The delay procedure in deep inferior epigastric artery perforator flap breast reconstruction.

BACKGROUND: The delay procedure in DIEP flap breast reconstruction, in which the reduced-caliber choke vessels play a major role, can provide more well-perfused tissue than a standard DIEP flap. The aim of this study was to review our experience with this technique, to evaluate the indications, and to analyze the surgical outcomes. METHODS: A retrospective study was conducted of all consecutive DIEP delay procedures performed between March 2019 and June 2021. Patient demographics, operative details, and complications were registered. Patients had preoperative imaging by MRA to select dominant perforators. The surgical technique involves a two-stage operation. During the first operation the flaps were pedicled on a dominant perforator and a lateral skin bridge extending towards the lateral flank and lumbar fat, and in a second stage the flap is harvested and transferred. RESULTS: A total of 82 extended DIEP delay procedures were performed to reconstruct 154 breasts. The majority were bilateral breast reconstructions (87.8%). The delay procedure was used for 38 primary reconstructions (46.3%) and 32 tertiary reconstructions (39.0%). The primary indication was the need for additional volume (79.3%), followed by extensive abdominal scarring and liposuction. After the first operation seroma was the most frequently observed complication (7.3%). After the second operation three total flap losses (1.9%) were observed. CONCLUSIONS: The delay procedure in DIEP flap breast reconstruction results in the harvest of a good amount of abdominal tissue by adding a preliminary procedure. This technique can convert patients previously considered unsuitable into suitable candidates for abdominal-based breast reconstruction.

The Stacked Hemiabdominal Extended Perforator Flap for Autologous Breast Reconstruction.

BACKGROUND: Options for bilateral autologous breast reconstruction in thin women are limited. The aim of this study was to introduce a novel approach to increase abdominal flap volume with the stacked hemiabdominal extended perforator (SHAEP) flap. The authors describe the surgical technique and analyze their results. METHODS: A retrospective study was conducted of all SHAEP flap breast reconstructions performed since February of 2014. Patient demographics, operative details, complications, and flap reexplorations were recorded. The bipedicled hemiabdominal flap was designed as a combination of the deep inferior epigastric artery perforator (DIEP) and a second, more lateral pedicle: the deep or superficial circumflex iliac perforator vessels, the superficial inferior epigastric artery, or a lumbar artery or intercostal perforator. RESULTS: A total of 90 SHAEP flap breast reconstructions were performed in 49 consecutive patients. Median operative time was 500 minutes (range, 405 to 797 minutes). Median hemiabdominal flap weight that was used for reconstruction was 598 g (range, 160 to 1389 g). No total flap losses were recorded. Recipient-site complications included partial flap loss (2.2 percent), hematoma (3.3 percent), fat necrosis (2.2 percent), and wound problems (4.4 percent). Minor donor-site complications occurred in five patients (10.2 percent). Most flaps were harvested on a combination of the DIEP and deep circumflex iliac artery vessels. CONCLUSIONS: This study demonstrated that the SHAEP flap is an excellent option for bilateral autologous breast reconstruction in women who require significant breast volume but have insufficient abdominal tissue for a bilateral DIEP flap. The bipedicled SHAEP flap allows for enhanced flap perfusion, increased volume, and abdominal contour improvement using a single abdominal donor site. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Breast Tissue Expanders with Magnetic Ports: Clinical Experience at 1.5 T.

BACKGROUND: The purpose of this study was to evaluate breast tissue expanders with magnetic ports for safety in patients undergoing abdominal/pelvic magnetic resonance angiography before autologous breast reconstruction. METHODS: Magnetic resonance angiography of the abdomen and pelvis at 1.5 T was performed in 71 patients in prone position with tissue expanders with magnetic ports labeled "MR Unsafe" from July of 2012 to May of 2014. Patients were monitored during magnetic resonance angiography for tissue expander-related symptoms, and the chest wall tissue adjacent to the tissue expander was examined for injury at the time of tissue expander removal for breast reconstruction. Retrospective review of these patients' clinical records was performed. T2-weighted fast spin echo, steady-state free precession and gadolinium-enhanced spoiled gradient echo sequences were assessed for image artifacts. RESULTS: No patient had tissue expander or magnetic port migration during the magnetic resonance examination and none reported pain during scanning. On tissue expander removal (71 patients, 112 implants), the surgeons reported no evidence of tissue damage, and there were no operative complications at those sites of breast reconstruction. CONCLUSION: Magnetic resonance angiography of the abdomen and pelvis in patients with certain breast tissue expanders containing magnetic ports can be performed safely at 1.5 T for pre-autologous flap breast reconstruction perforator vessel mapping. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Magnetic resonance angiography in perforator flap breast reconstruction.

Magnetic resonance angiography (MRA) is an extremely useful preoperative imaging test for evaluation of the vasculature of donor tissue to be used in autologous breast reconstruction. MRA has sufficient spacial resolution to reliably visualize 1 mm perforating vessels and to accurately locate vessels in reference to a patient's anatomic landmarks without exposing patients to ionizing radiation or iodinated contrast. The use of a blood pool contrast agent and the lack of radiation exposure allow multiple studies of multiple anatomic regions in one examination. The following article is a detailed description of our MRA protocol developed with our radiologists with examples that illustrate the utility of MRA in perforator flap breast reconstruction.

