This study aimed to evaluate the efficacy of venous augmentation using superficial inferior epigastric vein (SIEV) in transverse rectus abdominis musculocutaneous (TRAM) and deep inferior epigastric artery perforator (DIEP) flap. A retrospective review was performed of 62 free TRAM and 6 DIEP unilateral breast reconstructions from September 2017 to July 2022. Intraoperative indocyanine green angiography was performed with the SIEV contralateral to the pedicle clamped and declamped for 20 min. The ratio of hypoperfused area was calculated and compared quantitatively. The preoperative computed tomography angiography was reviewed to measure the SIEV diameter and number of midline-crossing medial branches. Sixty-two percent (42/68 cases) resulted in perfusion improvement after SIEV superdrainage (Group 1), whereas 29.4 percent (20/68 cases) resulted in sustained (Group 2) and 8.8 percent (6/68 cases) in aggravated perfusion (Group3). The mean number of midline-crossing branches (p = 0.002) and mean difference in the diameter of bilateral SIEVs (p = 0.039) were significantly greater in Group 1 compared to the other groups. Superdrainage using the contralateral SIEV in TRAM/DIEP flap is recommended when there are more than 2 midline-crossing medial branches of SIEV and when the caliber of draining vein is greater than that of the pedicle side.
Silicone breast implant insertion is a commonly performed surgical procedure for breast augmentation or reconstruction. Among various postoperative complications, infection is one of the main causes of patient readmission and may ultimately require explantation. We report a case of infective costochondritis after augmentation mammoplasty, which has rarely been reported and is therefore difficult to diagnose. A 36-year-old female visited the clinic for persistent redness, pain, and purulent discharge around the left anteromedial chest, even after breast implant explantation. Magnetic resonance imaging showed abscess formation encircling the left 4th rib and intracartilaginous and bone marrow signal alteration at the left body of the sternum and left 4th rib. En bloc resection of partial rib and adjacent sternum were done and biopsy results confirmed infective costochondritis. Ten months postoperatively, the patient underwent chest wall reconstruction with an artificial bone graft and acellular dermal matrix. As shown in this case, early and aggressive surgical debridement of the infected costal cartilage and sternum should be performed for infective costochondritis. Furthermore, delayed chest wall reconstruction could significantly contribute to the quality of life.
Although single mesh insertion is recommended for simple incisional hernia, there is no established treatment of choice for severe incisional hernia accompanied with large muscular defects. Single mesh insertion cannot provide sufficient mechanical force, and muscle flaps could lead to donor site morbidity while also requiring longer operation times. In this case, dual application of mesh through a hybrid technique could be a good option. A 46-year-old woman with rectus abdominis muscle defect due to previous surgery visited our clinic with abdominal bulging. Abdomen-pelvis computed tomography demonstrated a 6.5×11.5 cm rectus abdominis defect along with small bowel herniation. We decided to reinforce the existing hybrid intraperitoneal onlay mesh technique through additional insertion of suprafascial mesh to prevent recurrence and minimize complications. The patient’s abdominal contour was well preserved postoperatively for 1 year. We believe dual-layer mesh insertion through a hybrid approach could be a better alternative for severe incisional hernia with large muscle defects because of its treatment efficacy, short operation time, simple technical requirements, and absence of donor or flap complications.
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