A Plea for Recipient Vascular Pedicle Versatility in Microvascular Breast Reconstruction

Pradas-Irun, Concepcion; Azzawi, Khayam; Malata, Charles M.

doi:10.1097/prs.0b013e31823aeec2

Cited by 10 publications

(4 citation statements)

References 9 publications

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“…It is also easier to use the TDVs if the reconstruction is immediate with an associated axillary lymph node clearance. This exposes the vessels in advance, a key advantage of the subscapular-thoracodorsal system ( 24 , 25 ).…”

Section: Discussionmentioning

confidence: 99%

Decision Making in Double-Pedicled DIEP and SIEA Abdominal Free Flap Breast Reconstructions: An Algorithmic Approach and Comprehensive Classification

Malata

Rabey

2015

Front. Surg.

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IntroductionThe deep inferior epigastric artery perforator free flap is the gold standard for autologous breast reconstruction. However, using a single vascular pedicle may not yield sufficient tissue in patients with midline scars or insufficient lower abdominal pannus. Double-pedicled free flaps overcome this problem using different vascular arrangements to harvest the entire lower abdominal flap. The literature is, however, sparse regarding technique selection. We therefore reviewed our experience in order to formulate an algorithm and comprehensive classification for this purpose.MethodsAll patients undergoing unilateral double-pedicled abdominal perforator free flap breast reconstruction (AFFBR) by a single surgeon (CMM) over 40 months were reviewed from a prospectively collected database.ResultsOf the 112 consecutive breast free flaps performed, 25 (22%) utilised two vascular pedicles. The mean patient age was 45 years (range = 27–54). All flaps, but one (which used the thoracodorsal system), were anastomosed to the internal mammary vessels using the rib-preservation technique. The surgical duration was 656 min (range = 468–690 min). The median flap weight was 618 g (range = 432–1275 g) and the mastectomy weight was 445 g (range = 220–896 g). All flaps were successful and only three patients requested minor liposuction to reduce and reshape their reconstructed breasts.ConclusionBipedicled free abdominal perforator flaps, employed in a fifth of all our AFFBRs, are a reliable and safe option for unilateral breast reconstruction. They, however, necessitate clear indications to justify the additional technical complexity and surgical duration. Our algorithm and comprehensive classification facilitate technique selection for the anastomotic permutations and successful execution of these operations.Levels of evidenceTherapeutic level IV.

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Section: Discussionmentioning

confidence: 99%

Decision Making in Double-Pedicled DIEP and SIEA Abdominal Free Flap Breast Reconstructions: An Algorithmic Approach and Comprehensive Classification

Malata

Rabey

2015

Front. Surg.

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“…We were able to perform the total ‘rib’-preservation technique in all our cases, without having to partially resect any costal cartilages apart from one patient in whom the IM vein was “absent” as it was encased in tumour and extensive scar tissue and the 2nd CC had to be resected to expose usable vein [30] . This is in contrast to Kim et al.…”

Section: Discussionmentioning

confidence: 99%

Total ‘rib’-preservation technique of internal mammary vessel exposure for free flap breast reconstruction: A 5-year prospective cohort study and instructional video

Rosich-Medina

Bouloumpasis

Candia

et al. 2015

Annals of Medicine &Amp; Surgery

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IntroductionThe total ‘rib’-preservation method of dissecting out the internal mammary vessels (IMV) during microvascular breast reconstruction aims to reduce free flap morbidity at the recipient site. We review our five-year experience with this technique.Patients & methodsAn analysis of a prospectively collected free flap data cohort was undertaken to determine the indications, operative details and reconstructive outcomes in all breast reconstruction patients undergoing IMV exposure using the total ‘rib’-preservation method by a single surgeon.Results178 consecutive breast free flaps (156 unilateral, 11 bilateral) were performed from 1st June 2008 to 31st May 2013 in 167 patients with a median age of 50 years (range 28–71). There were 154 DIEP flaps, 14 SIEA flaps, 7 muscle-sparing free TRAMs, 2 IGAP flaps and one free latissimus dorsi flap. 75% of the reconstructions (133/178) were immediate, 25% (45/178) were delayed. The mean inter-costal space distance was 20.9 mm (range 9–29). The mean time taken to expose and prepare the recipient IMV's was 54 min (range 17–131). The mean flap ischaemia time was 95 min (range 38–190). Free flap survival was 100%, although 2.2% (4 flaps) required a return to theatre for exploration and flap salvage. No patients complained of localised chest pain or tenderness at the recipient site and no chest wall contour deformity has been observed.Discussion & conclusionThe total ‘rib’-preservation technique of IMV exposure is a safe, reliable and versatile method for microvascular breast reconstruction and should be considered as a valid alternative to the ‘rib’-sacrificing techniques.

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“…Internal mammary vein anatomy has been widely studied and is highly variable both in terms of number and patterns of division/confluence [2,3,6,7]. Four patterns of IMV anatomy were described by Arnez classifying the relationship of the vein to the internal mammary artery (IMA) [3].…”

Section: Discussionmentioning

confidence: 99%

“…Total rib-preserving vessel preparation is now well established and it involves exposing the vessels in either the 2nd or the 3rd intercostal space (ICS). Internal mammary vein (IMV) anatomy has been widely studied by Rohrich and Arnez, and is highly variable [2,3,6,7]. We proved that the pertinent vessel anatomy of the 2nd ICS is much more predictable with a larger space and a single vein in more than 80% of the cases hence it is our preferred technique [8].…”

Section: Introductionmentioning

confidence: 86%

An unusual “venous circle” of the internal mammary vein encountered during microvascular anastomosis and implications for practice

Samaras

McKelvie

Oni

et al. 2020

Case Reports in Plastic Surgery and Hand Surgery

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A Plea for Recipient Vascular Pedicle Versatility in Microvascular Breast Reconstruction

Cited by 10 publications

References 9 publications

Decision Making in Double-Pedicled DIEP and SIEA Abdominal Free Flap Breast Reconstructions: An Algorithmic Approach and Comprehensive Classification

Decision Making in Double-Pedicled DIEP and SIEA Abdominal Free Flap Breast Reconstructions: An Algorithmic Approach and Comprehensive Classification

Total ‘rib’-preservation technique of internal mammary vessel exposure for free flap breast reconstruction: A 5-year prospective cohort study and instructional video

An unusual “venous circle” of the internal mammary vein encountered during microvascular anastomosis and implications for practice

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