Needing a large DIEAP flap for unilateral breast reconstruction: double-pedicle flap and unipedicle flap with additional venous discharge.

BACKGROUND: In selected cases a four zone-deep inferior epigastric artery perfortor (DIEAP) flap is needed for unilateral breast reconstruction. It may happen in patients with a midline scar of the abdomen or with minimal abdominal tissue, as well as in case the recipient site needs a big amount of tissue for the breast reconstruction. The purpose of this paper is to describe two options: to raise an unipedicle DIEAP flap including large size medially located perforator/s with an additional venous outflow, or to raise a double-pedicle DIEAP flap. METHODS: Since 2000 34 cases of unilateral breast reconstruction with a four-zone unipedicle DIEAP flap (two cases) or a double-pedicle DIEAP flap (32 cases) have been performed. Preoperative examination of the superficial and deep epigastric vascular system with color doppler sonography (CDS) and/or multidetector-row CT (MDCT) were performed to assess the dominant abdominal perforator/s. If one or two large size, medially located perforators were identified and the superficial venous system showed vascular connections between right and left hemiabdomen, it was possible to use an unipedicle four-zone DIEAP flap with an additional anastomosis of the superficial vein. If this specific vascular situation did not exist, a double-pedicle DIEAP flap was raised. RESULTS: There were no major complications, and very satisfactory results have been obtained. CONCLUSIONS: This retrospective study showed that both options of raising a large DIEAP flap for unilateral breast reconstruction, namely unipedicled flap based on large medial perforator/s plus additional venous discharge or double-pedicle flap, are safe. Preoperative examination of the dominant perforator/s with CDS and/or MDCT is mandatory in both cases.

Neovaginal reconstruction with the modified McIndoe technique: a review of 32 cases.

The authors reviewed 32 patients who underwent vaginal reconstruction using a modified McIndoe procedure during the past 15 years. This technique consists of the application of split-thickness skin grafts into a new cavity created between the rectum, bladder, and urethra. The grafts are placed previously on a mold of Optosil, which is a silicon-based condensation curing impression material used by dentists. The mold is kept for 3 months 24 hours each day. During the next 3 to 4 weeks it is applied 12 hours per day. Later, according to sexual activity, the mold can be removed completely. In case of no sexual activity it should be used 1 hour per week. Parameters assessed during the follow-up were mold management, grade of pseudomucinous metaplasia of the skin grafts, sensation of the neovagina, neovagina size changes, sexual satisfaction, and complications. Postoperative complications included partial take of skin grafts (N = 3), postoperative anxiety (N = 2), donor site cheloids (N = 1), and neovaginal stricture in 3 patients who used the mold for 1 month only without having any further sexual activity. Patients who managed the mold correctly or who had constant sexual activity obtained satisfactory dimensions of the neovagina in terms of length, diameter, and elasticity.