Technical difficulties and key points of DIEP in breast reconstruction / 中华内分泌外科杂志

Surgical treatment is an important part of comprehensive management for breast cancer patients. Loss of breast will bring serious psychological trauma to patients and greatly reduce the quality of life. In autologous breast reconstruction, deep inferior epigastric artery perforator flap (DIEP) -a representative reconstructive technology has its incomparable advantages. The flap has sufficient blood supply. The reconstructed breast has natural contour and texture, and the complications in the donor area were quite low. It is also an important alternative to rescue the reconstructive failures. However, DIEP flap is difficult and has a long learning curve. The key technical points and difficulties not only run through the whole process of operation, but also exist before and after operation. On the basis of mastering the main concepts of DIEP, this paper would elaborate the important details in the operation process and emphasize the monitoring of skin flap after operation and the corresponding plan. This will help to better popularize the operation technique, improve the success rate of operation and patient satisfaction, while reduce operative complications and benefit more breast cancer patients.

The application of turbocharging technique in repairing large defect with free perforator flap / 中华整形外科杂志

Objective@#To investigate the feasibility and clinic outcome of the turbocharging technique in repairing large defect with free perforator flap.@*Methods@#From January 2017 to December 2018, 6 patients with defect of over length or large size were repaired with free perforator flaps, anterolateral thigh(ALT) flap in 3 cases and deep inferior epigastric artery perforator(DIEP) flap in 3 cases in Department of Hand Surgery, Ningbo No.6 Hospital. There were 4 males and 2 females, aged from 29 to 54 years old, with an average age of 41 years old.It was found that the size of the flap beyond the perforasome, while multiple perforators in the flaps were not from the same pedicle. The turbocharging technique was applied in the operation. The distal perforator of the flap was anastomosed with the proximal pedicle branch. The flap size ranged from 20 cm×8 cm to 25 cm×12 cm. The donor sites were closed directly for 3 cases and skin grafting for 3 cases.@*Results@#All the flaps survived successfully, no distal necrosis occurred. The patients were followed up for 3 to 12 months, with an average of 9 months. All flaps survived well with satisfactory appearance and pliable texture. The healing of skin graft was satisfactory in 3 cases in donor site. No graft skin contracture occurred. The donor sites closed directly in 3 cases had linear scar in donor site, no obvious contracture occurred. The flap sensation returned to S2-S3.@*Conclusions@#If the size of the flap is super long or large, beyond the perforasome, while multiple perforators in the flaps were not from the same pedicle, the application of turbocharging technique can avoid partial necrosis of the flap and improve the survival rate of the flap, which is an ideal alternative.

Reconstrucción mamaria con colgajo perforante de arteria epigástrica inferior profunda (DIEP) / Breast reconstruction with DIEP flaps

Introducción. La reconstrucción mamaria sigue siendo hoy en día un verdadero desafío para la cirugía reparadora, que tiene como objetivo principal recuperar la imagen corporal y la calidad de vida de estos pacientes. Para lograr este cometido se cuenta con un amplio arsenal terapéutico. La reconstrucción con implantes es la forma más común de reconstrucción en el mundo. Sin embargo, las técnicas con tejidos autólogos han ganado terreno en los últimos años por su mejor calidad reconstructiva y durabilidad en el tiempo. Material y método. El colgajo DIEP consiste en un colgajo libre, compuesto por piel y tejido celular subcutáneo de la región abdominal inferior, basado en perforantes de la arteria epigástrica inferior profunda. Brinda buenos resultados reconstructivos, sin sacrifi cio funcional de la pared abdominal. El objetivo del trabajo es resaltar algunas de las características más relevantes de esta técnica y la experiencia de nuestro servicio en su utilización para la reconstrucción mamaria. Resultados y discusión. La experiencia del servicio con la utilización de este colgajo ha sido satisfactoria, con buenos resultados, bajas complicaciones y aceptación por parte de las pacientes. Conclusiones. Si bien se trata de un colgajo que requiere una técnica microquirúrgica, con una importante curva de aprendizaje, logra devolver una mama con características similares a la contralateral en forma, volumen y textura, con el benefi cio estético del contorneado corporal abdominal y sin las complicaciones del uso del material protésico, considerándose hoy en día como una herramienta más a tener en cuenta para la reconstrucción mamaria.

