Plastic and Reconstructive Surgery • August 2014 advantage of today’s most advanced hand prostheses, which are capable of many simultaneous degrees of freedom. Should partial muscle grafts prove reliable in regenerative peripheral nerve interface construction, they will support more intuitive voluntary prosthetic motion, bypass the limitations of skin-surface electromyography, and possibly serve as a platform for implantable, wireless prosthetic control. Signal detection will not be restricted by the remaining muscle volume within the residual limb or on the chest wall, which is a perceived disadvantage of targeted muscle reinnervation.5 In summary, partial muscle regenerative peripheral nerve interfaces are promising devices that may one day augment amputee functional recovery and quality of life. DOI: 10.1097/PRS.0000000000000317
Shoshana L. Woo, M.D. Melanie G. Urbanchek, Ph.D. Paul S. Cederna, M.D. Nicholas B. Langhals, Ph.D. Section of Plastic Surgery University of Michigan Ann Arbor, Mich. Correspondence to Dr. Langhals Department of Surgery Section of Plastic Surgery Department of Biomedical Engineering University of Michigan 1150 West Medical Center Drive, A570 MSRB II Ann Arbor, Mich. 48109-5664 [email protected]
ACKNOWLEDGMENTS This work was supported by the Defense Advanced Research Projects Agency (N66001-11-C-4190), the Plastic Surgery Foundation, and the Frederick A. Coller Surgical Society. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. REFERENCES 1. Thompson N. Autogenous free grafts of skeletal muscle: A preliminary experimental and clinical study. Plast Reconstr Surg. 1971;48:11–27. 2. Hakelius L. Transplantation of free autogenous muscle in the treatment of facial paralysis: A clinical study. Scand J Plast Reconstr Surg. 1974;8:220–230. 3. Boyce RG, Nuss DW, Kluka EA. The use of autogenous fat, fascia, and nonvascularized muscle grafts in the head and neck. Otolaryngol Clin North Am. 1994;27:39–68. 4. Kung T. A., Langhals N. B., Martin D. C., Johnson P. J., Cederna, P. S., Urbanchek, M. G. Regenerative peripheral nerve interface viability and signal transduction with an implanted electrode. Plast Reconstr Surg. 2014;1331380–1394. 5. Dumanian GA, Ko JH, O’Shaughnessy KD, Kim PS, Wilson CJ, Kuiken TA. Targeted reinnervation for transhumeral amputees: Current surgical technique and update on results. Plast Reconstr Surg. 2009;124:863–869.
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Conjoint Deep Inferior Epigastric Artery Perforator Flaps: Case Series of Two Patients with Subfascial Communication of the Deep Inferior Epigastric Vein Sir: he deep inferior epigastric artery perforator flap has become the flap of choice for the majority of microsurgical breast reconstructions.1 Venous outflow problems are the most common causes of partial and complete flap failures.2 The venous drainage of the lower anterior abdominal wall occurs through superficial and deep inferior epigastric systems. Although it has been shown that there is midline crossover of the superficial inferior epigastric venous system,3 there are no reports of venous communication across the midline involving the deep inferior epigastric venous system. Rozen et al.3 demonstrated in their anatomical and clinical studies that superficial inferior epigastric veins communicate across the midline through large (>1 mm) medial branches in 86 percent of cases. In most instances, this medial branch crosses the midline below the arcuate line. Additional sites of crossover of medial branches of superficial inferior epigastric veins include just below and just above the umbilicus. We report two patients in which there was a subfascial communication of the deep inferior epigastric veins across the midline approximately at the level of the arcuate line (Figs. 1 and 2). In both patients, medial branches of the left and right deep inferior epigastric veins coursed toward the linea alba and then sent a transverse communicating branch across the midline to the opposite deep inferior epigastric vein before giving rise to an ipsilateral cutaneous perforator. One patient underwent bilateral deep inferior epigastric perforator flap breast reconstruction using one of the two communicating perforators for each flap, and one patient underwent unilateral reconstruction using deep inferior epigastric perforator flap reconstruction using the ipsilateral communicating perforator and a second more proximal ipsilateral perforator. On preoperative magnetic resonance angiography, communication of the deep inferior epigastric vein beneath the anterior rectus fascia was appreciated in both patients and guided surgical planning and perforator selection. The communicating vein was of large caliber (2 to 3 mm) in both cases. In the bilateral reconstruction, the adequacy of venous drainage of each hemiabdominal flap was tested by placing a venous clamp across the communicating branch. After ensuring that there was no venous congestion in either flap, the flaps were separated and each one used to reconstruct a single breast. In the unilateral reconstruction, the bridging vein was divided and the flap taken on two perforators from one side. The medial row perforators frequently perfuse overlying skin and subcutaneous fat well across the midline and therefore are often used in unilateral reconstruction when inclusion of zone 3 of the flap is desired (as demonstrated in our unilateral reconstruction case). These medial perforators may also represent
T
Volume 134, Number 2 • Viewpoints Alex Kagen, M.D. Department of Radiology Beth Israel Medical Center New York, N.Y.