Autologous breast reconstruction: preoperative magnetic resonance angiography for perforator flap vessel mapping.

BACKGROUND: Selection of a vascular pedicle for autologous breast reconstruction is time consuming and depends on visual evaluation during the surgery. Preoperative imaging of donor site for mapping the perforator artery anatomy greatly improves the efficiency of perforator selection and significantly reduces the operative time. In this article, we present our experience with magnetic resonance angiography (MRA) for perforator vessel mapping including MRA technique and interpretation. METHODS: We have performed over 400 MRA examinations from August 2008 to August 2013 at our institution for preoperative imaging of donor site for mapping the perforator vessel anatomy. Using our optimized imaging protocol with blood pool magnetic resonance imaging contrast agents, multiple donor sites can be imaged in a single MRA examination. Following imaging using the postprocessing and reporting tool, we estimated incidence of commonly used perforators for autologous breast reconstruction. RESULTS: In our practice, anterior abdominal wall tissue is the most commonly used donor site for perforator flap breast reconstruction and deep inferior epigastric artery perforators are the most commonly used vascular pedicle. A thigh flap, based on the profunda femoral artery perforator has become the second most used flap at our institution. In addition, MRA imaging also showed evidence of metastatic disease in 4% of our patient subset. CONCLUSION: Our MRA technique allows the surgeons to confidently assess multiple donor sites for the best perforator and flap design. In conclusion, a well-performed MRA with specific postprocessing provides an accurate method for mapping perforator vessel, at the same time avoiding ionizing radiation.

Microlymphatic surgery for the treatment of iatrogenic lymphedema.

Lymphedema is a chronic and progressive condition that occurs after cancer treatment. Autologous lymph node transplant, or microsurgical vascularized lymph node transfer (ALNT), is a surgical treatment option that brings vascularized vascular endothelial growth factor-C-producing tissue into the operated field to promote lymphangiogenesis and bridge the distal obstructed lymphatic system with the proximal lymphatic system. Operative techniques for upper- and lower-extremity ALNT are described with 3 donor lymph node flaps (inguinal, thoracic, cervical). Surgical technique is described for the combination of ALNT with abdominal flaps and nonabdominal flaps. Imaging showing restoration of lymphatic drainage after ALNT is shown.

Deep femoral artery perforator flap: a new perforator flap for breast reconstruction.

We present the deep femoral artery perforator (DFAP) flap, a new perforator flap for breast reconstruction, with a detailed description of operative technique and four clinical examples. The DFAP flap allows harvest of tissue from the lower buttock and lateral thigh with similar territory to an in-the-crease inferior gluteal artery perforator (IGAP) flap but based on a different perforator. When present, the DFAP is the largest vessel supplying this territory and is often septocutaneous, facilitating dissection when compared with the IGAP flap. We used preoperative imaging with magnetic resonance angiography to assist in accurate flap planning which also permitted precise determination of perforator origin. In patients with either a contraindication to abdominal wall-based perforator flaps or weight distribution below the waist, the DFAP flap provides an alternative to the IGAP flap with an excellent pedicle and a favorable location on the lateral thigh.

Contrast-enhanced magnetic resonance angiography.

With technological advances in magnetic resonance angiography (MRA), spatial resolution of 1-mm perforating vessels can reliably be visualized and accurately located in reference to patients' anatomic landmarks without exposing patients to ionizing radiation or iodinated contrast, resulting in optimal perforator selection, improved flap design, and increased surgical efficiency. As their experience with MRA in breast reconstruction has increased, the authors have made changes to their MRA protocol that allow imaging of the vasculature in multiple donor sites (buttock, abdomen, and upper thigh) in one study. This article provides details of this experience with multiple donor site contrast-enhanced MRA.

Anatomic imaging of gluteal perforator flaps without ionizing radiation: seeing is believing with magnetic resonance angiography.

Preoperative imaging is essential for abdominal perforator flap breast reconstruction because it allows for preoperative perforator selection, resulting in improved operative efficiency and flap design. The benefits of visualizing the vasculature preoperatively also extend to gluteal artery perforator flaps. Initially, our practice used computed tomography angiography (CTA) to image the gluteal vessels. However, with advances in magnetic resonance imaging angiography (MRA), perforating vessels of 1-mm diameter can reliably be visualized without exposing patients to ionizing radiation or iodinated intravenous contrast. In our original MRA protocol to image abdominal flaps, we found the accuracy of MRA compared favorably with CTA. With our increased experience with MRA, we decided to use MRA to image gluteal flaps. Technical changes were made to the MRA protocol to improve image quality and extend the field of view. Using our new MRA protocol, we can image the vasculature of the buttock, abdomen, and upper thigh in one study. We have found that the spatial resolution of MRA is sufficient to accurately map gluteal perforating vessels, as well as provide information on vessel caliber and course. This article details our experience with preoperative imaging for gluteal perforator flap breast reconstruction.