Background: Breast reconstruction remains as a real challenge for restorative surgery today, with the main objective of recovering the body image and the quality of life of these patients. To achieve this, there is a broad therapeutic arsenal. Reconstruction with implants is the most common form of reconstruction in the world; however, autologous tissue techniques have gained ground in recent years for their improved reconstructive quality and durability over time. Material and Method:The DIEP fl ap is a free fl ap, composed of skin and subcutaneous cellular tissue of the lower abdominal region, based on perforators of the deep inferior epigastric artery, providing good reconstructive results, without functional sacrifi ce of the abdominal wall. The objective of this work is to highlight some of the most relevant characteristics of this technique and the experience of our service in its use for breast reconstruction. Results and Discussion: The experience of the Service with the use of this fl ap has been satisfactory, with good results, low complications and acceptance by the patients. Conclusions: Although it is a fl ap that requires a microsurgical technique, with an important learning curve, it manages to return a breast with similar characteristics to the contralateral in shape, volume and texture, with the esthetic benefi t of abdominal body contouring and without complications of the use of prosthetic material, being considered nowadays as one more tool to take into account for the reconstruction mammary.

Immediate simultaneous bilateral breast reconstruction with deep inferior epigastric (DIEP) free flap and transverse rectus abdominis musculocutaneous (TRAM) pedicled flap

Breast reconstructive surgery has evolved tremendously since its inception. Following tumour clearance surgery, physical restoration with breast reconstruction is an important aspect of physical and emotional rehabilitation. Various methods have been described to suit patients demand for the best aesthetic outcome. Surgeon’s preference, experience and practicality of differing procedures must be considered. We describe a simultaneous bilateral breast reconstruction with free deep inferior epigastric (DIEP) flap and pedicled transverse rectus abdominis musculocutaneous (TRAM) flap immediately post mastectomies for bilateral breast cancers. The surgery described has resulted in a reasonable technical ease, acceptable flap and abdominal morbidity and good aesthetic outcome.

Uso de colgajos libres perforantes de la región abdominal tipo DIEP y SIEA para reconstrucción mamaria / Use of perforator flaps from the lower abdomen (DIEP and SIEA) for breast reconstruction

Introducción: El cáncer de mama es la neoplasia que afecta en forma más frecuente a las mujeres en el mundo. Posterior a una mastectomía, el uso de tejidos autógenos para la reconstrucción mamaria tiene mejores resultados a largo plazo. La utilización de colgajos libres obtenidos del abdomen se ha planteado como una alternativa adecuada. Objetivos: Se reportan una serie de casos con el uso de colgajos libres de vasos perforantes de la arteria epigástrica inferior profunda (DIEP) y vasos epigástricos inferiores superficiales (SIEA) en la reconstrucción de mama. Pacientes y método: Describimos 21 casos de reconstrucción mamaria utilizando el colgajo DIEP y 3 casos de colgajo SIEA en la Clínica Las Condes (CLC) entre el 2007 y 2015. Resultados: De un total de 24 pacientes con un rango de edad de entre 48 y 60 años, 18 de ellas fueron sometidas a reconstrucción unilateral, 3 a reconstrucción bilateral con DIEP, y 3 fueron sometidas a reconstrucción unilateral con colgajo SIEA. El tiempo operatorio promedio fue de 6,5 h y el tiempo de hospitalización, de 6 días. En una reconstrucción bilateral hubo pérdida del colgajo izquierdo por trombosis venosa, la cual se sometió a una segunda reconstrucción con colgajo libre. Discusión: En nuestra experiencia en la CLC, la reconstrucción mamaria con colgajos libres perforantes de la zona inferior del abdomen tiene una baja morbilidad. La literatura avala esta técnica como una alternativa válida en pacientes seleccionadas.

