Original Article
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Stacked Abdominal Flap for Unilateral Breast Reconstruction Alexandra Murray, MBChB, MD, FRCS(Plast)1,2,3 Jason Wasiak, MPH4 Warren Matthew Rozen, MBBS, BMedSc, MD, PhD1,2,3 Scott Ferris, MBBS, FRACS(Plast)1,2,3 Damien Grinsell, MBBS, FRACS(Plast)1,2,3
Australia 2 Plastic Surgery Department, St Vincent’s Private, East Melbourne, Victoria, Australia 3 Plastic Surgery Department, Western Hospital, Gordon Street, Footscray, Victoria, Australia 4 Victorian Adult Burns Service and School of Public Health and Preventive Medicine, Monash University, The Alfred Hospital, Commercial Road, Melbourne, Victoria, Australia
Address for correspondence Alexandra M. Murray, MBChB, MD, FRCS (Plast), Unit 6, 14, Victoria Ave, Claremont, WA 6010, Australia (e-mail: [email protected]).
J Reconstr Microsurg 2015;31:179–186.
Abstract
Keywords
► ► ► ► ►
breast stacked DIEP reconstruction classification
Background The abdominal flap can be used in a stacked, double-pedicle configuration for unilateral breast reconstruction. Aided by preoperative mapping, this is a good option when a single-pedicle flap is deemed unsuitable. We present reliable outcomes using the stacked flap and a logical classification system for its use. Methods From 2008 to 2013, 18 patients underwent a stacked abdominal flap for unilateral breast reconstruction. Flaps utilized deep inferior epigastric (D) and superficial inferior epigastric (S) pedicle combinations. Preoperative computed tomography angiogram was performed on all patients. Medical records were reviewed for complications and clinical data, and a thorough clinical evaluation was performed on all patients at follow-up. Flaps were all double-pedicled, with the secondary pedicle anastomosed onto the primary pedicle (type 1 to 3) or onto a second recipient vessel (type 4). Flaps were then classified into groups, based on pedicle dominance and intraflap anastomosis. Results Twelve reconstructions were immediate and six delayed. Mean operative time was 7 hours, the most frequently used configuration being a type 1 DD, that is, secondary pedicle (D) anastomosed end-to-end onto the superior continuation of the primary pedicle (D). Average hospital stay was 6 days. There were no flap losses and minimal complications, and mean follow-up was 20 months. Conclusion Use of this flap poses a greater challenge to the microsurgical breast reconstruction. We demonstrate its reliable use in women deemed unsuitable for a single-pedicle flap. Our structured system clarifies vascular options, and preoperative perforator mapping tools are essential to the success of this technique.
The deep inferior epigastric artery perforator (DIEP) flap is now universally felt to be the most ideal breast reconstruction, with minimal donor site morbidity and aesthetic excellence.1–4
The abdominal flap’s reliability has been increased by preoperative perforator mapping.5 Computed tomography angiography (CTA) has recently been shown to have 99.6% positive predictive value for mapping perforators.6 Moreover,
received March 3, 2014 accepted after revision August 6, 2014 published online September 26, 2014
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1390165. ISSN 0743-684X.
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1 Plastic Surgery Department, St Vincent’s Hospital, Fitzroy, Victoria,
Stacked Abdominal Flap for Unilateral Breast Reconstruction
Murray et al.
Materials and Methods
Fig. 1 Flap raise and inset schematic to demonstrate flap raise and the folded inset with preferential use of internal mammary artery and vein/s recipients.
CTA and cadaveric studies have more clearly defined branching patterns of the deep inferior epigastric artery and veins (DIEA/V) and the effects of abdominal wall scarring on vascularity.5,7,8 The flap we describe has been termed “stacked,” “doublepedicled,” or “bipedicled” and involves raising the entire abdominal pannus on two pedicles, creating a breast mound using a layered or folded configuration. Arnez et al described the successful use of a “bipedicled” free transverse rectus abdominis myocutaneous (TRAM) flap, anastomosed onto both the thoracodorsal and serratus collateral branches.9 However, donor morbidity associated with raising both recti was shown to be unacceptable.10,11 The “stacked” or “doublepedicle” idea continued to evolve, with various crossover anastomoses described, reporting successful vascularization of the entire abdominal pannus for unilateral breast reconstruction.12–19 Specific attention has since been given to maximize the flap in thinner patients20 and provide a classification for pedicle arrangements.21,22 However, no study has been fully inclusive of all vascular options for this flap. All advancements in microsurgical reconstruction require a logical approach. We, therefore, propose a comprehensive classification system for the use of this flap—more inclusive than previously described—and present its successful use in our clinical outcome series of 18 cases.
