur after an immediate breast reconstruction.     

Experience with reduction mammaplasty combined with breast conservation therapy in the treatment of breast cancer

As the inclusion criteria for breast conservation therapy have continued to evolve to include lower quadrant tumors, very large breasts, and central tumors, the potential for significant disfigurement after breast conservation therapy has also increased. This has led some centers to develop coordinated oncology-plastic surgery approaches to ensure both adequate cancer resection and aesthetic appearance to the breasts. The authors applied this principle to a specific group of breast cancer patients--women with macromastia--who would benefit from reduction mammaplasty. Eleven women were identified from the senior author's (S.L.S.) reconstructive practice who underwent breast conservation therapy followed by breast reconfiguration and bilateral reduction mammaplasty. Preoperative brassiere sizes ranged from 34D to 46D. All women had immediate reduction after frozen sections from the lumpectomy/partial mastectomy margins were determined to be negative. A total of 22 reduction mammaplasties were performed (eight free-nipple grafts, five inferior pedicle flaps, seven superomedial pedicle flaps, and two superolateral flaps) and an average of 1085 g was removed per breast. All patients underwent radiation therapy postoperatively. There were eight minor complications in six patients (one hematoma, one keloid, one radiation burn, two cases of nipple hypopigmentation, and three cases of fat necrosis). After an average of 24 months' follow-up, there were no local recurrences and one death from distant metastasis. Seven of the 11 patients were available and agreed to rate their aesthetic satisfaction on the basis of a scale from 1 to 4, with 4 being the best. The mean satisfaction score was 3.3. Aesthetic outcomes before radiation therapy and after radiation therapy were evaluated by a panel of plastic surgery residents blinded to the purpose of the study. Using a scale of 1 to 4, the aesthetic mean before radiation therapy was 2.9 and the aesthetic mean after radiation therapy was 3.03. By combining breast conservation therapy with breast reconfiguration or reduction in large-breasted women, multiple benefits are derived. Larger segmental or partial mastectomies can be performed without disfigurement risk, ensuring adequate surgical margins. Immediate reconfiguration of the breast with reduction of the contralateral side creates symmetric, aesthetically pleasing breasts; allows contralateral breast tissue to be evaluated; and spares women from undergoing a second operative procedure. Such a coordinated program gives women an important boost, both physically and psychologically, during management of their breast cancer.     

Transverse dual-perforator fascia-sparing free TRAM flap: technique description

As techniques for breast reconstruction with autologous abdominal tissue have evolved, free transverse rectus abdominis myocutaneous flaps have persevered because of their superior reliability and minimal donor-site morbidity compared with muscle-sparing techniques. Further refinements are described in this article to maximize abdominal flap perfusion and ensure primary closure of the rectus fascia. It has been well documented that incorporating both the lateral and medial perforators provides maximal perfusion to all zones of the lower abdominal transverse skin flap. However, dissection and harvest of both sets of perforators requires disruption and/or sacrifice of abdominal wall tissues. The technique presented here was designed to use both the lateral and medial row perforators, and to minimize abdominal wall disruption. Deep inferior epigastric artery medial and lateral row perforators are selected for their diameter, proximity, and transverse orientation to each other. A transverse ellipse of fascia is incised to incorporate both perforators. The fascial incision is then extended inferiorly in a T configuration to allow for adequate exposure and harvest of the vascular pedicle and/or rectus abdominis, and primary closure. Limiting perforator selection to one row of inferior epigastric arteries diminishes perfusion to the abdominal flap. Furthermore, perforator and inferior epigastric artery dissection often results in fascial defects that are not amenable to primary closure. However, maximal abdominal flap perfusion and minimal donor-site morbidity can be achieved with the transverse dual-perforator fascia-sparing free transverse rectus abdominis myocutaneous flap technique and can be performed in most patients.     