William Samson, M.D. Department of Surgery Division of Plastic Surgery St. Luke’s–Roosevelt Medical Center New York, N.Y.
Mark Sultan, M.D. Joseph Dayan, M.D. Mark L. Smith, M.D. Department of Surgery Division of Plastic Surgery Beth Israel Medical Center New York, N.Y.
Fig. 1. Subfascial communication of the deep inferior epigastric vein across the midline.
the dominant perforators arising from the deep inferior epigastric system and, consequently, despite their eccentric location in the flap, may be the perforators of choice in a bilateral reconstruction (as was demonstrated in our bilateral case). Familiarity with this anatomical variation may prevent inadvertent injury to the perforator if such a variant is encountered during flap harvest. Also, the routine use of preoperative magnetic resonance angiography may reduce the risk of perforator injury caused by anatomical variations and facilitate judicious perforator selection in this setting. There are no reported cases showing this anomaly in the literature. Its embryologic basis is not clear. DOI: 10.1097/PRS.0000000000000316
Gangadasu S. Reddy, M.D., M.S. Department of Plastic Surgery University of Texas Southwestern Dallas, Texas
Correspondence to Dr. Reddy Outpatient Surgical Center, WA4.238 University of Texas Southwestern Medical Center 1800 Inwood Road Dallas, Texas 75390 [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this article. references 1. American Society of Plastic Surgeons. 2012 Plastic Surgery Statistics Report. Available at: http://www.plasticsurgery. org/Documents/news-resources/statistics/2012-Plastic-Surgery-Statistics/full-plastic-surgery-statistics-report.pdf. 2. Bui D, Cordeiro P, Hu QY, Disa J, Pusic A, Mehrara B. Free flap reexploration: Indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg. 2007;119:2092–2100. 3. Rozen W, Pan WR, Le Roux C, Taylor I, Ashton M. The venous anatomy of the anterior abdominal wall: An anatomical and clinical study. Plast Reconstr Surg. 2009;124:848–853.
Novel Technique for Underlay Mesh Placement for Ventral Hernia Repair Sir:
A
Fig. 2. Midline communication of the deep inferior epigastric vein with two isolated vascular pedicles connected to each hemiabdomen.
bdominal wall hernia is still the most significant problem associated with laparotomy, complicating 11 to 50 percent of all such procedures.1 Even after primary repair, recurrence rates reportedly range between 3 and 60 percent, with the average being approximately 25 percent.2 The concepts of a tensionfree reconstitution of the midline and the use of surgical mesh reinforcement for a more durable repair have become widely accepted.3 For the repair of incisional hernias, surgical mesh can be placed in an onlay, interposition (or inlay), retrorectus (or sublay), or underlay position. De Vries Reilingh et al. compared the onlay, inlay, and underlay techniques
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Shoshana L. Woo, M.D. Melanie G. Urbanchek, Ph.D. Paul S. Cederna, M.D. Nicholas B. Langhals, Ph.D. Section of Plastic Surgery University of Michigan Ann Arbor, Mich. Correspondence to Dr. Langhals Department of Surgery Section of Plastic Surgery Department of Biomedical Engineering University of Michigan 1150 West Medical Center Drive, A570 MSRB II Ann Arbor, Mich. 48109-5664 [email protected]
ACKNOWLEDGMENTS This work was supported by the Defense Advanced Research Projects Agency (N66001-11-C-4190), the Plastic Surgery Foundation, and the Frederick A. Coller Surgical Society. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. REFERENCES 1. Thompson N. Autogenous free grafts of skeletal muscle: A preliminary experimental and clinical study. Plast Reconstr Surg. 1971;48:11–27. 2. Hakelius L. Transplantation of free autogenous muscle in the treatment of facial paralysis: A clinical study. Scand J Plast Reconstr Surg. 1974;8:220–230. 3. Boyce RG, Nuss DW, Kluka EA. The use of autogenous fat, fascia, and nonvascularized muscle grafts in the head and neck. Otolaryngol Clin North Am. 1994;27:39–68. 4. Kung T. A., Langhals N. B., Martin D. C., Johnson P. J., Cederna, P. S., Urbanchek, M. G. Regenerative peripheral nerve interface viability and signal transduction with an implanted electrode. Plast Reconstr Surg. 2014;1331380–1394. 5. Dumanian GA, Ko JH, O’Shaughnessy KD, Kim PS, Wilson CJ, Kuiken TA. Targeted reinnervation for transhumeral amputees: Current surgical technique and update on results. Plast Reconstr Surg. 2009;124:863–869.
