LETTER TO THE EDITOR

MICROSURGERY 00:1–2 (2014)

R ASSISTED DEEP INFERIOR EPIGASTRIC ARTERY OMNI-TRACTV PERFORATOR FLAP HARVESTING

Dear Editor,

Deep inferior epigastric vessels perforator (DIEP) flap elevation can be challenging depending on the patients anatomical condition.1–4 As any perforator flap, safe perforator dissection is a must. For the microsurgeon working in solo or with less trained surgeons, optimal tissue retraction during dissection is very helpful, enhancing the visualization of the vessels and therefore reducing the likelihood of perforator or motor nerve damage. Stay hooks and elastic bands help during intramuscular dissection, but do not do a great job during suprafascial dissection or during submuscular dissection of the pedicle. We 5 R separator during DIEP report the use of Omni-tractV flap elevation. So far we have used this separator in four consecutive cases. The first case was a double free DIEP flap for lower extremity reconstruction. A 3.0 silk suture was used to hang the lateral corner of each DIEP flap to the separator during suprafascial dissection. The tension of the suture was adjusted while the dissection progressed from lateral to medial. This allowed for comfortable simultaneous elevation of both flaps. Once the perforators were located, the flaps remained hung during intramuscular dissection. After intramuscular dissection was completed, a rubber band fixed to the separator elevated a bundle of rectus abdominis muscle to assist during submuscular dissection of the pedicle. In the following cases (one single free DIEP flap for breast reconstruction and two bilateral breast reconstruction **Correspondence to: Alejandro E. Ramirez; Section of Plastic and Reconstructive Surgery, Pontifical Catholic University of Chile, Santiago, Chile. E-mail: [email protected] Received 3 August 2014; Accepted 25 August 2014 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22323 Ó 2014 Wiley Periodicals, Inc.

cases), the separator was used in the same way as formerly described (Fig. 1). In future cases, we are considering incorporating the use of the malleable swivel blade to push down the fascia transversalis during the submuscular dissection of the pedicle, making flap elevation even easier and more autonomous. In these cases, all perforators were successfully dissected with the assistance of the separator and all flaps were transferred without problems. We think the use of the separator eliminates the risk of inappropriate pulling of the flap or the muscle by the assistant surgeon during flap elevation, decreasing the risk of perforator damage. Using the retractor, each flap is easily hung from a stable bar, allowing comfortable dissection. In case of unexpected movement of the patient (i.e., premature lightening of the anesthesia), the traction from the sutures can be quickly released just by cutting the suture. The inset of the separator in the surgical field takes less than 5 min and it can be readily removed for abdominal closure. In a double DIEP flap elevation as in some of these cases, it helps for a twoteam approach for simultaneous bilateral DIEP flap harvesting, diminishing surgical time. This approach is highly appealing, especially considering the recent safety questionings in bilateral DIEP flap breast reconstruction.6 In summary, to our knowledge, this is the first report of R for DIEP flap elevation, its use the use of Omni-tractV seems to be safe and it is especially helpful for double DIEP flap elevation. ALEJANDRO E. RAMIREZ,* Plastic and Reconstructive Surgery Resident, Pontifical Catholic University of Chile, Santiago, Chile Former Microsurgery Fellow Chang Gung Memorial Hospital, Taipei, Taiwan

2

R separator. The flaps can be seen hanging from Figure 1. (A) Two-team approach for bilateral DIEP flap harvesting using the Omni-tractV the separator. (B) Suprafascial dissection. After lateral perforator row is identified, the flap is hung from the separator to continue with the intramuscular dissection. (C) After intramuscular dissection, a bundle of muscle can also be suspended from the separator using a rubber band to assist with the submuscular dissection of the pedicle. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

CLAUDIO GUERRA, ALVARO CUADRA, SUSANA SEARLE, AND BRUNO L. DAGNINO Chief of the Section of Plastic and Reconstructive Surgery, Pontifical Catholic University of Chile, Santiago, Chile

REFERENCES 1. Molina AR, Jones ME, Hazari A, Francis I, Nduka C. Correlating the deep inferior epigastric artery branching pattern with type of abdominal free flap performed in a series of 145 breast reconstruction patients. Ann R Coll Surg Engl 2012;94:493–495.

Microsurgery DOI 10.1002/micr

2. Itoh Y, Arai K. The deep inferior epigastric artery free skin flap: anatomic study and clinical application. Plast Reconstr Surg 1993;91: 853–863; discussion 864. 3. Ting J, Rozen WM, Morsi A. Improving the subfascial dissection of perforators during deep inferior epigastric artery perforator flap harvest: The hydrodissection technique. Plast Reconstr Surg. 2010; 126:87e–89e. 4. Gravvanis A, Niranjan NS. Retrograde dissection of the vascular pedicle of deep inferior epigastric artery perforator (DIEAP) flap. Ann Plast Surg. 2008;60:395–397. 5. Ahmad F, Nassab R, Bell D. The Omni-Tract surgical retractor in abdominoplasty–taking the weight from the surgeon. J Plast Reconstr Aesthet Surg. 2011;64:1114–1115. 6. Wormald JC, Wade RG, Figus A. The increased risk of adverse outcomes in bilateral deep inferior epigastric artery perforator flap breast reconstruction compared to unilateral reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2014;67: 143–156.

Omni-tract(®) assisted deep inferior epigastric artery perforator flap harvesting.

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