History Vincenz CzernyOncology, gynecology In 1895 he published the first account of a breast implant which he had carried out, by transferring a benign lipoma to "avoid asymmetry" after removing a tumor in a patients breast. 1879 performed the first total hysterectomy via the vagina
Why Breast Reconstructionwith abdominal tissue became popular?
Free DIEP > Free TRAM (Plast. Reconstr. Surg. 124: 752, 2009 Donor Site Morbidity DIEP patients has one-half the risk of abdominal bulge or hernia
Plast. Reconstr. Surg. 125: 772, 2010.) Each perforators was injected with contrast and the flaps were subjected to dynamic computed tomography scanning.Three-dimensional and four-dimensional computed tomographicangiography was utilized to reappraise the zones of vascularity.
Three-dimensional computed tomography angiogramPerfusion tends to stay in one hemi- The injected medial perforator was connectedabdomen. to the contralateral medial row perforator through indirect linking vessels via the subdermal plexus.
(Above) Lateral row perforator is injected. At least two sets of linking vessels needto be crossed to reach the midline(Below) Medial row perforator is injected. Fewer linking vessels are required to crossthe midline,thus contrast flows into zone II more easily, hence a more centralizedperfusion..
Illustration of a medial perforator DIEPflap, in which perfusion is morecentralized and has a bigger vascularterritory.These are useful for large breastreconstructions.Medial perforator DIEP flaps followHartrampf zones of perfusion. Zone II ison the contralateral hemi-abdomen.
Illustration of a lateral perforator DIEPflap, in which perfusion is morelateralized. These are useful for small tomoderate sized and bilateral breastreconstructions. Lateral perforator DIEP flaps follow Holm’s zones of perfusion. Zone II is on the ipsilateral hemi-abdomen.
Intraoperatively angiography following administration of 5 mg of indocyanine green in aperipheral intravenous catheter
ResultsComparison of perfusion: DIEP – MS TRAM –Pedicle TRAM not a significant difference between zones 2 and 3
(Plast. Reconstr. Surg. 128: 581e, 2011 There were 228 patients, with 120 medial (52.6percent) and 108 lateral (47.4 percent) branch flaps
Regardless of whether the dominant perforator is laterally or medially located, as long as it is included, a safe flap can beharvested and the perfusion related complications can be reduced to an absolute minimum.
3 Key Points1. Vessel diameter is important and Poiseuille’s law is determining. The flow through a tube is related to the fourth power of the radius of a vessel The flow in a vessel with a 2-mm diameter is approximately 16 times higher than in a vessel with a diameter of 1 mm
3 Key Points1. Vessel diameter is important and Poiseuille’s law is determining2. The central positioning of the perforator in the flap is essential3. The number and three-dimensional structure of the branches of the perforator, once it has pierced the deep fascia, will determine which areas of the flap will be vascularized
Computed tomographic scan of a perforator originating from the lateralbranch of the right deep inferior epigastric artery with a perforator thatbends off laterally and vascularizes only the most lateral and ipsilateralpart of the flap. The Perfusion of the conventionally designed flap will be extremely poor
Multi-detector CT angiography scan Info on perforator location, diameter (>0.3mm, >1mm included), intramuscular course, high spatial resolution allows multi-planar evaluation (3D view), less habitus dependent, predictive value on outcome (DIEP Vs MS free TRAM), can evaluate SIEA system Reduced operative time. Sensitivity 99.6% (Rozen et al.) Op time reduction average 100min (Casey et al, Smit et al, Masia et al) Expensive Radiation dose Contrast
Dissection of the lower abdomen skin Longitudinal incision to the anterior rectusand fat flap from the underlying sheath approximately 0.5 cm medial to theaponeurosis terminates when the lateral borderlateral border of anterior rectus sheathis reached
The semilunar incision line (dotted line) through theanterior rectus sheath that is lateral to the lateral rowof perforators
Identification of the lateral row of Transverse incision of the aponeurosisperforators of the deep inferior toward the perforatorepigastric artery (DIEA) in thesubaponeurotic layer.
Subaponeurotic blunt dissection of the The anterior rectus sheath has beendeep inferior epigastric artery perforators incised and raised exposing theis performed perforators piercing the posterior surface of the fascia
Advantages Save time: easy plane between fascia and muscle Safe dissection: blunt dissection Easy to define the largest perforator
Raising a flap with a skin paddle with less vertical height reduces the donorsite morbidity, especially in terms of reducing the risk of wound dehiscence,as tight abdominal closure is avoided (e.g in thin patients)The technique we describe offers the patient a naturally shaped breast thatcan be achieved without the need to raise a very large abdominal flap
Projection the mastectomy scar onto the contralateral breast and measurement ofthe dimensions of skin in the area of the breast inferior to this imaginary scar line
An inverted V-shaped flap is designed on the inferior mastectomy skin flap and atemplate of this also madeThis triangular template is then superimposed on the inferior aspect of the templateand excised because this part of the skin in the new breast will be created by themastectomy skin flap
When the breast template is opened and flattened the shape of the requiredflap is almost rectangular.The V shaped scar is on the underside of the breast occupying a naturalaesthetic subunit of the breast, thus making it inconspicuous.A fatty layer is also included from the upper abdominoplasty flap topartially fill the upper poles of the new breast.
Two-esthetic unit breast reconstruction. (A) Single-esthetic unit breast reconstruction.The mastectomy scar is excised. (B) The DIEAP (A) The skin in between the mastectomy scarflap is inset in the center of the breast mound and the new inframammary fold is de-creating a breast consisting of two-esthetic epithelialized. (B) The DIEAP flap extends tounits: the native skin and the flap’s skin paddle. the inframammary fold, reconstructing the entire breast
A skin envelope is created with tissue expander and then the expander isreplaced with a de-epithelialised flap, leaves a breast with the originalmastectomy scar and no skin island
Can we perform abdominalflaps after liposuction or with the existence ofvertical laparotomy scars?
8 cases (7 autologous breast reconstruction, 1thigh reconstruction.All patients had a vertical abdominal midlinescar as a result of a previous surgicalintervention.
•In the past was contraindication•Preoperative colour duplex or CT angiography is mandatory•The dissection of the perforator flaps was sometimes moredifficult due to increased fibrosis and scar formation of thesubcutaneous tissue.
(Ann Plast Surg 2011;67: 251–254)11 DIEPS contained a midline scar In flaps with a midline scar approximately 70% of the entire flap volume appeared to be well vascularized (pink area) after harvest