EASO2011 BRS 4 McCulley


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  • As previously described, the majority of the perforators were located in a circular area 3cm diameter centred on the mid-point of a line between the anterior-superior iliac spine and the upper lateral border of the patella.
  • EASO2011 BRS 4 McCulley

    1. 1. Microvascular abdominal flap reconstruction Stephen McCulley Consultant Plastic and Oncoplastic Breast Surgeon Nottingham
    2. 2. Advantages of abdominal autologous reconstruction <ul><li>“ Alive” and natural </li></ul><ul><li>Changes and ages with patient </li></ul><ul><li>Lower abdominal fat and skin ideal replacement </li></ul><ul><li>Large quantity tissue available </li></ul><ul><li>Potential for an improved abdomen (only flap with this potential) </li></ul><ul><li>Potential for an improved abdomen (only flap with this potential) </li></ul>
    3. 3. Bilateral DIEP Surgery ‘Optimal breast’ ‘Optimal abdomen’
    4. 4. Nottingham Breast Unit <ul><li> IMPLANT LD DIEP/ Free TRAM </li></ul><ul><li>Reconstruction </li></ul><ul><li>Primary 33% 42% 25% </li></ul><ul><li>Secondary 3% 27% 67% </li></ul>
    5. 6. Superior Epigastric Artery Pedicled TRAM Deep Inferior Epigastric Artery Free TRAM DIEA – DIEP flap Superficial Inferior Epigastric artery – SIEA flap
    6. 7. DIEP flap
    7. 8. Free TRAM or MS-TRAM
    8. 9. SIEA flap <ul><li>Advantages </li></ul><ul><ul><li>No impact on abdominal wall </li></ul></ul><ul><ul><li>Quicker to raise </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Smaller vessels making microsurgery more difficult </li></ul></ul><ul><ul><li>Vascular territory smaller so smaller flaps available </li></ul></ul>
    9. 10. SIEA flap pedicle
    10. 11. DIEP flap <ul><li>Advantages </li></ul><ul><ul><li>Minimal impact on abdominal wall </li></ul></ul><ul><ul><li>Quicker recovery </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Question over venous return and hence fat necrosis rate </li></ul></ul><ul><ul><li>Takes longer to do </li></ul></ul>
    11. 12. If the perforators are difficult do a TRAM or MS-TRAM <ul><li>DIEP trends are better strength, quicker recovery, less pain, lower abdominal complications </li></ul><ul><li>However the more perforators needed the higher complications so probably an inferior flap to TRAM </li></ul>
    12. 13. My use abdominal flaps <ul><li>DIEP flaps 70% </li></ul><ul><li>TRAM flaps 20% </li></ul><ul><li>MS-TRAM 5% </li></ul><ul><li>SIEA 5% </li></ul>
    13. 14. Pedicled TRAM vs DIEP/Free TRAM “Both are good operations”
    14. 15. Pedicled TRAM vs DIEP/Free TRAM <ul><li>Donor site complications </li></ul><ul><li>Flap Complications – Fat necrosis, Flap loss </li></ul><ul><li>Inset and shaping of flap </li></ul><ul><li>Vascularity of flaps </li></ul><ul><ul><li>– size of flaps possible </li></ul></ul><ul><ul><li>Need for contralateral surgery </li></ul></ul>
    15. 16. Impact on abdominal wall <ul><li>Pedicled TRAM Takes whole rectus WORST </li></ul><ul><li>Free TRAM Takes block of full width muscle </li></ul><ul><li>MS-TRAM Takes window of muscle </li></ul><ul><li>DIEP Takes no muscle but muscle split (nerve preserving) </li></ul><ul><li>SIEA Does not enter abdominal wall BEST </li></ul>
    16. 17. Compared Free TRAM to DIEP <ul><li>Blondeel, P. N., Vamderstraeten, G. G., Monstrey, S. J., et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br. J. Plast. Surg . 50: 322, 1997. </li></ul><ul><li>Futter, C. M., Webster, M. H. C., Hagen, S., and Mitchell, S. L. A retrospective comparison of abdominal muscle strength following breast reconstruction with a free TRAM or DIEP flap. Br. J. Plast. Surg . 53: 578, 2000. </li></ul>
    17. 19. Vascularity I II III IV Zones I always (and zone III usually) safe in pedicled TRAM Zones I and III always (and zone II usually) safe in free TRAM/DIEP M ain cause flap loss/partial loss is VENOUS problems
    18. 20. Complications in Pedicled TRAM Breast Reconstruction Spear, Scott L. M.D.et al PRS 2005.