Introduction: Breast cancer is the most frequent neoplasia affecting women worldwide. After mastectomy for breast cancer, autologous tissue breast reconstruction offers better long-term results. The use of abdominal free flaps has shown to be an adequate option. Aim: We report a series of cases of deep inferior epigastric perforator flap (DIEP flap) and superficial inferior epigastric artery flap reconstructions. Patients and methods: We describe 21 patients with breast reconstruction using DIEP flap and 3 cases of SIEA flap in CLC between 2007 and 2012. Results: 24 patients underwent the procedure with an age range of 48 to 60 years; 18 patients underwent a unilateral reconstruction and 3 patients bilateral reconstructions with DIEP flaps; 3 patients underwent unilateral breast reconstruction with SIEA flap. Mean operative time was 6,5 h and mean hospitalization was 6 days. In one bilateral reconstruction the left flap was lost, which required a second free flap reconstruction. Discussion: In our experience, microvascular breast reconstruction using perforator flaps has a low morbidity. As described in the literature, this is a valid alternative in selected patients.

Uso de doble colgajo diep para reconstrucción de extremidad inferior / Double diep flap for lower extremities reconstruction

Introduction: A soft tissue defect considering the extent, location, depth and involved structures can be a complex task, leading to search for unusual reconstructive alternatives. Case report: Puerperal woman, 21 years, previously healthy, admitted for septic shock and skin necrosis of both extremities secondary to purpura fulminans. Escharectomy was performed and the final defect was 27 percent of total body surface, corresponding to necrotic areas of both superior and lower extremities. Is remarkable the presence of musculocutaneous perforating vessels thrombosis and segmental muscular necrosis in legs and interosseous muscles necrosis in hands. In upper extremity coverage was performed with dermoepidermal grafts. To cover peroneal malleolus and feet dorsum, whereas there were no regional or local alternatives, we realize a double DIEP flap. Flap elevation of bilateral DIEP flap was performed simultaneously for two surgical teams. The patient had no complications and was discharged with complete soft tissue coverage.

Introducción: Un defecto de cobertura extenso de extremidades inferiores (EEII), considerando ubicación, profundidad y estructuras involucradas es de una alta complejidad y puede llevar a buscar alternativas reconstructivas poco habituales. Caso Clínico: Paciente de 21 años, puérpera, ingresa por shock séptico y necrosis cutánea extensa de extremidades secundario a un purpura fulminans. Se realiza escarectomía y el defecto resultante es de 27 por ciento de superficie corporal, correspondiendo a zonas necróticas en ambas extremidades, superiores e inferiores. Destaca la presencia de trombosis de vasos perforantes musculocutáneos, necrosis muscular segmentaria en piernas y de musculatura interósea en manos. En extremidades superiores se realizó cobertura con injertos dermoepidérmicos. Para la exposición de ambos maléolos peroneos y dorso de pies, considerando que no existen alternativas locales ni regionales, se decide realizar un colgajo DIEP bilateral; se eleva en un tiempo, con dos equipos quirúrgicos simultáneos. La anastomosis microquirúrgica se realizó a los vasos tibiales de cada extremidad. La evolución postoperatoria fue favorable. La paciente es dada de alta en buenas condiciones generales, extubada, con cobertura cutánea completa.

Continuously observing cutaneous vitality of DIEP flap in rat model / 中华显微外科杂志

Objective To carried out rat as deep inferior epigastic perforator (DIEP) flap necrosis model,to reveal the continuous blood fluid change in process of flap necrosis.Methods Seven SpragueDawley rats of male were used.The designed DIEP flap model was pedicled on the right-sided cranial perforator.Near-infrared fluorescent angiography was performed using SPY imaging system pre-and-aft operation and all angiography videos were compared and analyzed.Results Using SPY imaging system could observe the process of the blood fluid scattered from perforator through choke anastomoses to next vascular territories in living body.The study could clearly observe sequence change of blood fluid pr-and-aft operation,which could give the important information in revealing the reason of necrosis in DIEP flap.Cross-midline traffic vascular sparse and eventually could no longer wear through the contralateral abdominal wall vessel area and open in the region of lateral thoracic vascular occlusion of blood vessels to reach the flap to the far left side,and showed no blood flow in the dark zone.Conclusion The reasons of necrosis of contralateral distal zone of the flap model,are the choke anastomoses across the midline to the contralateral side appeared small,less intensity and the blood supply to contralatral distal zone should through twice choke anastomoses.