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Conjoint Deep Inferior Epigastric Artery Perforator Flaps: Case Series of Two Patients with Subfascial Communication of the Deep Inferior Epigastric Vein Sir: he deep inferior epigastric artery perforator flap has become the flap of choice for the majority of microsurgical breast reconstructions.1 Venous outflow problems are the most common causes of partial and complete flap failures.2 The venous drainage of the lower anterior abdominal wall occurs through superficial and deep inferior epigastric systems. Although it has been shown that there is midline crossover of the superficial inferior epigastric venous system,3 there are no reports of venous communication across the midline involving the deep inferior epigastric venous system. Rozen et al.3 demonstrated in their anatomical and clinical studies that superficial inferior epigastric veins communicate across the midline through large (>1 mm) medial branches in 86 percent of cases. In most instances, this medial branch crosses the midline below the arcuate line. Additional sites of crossover of medial branches of superficial inferior epigastric veins include just below and just above the umbilicus. We report two patients in which there was a subfascial communication of the deep inferior epigastric veins across the midline approximately at the level of the arcuate line (Figs. 1 and 2). In both patients, medial branches of the left and right deep inferior epigastric veins coursed toward the linea alba and then sent a transverse communicating branch across the midline to the opposite deep inferior epigastric vein before giving rise to an ipsilateral cutaneous perforator. One patient underwent bilateral deep inferior epigastric perforator flap breast reconstruction using one of the two communicating perforators for each flap, and one patient underwent unilateral reconstruction using deep inferior epigastric perforator flap reconstruction using the ipsilateral communicating perforator and a second more proximal ipsilateral perforator. On preoperative magnetic resonance angiography, communication of the deep inferior epigastric vein beneath the anterior rectus fascia was appreciated in both patients and guided surgical planning and perforator selection. The communicating vein was of large caliber (2 to 3 mm) in both cases. In the bilateral reconstruction, the adequacy of venous drainage of each hemiabdominal flap was tested by placing a venous clamp across the communicating branch. After ensuring that there was no venous congestion in either flap, the flaps were separated and each one used to reconstruct a single breast. In the unilateral reconstruction, the bridging vein was divided and the flap taken on two perforators from one side. The medial row perforators frequently perfuse overlying skin and subcutaneous fat well across the midline and therefore are often used in unilateral reconstruction when inclusion of zone 3 of the flap is desired (as demonstrated in our unilateral reconstruction case). These medial perforators may also represent
T
Volume 134, Number 2 • Viewpoints Alex Kagen, M.D. Department of Radiology Beth Israel Medical Center New York, N.Y.
William Samson, M.D. Department of Surgery Division of Plastic Surgery St. Luke’s–Roosevelt Medical Center New York, N.Y.
Mark Sultan, M.D. Joseph Dayan, M.D. Mark L. Smith, M.D. Department of Surgery Division of Plastic Surgery Beth Israel Medical Center New York, N.Y.
Fig. 1. Subfascial communication of the deep inferior epigastric vein across the midline.
the dominant perforators arising from the deep inferior epigastric system and, consequently, despite their eccentric location in the flap, may be the perforators of choice in a bilateral reconstruction (as was demonstrated in our bilateral case). Familiarity with this anatomical variation may prevent inadvertent injury to the perforator if such a variant is encountered during flap harvest. Also, the routine use of preoperative magnetic resonance angiography may reduce the risk of perforator injury caused by anatomical variations and facilitate judicious perforator selection in this setting. There are no reported cases showing this anomaly in the literature. Its embryologic basis is not clear. DOI: 10.1097/PRS.0000000000000316
Gangadasu S. Reddy, M.D., M.S. Department of Plastic Surgery University of Texas Southwestern Dallas, Texas
Correspondence to Dr. Reddy Outpatient Surgical Center, WA4.238 University of Texas Southwestern Medical Center 1800 Inwood Road Dallas, Texas 75390 [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this article. references 1. American Society of Plastic Surgeons. 2012 Plastic Surgery Statistics Report. Available at: http://www.plasticsurgery. org/Documents/news-resources/statistics/2012-Plastic-Surgery-Statistics/full-plastic-surgery-statistics-report.pdf. 2. Bui D, Cordeiro P, Hu QY, Disa J, Pusic A, Mehrara B. Free flap reexploration: Indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg. 2007;119:2092–2100. 3. Rozen W, Pan WR, Le Roux C, Taylor I, Ashton M. The venous anatomy of the anterior abdominal wall: An anatomical and clinical study. Plast Reconstr Surg. 2009;124:848–853.
Novel Technique for Underlay Mesh Placement for Ventral Hernia Repair Sir:
A
Fig. 2. Midline communication of the deep inferior epigastric vein with two isolated vascular pedicles connected to each hemiabdomen.
bdominal wall hernia is still the most significant problem associated with laparotomy, complicating 11 to 50 percent of all such procedures.1 Even after primary repair, recurrence rates reportedly range between 3 and 60 percent, with the average being approximately 25 percent.2 The concepts of a tensionfree reconstitution of the midline and the use of surgical mesh reinforcement for a more durable repair have become widely accepted.3 For the repair of incisional hernias, surgical mesh can be placed in an onlay, interposition (or inlay), retrorectus (or sublay), or underlay position. De Vries Reilingh et al. compared the onlay, inlay, and underlay techniques
347e