    19. 21. Abdominal Wall following Free TRAM or DIEP Flap Reconstruction: A Meta-Analysis and Critical Review Li-Xing Man, M.D., M.Sc. Jesse C. Selber, M.D., M.P.H. Joseph M. Serletti, M.D. Pittsburgh and Philadelphia, PRS 2009 <ul><li>Pooled Complication Rates for DIEP and TRAM Flap Patients </li></ul><ul><li> No. Studies Total n. of Flaps ComplicationRate (%) 95% CI p Value </li></ul><ul><li>DIEP flap patients </li></ul><ul><li>Fat necrosis 15 1872 10.1 6.3–14.0 0.01 </li></ul><ul><li>Partial flap loss 13 1680 2.5 1.1–3.9 0.02 </li></ul><ul><li>Total flap loss 16 1920 2.0 1.0–2.9 0.03 </li></ul><ul><li>Abdominal bulge, laxity , </li></ul><ul><li>or weakness 11 930 3.1 1.6–4.6 0.20 </li></ul><ul><li>Abdominal hernia 10 1529 0.8 0.2–1.3 0.56 </li></ul><ul><li>TRAM flap patients </li></ul><ul><li>Fat necrosis 14 2650 4.9 3.2–6.7 0.01 </li></ul><ul><li>Partial flap loss 17 2605 1.8 0.9–2.6 0.10 </li></ul><ul><li>Total flap loss 22 3165 1.0 0.5–1.4 0.22 </li></ul><ul><li>Abdominal bulge, laxity, </li></ul><ul><li>or weakness 14 2015 5.9 3.6–8.1 0.01 </li></ul><ul><li>Abdominal hernia 18 2609 3.9 2.4–5.3 0.03 </li></ul>
    20. 22. Freedom of size of flap and/or need C/L reduction
    21. 23. <ul><li>Inset of flap </li></ul><ul><li>Crease maintained </li></ul><ul><li>No muscle pedicle in way </li></ul><ul><li>Freedom to turn flap in any direction </li></ul>
    22. 24. Performing a DIEP flap
    23. 25. Surgical profile <ul><li>3-6.5 hour procedure </li></ul><ul><li>3-6 day hospital stay </li></ul><ul><li>2 months off work </li></ul><ul><li>1-2% chance failure </li></ul><ul><li>~5% chance fat necrosis </li></ul><ul><li>10-20% chance other complications (abdominal wound etc) </li></ul>
    24. 26. <ul><li>Which perforator? </li></ul><ul><li>Medial row </li></ul><ul><li>Lateral row </li></ul><ul><li>Size </li></ul><ul><li>Course through muscle </li></ul><ul><li>Venous return </li></ul>
    25. 27. Pre-operative assessment and imaging <ul><li>Dynamic contrast-enhanced 3D-MRA </li></ul><ul><li>Patient supine </li></ul><ul><li>1.5T MRI scanner with phased array body coil </li></ul><ul><li>IV contrast gadolinium DPTA </li></ul><ul><li>Breath-holding during angiogram </li></ul><ul><li>15 minute procedure </li></ul>
    26. 33. Single muscle split for most If very medial then dual incision Preserve Intra-mural nerves Lignocaine for muscle
    27. 35. <ul><li>Usually internal mammary vessels used </li></ul><ul><li>No need to remove cartilage completely in 80% </li></ul><ul><li>Alternative is thoracodorsal axis </li></ul>
    28. 36. Position flap properly - Set up for success De-epithelialise superior edge
    29. 37. Usually do microsurgery standing
    30. 48. Abdomen closed with patient bent
    31. 49. Insert flap from mastectomy scar to crease Excise or de-epitheliailise depending on skin needs
    32. 52. Primary reconstruction
    33. 53. Good SSM essential to a good primary reconstruction
    34. 55. Lateral Lolli-pop incision
    35. 56. Vertical
    36. 57. Peri-aereolar mastectomy
    37. 58. Transverse
    38. 59. Skin paddle when needed for scars, tumour, previous radiotherapy or vascularity
    39. 60. Recurrent Invasive tumour Left breast – 70 years age
    40. 61. Large skin paddles
    41. 62. Wise pattern
    42. 64. DIEP and radiotherapy Debate about impact over time. MD Anderson , PRS study findings of significant impact being challenged
    43. 66. Bilateral DIEP Surgery
    44. 71. Secondary reconstruction
    45. 72. Delayed left reconstruction using DIEP flap. Patient in her 60 ’s
    46. 73. Pre-op Delayed DIEP flap Minor liposuction & Nipple reconstruction Stages of Secondary DIEP flap reconstruction
    47. 76. Implant salvage
    48. 77. Complications <ul><li>General patient </li></ul><ul><ul><li>DVT, PE, Chest infection </li></ul></ul><ul><li>Flap related </li></ul><ul><ul><li>Total failure </li></ul></ul><ul><ul><li>Partial failure </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><li>Donor related </li></ul><ul><ul><li>Wound breakdown </li></ul></ul><ul><ul><li>Hernia or bulge </li></ul></ul><ul><ul><li>Pain </li></ul></ul>