Comparison of three different supercharging procedures in a rat skin flap model

A significant clinical problem in reconstructive surgery is partial loss of a pedicled flap. To resolve this problem, various methods of vascular augmentation have been developed; "supercharging" is one of those techniques. A new rat flap model was developed for investigation of the supercharging procedure, and the efficacy of the arterial supercharging method was examined. The purpose of this study was to investigate how an arterial supercharging procedure could generate large flap survival areas with different supercharging positions in rats. On the basis of the vascular anatomical features of rats, a circumferential skin flap from the lower abdomen to the back, measuring 4 x 12 cm, was marked. The flap was divided along the dorsal midline. Forty rats were divided into four experimental groups, as follows: group 1 (control), flaps based only on the deep circumflex iliac artery and vein; group 2, flaps supercharged with the ipsilateral superficial inferior epigastric artery; group 3, flaps supercharged with the contralateral superficial inferior epigastric artery; group 4, flaps supercharged with the contralateral deep circumflex iliac artery. On the fourth postoperative day, the flaps were evaluated with measurements of necrosis and survival areas. Microfil (Flow Tech, Inc., Carver, Mass.) was then injected manually throughout the body, and the vascular changes produced by supercharging were angiographically evaluated. Compared with group 1 (control), the flap survival areas were significantly greater in distally supercharged flaps in groups 3 and 4 (mean flap survival, 91.2 +/- 5.2 percent and 90.5 +/- 10.6 percent, respectively; p < 0.001) and in proximally supercharged flaps in group 2 (45.9 +/- 4.1 percent, p < 0.05). Angiographic assessment of the flaps that survived completely revealed marked dilation of the choke veins among the territories and reorientation of dilated veins along the axes of the flaps. This study suggests that distal arterial supercharging (contralateral superficial inferior epigastric artery or contralateral deep circumflex iliac artery) is more effective than proximal arterial supercharging (ipsilateral superficial inferior epigastric artery) in increasing flap survival. Although the rat skin flap may not be analogous to human flaps, distal arterial supercharging might have useful therapeutic potential in increasing flap survival in clinical practice.     

The inferior gluteal free flap in breast reconstruction

The inferior gluteal musculocutaneous free flap usually provides a sufficient amount of autogenous tissue for breast reconstruction when adequate tissue is not present in the lower abdomen or back. Its arteriovenous pedicle is longer than the superior gluteal musculocutaneous free-flap pedicle and permits microvascular anastomosis in the axilla, avoiding medial rib and cartilage resection. In the thin patient, there is more available donor tissue than with the superior gluteal musculocutaneous free flap. Cadaver dissections confirm the greater pedicle length and the local area of the lower gluteus maximus muscle needed to carry the skin island and have helped define a safe approach to flap elevation. We have used four flaps for breast reconstruction without vascular compromise or the need for reexploration. The low donor-site scar in the inferior buttock fold has been acceptable, especially for a bilateral reconstruction. The anatomy of the gluteal region, the surgical technique for the inferior gluteal free-flap transfer, and a 3-year patient follow-up are presented.     

Anterolateral thigh flap for postmastectomy breast reconstruction

Most postmastectomy defects are reconstructed by use of lower abdominal-wall tissue either as a pedicled or free flap. However, there are some contraindications for using lower abdominal flaps in breast reconstruction, such as inadequate soft-tissue volume, previous abdominoplasty, lower paramedian or multiple abdominal scars, and plans for future pregnancy. In such situations, a gluteal flap has often been the second choice. However, the quality of the adipose tissue of gluteal flaps is inferior to that of lower abdominal flaps, the pedicle is short, and a two-team approach is not possible because creation of the gluteal flap requires that the patient's position be changed during the operation. In 2000, five cases of breast reconstructions were performed with anterolateral thigh flaps in the authors' institution. Two of them were secondary and three were immediate unilateral breast reconstructions. The mean weight of the specimen removed was 350 g in the three patients who underwent immediate reconstruction, and the mean weight of the entire anterolateral thigh flap was 410 g. Skin islands ranged in size from 4 x 8 cm to 7 x 22 cm, with the underlying fat pad ranging in size from 10 x 12 cm to 14 x 22 cm. The mean pedicle length was 11 cm (range, 7 to 15 cm). All flaps were completely successful, except for one that involved some fat necrosis. The quality of the skin and underlying fat and the pliability of the anterolateral thigh flap are much superior to those of gluteal flaps and are similar to those of lower abdominal flaps. In thin patients, more subcutaneous fat can be harvested by extending the flap under the skin. Use of a thigh flap allows a two-team approach with the patient in a supine position, and no change of patient position is required during the operation. However, the position of the scar may not be acceptable to some patients. Therefore, when an abdominal flap is unavailable or contraindicated, the creation of an anterolateral thigh flap for primary and secondary breast reconstruction is an alternative to the use of lower abdominal and gluteal tissues.