Atypical Patterns of Deep Inferior Epigastric Artery: Clinical Implication of Preoperative CT Angiography

PURPOSE: The free deep inferior epigastric artery perforator (DIEP) flap is a popular option for autologous breast reconstruction. However, the anatomy of the deep inferior epigastric artery(DIEA) may vary from one individual to another. Unexpected vascular anomaly can confuse the surgeon and affects on the safety of the free DIEP flap. MATERIALS AND METHODS: Thirty five consecutive patients who underwent free DIEP/TRAM flap for immediate breast reconstruction between Mar. 2010 and Oct. 2010 were enrolled in this study. Computed tomography angiography (CT angiography) of abdomen was evaluated part of our standard preoperative assessment: atypical patterns of DIEA/DIEP were evaluated by preoperative CT angiography and compared with intraoperative finding. RESULTS: Atypical patterns of DIEA/DIEP which may affect preoperative planning were noted as the following: Circummusclar/subfascial DIEA (n=1), DIEA running underneath rectus muscle (n=8), septocutaneous perforator (n=3), peritoneo-cutaneous perforator (n=1), a large branch going into peritoneum (n=1), and very early division and muscle penetration of DIEA (n=1). CONCLUSION: Atypical DIEA/DIEP that might change the operation plan is not rare, so the individualized planning based on the preoperative CT angiography is recommended. Preoperative CT angiography could help to select reliable and easy-to-dissect perforator in free DIEP/TRAM breast reconstruction.

Reconstrucción mamaria con colgajos de perforantes de la arteria epigástrica inferior: utilidad de la angio tomografía computada multidetector en la planificación prequirúrgica / Breast reconstruction with perforator flaps of the inferior epigastric artery: utility multidetector computed tomography angiography in preoperative planning

Objetivo: Valorar la utilidad de la Angio Tomografía Computada Multidetector (Angio TCMD) como principal herramienta diagnóstica en la evaluación prequirúrgica de pacientes mastectomizadas que serán sometidas a una reconstrucción mamaria con colgajo autólogo pediculado tipo DIEP (Deep inferior epigastric artery). Población: Entre abril de 2008 y marzo de 2011 se estudiaron 11 pacientes, a las cuales se les realizó posteriormente una recontrucción mamaria con colgajo autólogo. Método: localizar la arteria perforante responsable de la irrigación del colgajo que sería utilizado para la reconstrucción mamaria. Se correlacionaron los hallazgos de la Angio TCMD con el Doppler de Ultrasonidos intraoperatorio y posteriormente con los hallazgos de la disección quirúrgica. Conclusión: La Angio TCM con recontrucción tridimensional fue sumamente útil en la elección y ubicación de la arteria perforante de mayor calibre y menor trayecto intramuscular, convirtiendose en una excelente herramienta prequirúrgica para la planificación del colgajo de perforantes. Esto le permitió una reducción significativa del tiempo quirúrgico disminuyendo la morbimortalidad intra y postoperatoria.

Various Abdominal Flaps for Breast Reconstruction: Pedicled TRAM, Free TRAM, Muscle-sparing TRAM, DIEP, and SIEA Flaps / 영남의대학술지

The incidence of breast cancer, the second most prevalent cancer type in South Korea, has increased by 6.8% annually in the lastsix years.The higher number of breast cancer patients has led to an increase in the cases of skin-sparing mastectomies, thereby increasing the need for reconstructive procedures. The reconstruction options include alloplastic techniques such as implant or autologous reconstruction with numerous flaps. The abdominal area is the preferred donorsite for the harvest of autologous tissue for breast reconstruction. Breast reconstruction using abdonimal tissue is commonly accomplished using the transverse rectus abdominis myocutaneous (TRAM) flap. The establishment of microvascular surgery led to the development of the free TRAM flap because of its increased vascularity and decreased rectus abdominis sacrifice. The muscle-sparing TRAM, DIEP, and SIEA flap techniques were later developed in an effort to decrease the abdominal-donor-site morbidity by decreasing the injury to the rectus abdominis muscle and fascia. This article summarizes the various abdominal flaps for breast reconstruction.

Breast Reconstruction with Lower Abdominal Tissue Free Transfer

Lower abdominal tissue is regarded as an ideal donor site for the breast reconstruction because it provides large skin territory and huge amount of soft tissues enough to the breast size. However it is not easy for the surgeon to reconstruct the really natural breast, and needs the learning curve with long time experience.

Progress of Techniques in Breast Reconstruction Using Autologous Abdominal Tissue / 영남의대학술지

Breast reconstruction provides dramatic improvement for patients with severe deformity. The reconstruction not only restores aesthetically acceptable breast for patients with mastectomy deformity but also recovers psychological trauma of 'losing feminity' after the cancer mastectomy. There are many options for breast reconstruction from simple prosthetic insertion to a flap operation using autologous abdominal tissue. The choice of operation method depends on the physical condition of the patient, smoking habits, and economic status. Among the many options, the method that uses the lower abdominal tissue is known as the TRAM (transverse rectus abdonimis myocutaneous) flap. Since the introduction of the TRAM flap in 1982 by Hartrampf, the art of breast reconstruction using lower abdominal tissue has been progressively refined to pedicle flap, muscle-sparinga TRAM flap, and recently there have been exciting and revolutionary changes associated with the adoption of the concept of perforator flap. This refined method of breast reconstruction utilizes lower abdominal tissue nourished by the deep inferior epigastric perforator (DIEP). With the DIEP free flap, almost all of the rectus muscle and anterior rectus sheath are preserved and the donor morbidity is minimized. Different from previous flap methods using lower abdominal tissue, DIEP free flap method preserves function of the rectus muscle completely. Understanding the entire progression of breast reconstruction methods using lower abdominal tissue is necessary for plastic surgeons; the understanding of each step of the exciting progression and the review of the past history of the TRAM flap may provide insight for future development.

Breast reconstruction by deep inferior epigastric perforator flap / 中华医学美学美容杂志

Objective To present a method for breast reconstruction with the deep inferior epigastric perforator (DIEP) flap and to summarize the operative experiences. Methods DIEP flaps were elevated without carrying rectus abdominis muscle. The breast was shaped after the deep inferior epigastric artery and vein were anastomosed to the internal mammary artery and vein. Results Since 2000, we have used the DIEP flaps in 15 cases of breast reconstruction. There were 100 % survival in 10 flaps, distal skin necrosis in 2 flaps, and a full loss in 2 flaps. With the follow-up of 6～12 months, the reconstructed breasts were well-shaped and there were no complications such as abdominal heria, bulge and weakness in donor sites. Conclusion DIEP flap is the development and refinement of TRAM flap and possesses of advantages such as rich blood supply, abundant tissue volume, minimal donor site morbidity and easy shaping. It is a new but reliable and safe technique for autologous breast reconstruction.

Anatomic features of intercostal nerves with relation to TRAM and DIEP breast reconstruction / 中华医学美学美容杂志

Objective To supply anatomic foundation for TRAM and DIEP flaps breast reconstruction with both sensory innervation and rectus abdominis muscle function preserved. Methods Dissections of T8～T12 nerves in anterior abdominal wall were performed on 9 embalmed female cadavers (18 sides). By reconstructing DIEP flaps in 15 cases, the natures of the intercostal nerves and the relations with deep inferior epigastric perforators were investigated. Results Most intercostal nerves pierced the rectus abdominis muscle in the lateral one third. There were interconnections between muscular branches of segmental nerves. Sensory branches traveling with vascular perforators were divided into medial branch and lateral branch. The mean length of pure sensory nerve was (27.6?12.2)mm. Conclusion It is possible to preserve sensory innervation by coapting lower intercostal nerves to the 4th thoracic nerve in TRAM and DIEP breast reconstruction. Sparing lateral one third of rectus abdominis muscle does not cause denervated atrophy in the rectus abdominis muscle after TRAM breast reconstruction.