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This is a retrospective review of 18 patients who requested autologous unilateral breast reconstruction using an abdominal flap between 2008 and 2013. Out of all abdominal flaps, only patients with a relative contraindication to a single-pedicle flap were included. Therefore, in all cases, the flaps were required to extend beyond a single pedicle’s vascular territory to ensure adequate volume or skin replacement. Preoperative perforator mapping was performed on all patients using multidetector CTA. The same specialist (W.M.R.) reported all CTAs and all procedures were carried out as a two-team approach by the two senior authors (D.G. and S.F.). Clinical review of medical charts was done to include patient demographics and indications, surgical techniques used, operative times, and postoperative complications. Any evidence of fat necrosis or abdominal wall morbidity had been recorded at follow-up and further investigated if indicated. Once data was collated, flaps were subdivided based on pedicle dominance and anatomy and the intraflap anastomotic pattern used between the two pedicles. This allowed us to develop the classification system, which has been schematically illustrated for ease of understanding ( ►Figs. 1 and 2). The vascular options are summarized in ►Table 1. This study has received ethical approval from the local research and ethics committee and all patients who feature in this article have given fully informed consent, including for publication of images.
Classification System Definition of Pedicles and Recipient Vessels Primary pedicle: It provides the largest diameter and most centrally situated vascular supply to the flap, whether it is from the deep DIEA/V (D) or superficial inferior epigastric artery and veins (SIEA/V) (S) system. Secondary pedicle: Contralateral to the primary pedicle, this is the second largest diameter vascular supply to the flap, allowing the entire abdominal flap to be utilized, and can be from the deep DIEA/V (D) or superficial SIEA/V (S) system. Selection of both of these pedicles is based on preoperative CTA mapping and on-table assessment.
Double-Pedicle Options DIEA/V (primary pedicle); DIEA/V (secondary pedicle) ¼ DD DIEA/V (primary pedicle); SIEA/V (secondary pedicle) ¼ DS SIEA/V (primary pedicle); DIEA/V (secondary pedicle) ¼ SD SIEA/V (primary pedicle); SIEA/V (secondary pedicle) ¼ SS ►Fig. 1 demonstrates the approach to flap raise, folding, and inset. A type 4 SS is depicted in the figure.
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Fig. 2 Schematic illustration of the four types of anastomotic: type 1, type 2, type 3, and type 4.
Intraflap Anastomotic Configurations Type 1: Secondary pedicle anastomosed end to end onto superior continuity of primary pedicle; primary pedicle anastomosed onto primary recipient (►Fig. 2a). Type 2: Secondary pedicle anastomosed end to end onto side branch of primary pedicle; primary pedicle anastomosed onto primary recipient (►Fig. 2b). Table 1 Pattern of intraflap anastomosis and pedicles for each type Type
Pattern of intraflap anastomosis
Pedicle combinations
1
End to end
DD, DS
Secondary ! superior continuation of primary 2
End to end
DD, DS
Secondary ! side branch of primary 3
End to side None
Surgical Technique Flap Planning
DD, DS, SD, SS
Secondary ! primary (direct) 4
Type 3: Secondary pedicle anastomosed end to side onto primary pedicle; primary pedicle anastomosed onto primary recipient (►Fig. 2c). Type 4: Both primary and secondary pedicles anastomosed independently onto primary and secondary recipient vessels (►Fig. 2d). Primary recipients: The internal mammary artery and vein/s (IMA/V) antegrade or large intercostal perforator. The thoracodorsal pedicle is reserved for lifeboat scenarios. Secondary recipients: The IMA/V retrograde. This recipient is only used in type 4 anastomotic configurations, that is, when pedicles are independently anastomosed to two recipients (►Fig. 2d). The thoracodorsal pedicle is reserved for lifeboat scenarios.
DD, DS, SD, SS
Pedicles independent (two recipients) Note: For definitions of DD, DS, SD, and SS, see text.
Patients are only selected for the “stacked approach” if a single-pedicled flap cannot meet the defect requirements. CTA perforator mapping is performed on all, with pedicle choice preplanned where possible.
Operative Technique The flaps are raised completely sparing rectus abdominis musculature and fascia. Dissection of the flap usually begins Journal of Reconstructive Microsurgery
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Stacked Abdominal Flap for Unilateral Breast Reconstruction
Stacked Abdominal Flap for Unilateral Breast Reconstruction with the primary hemi-abdomen. The second team begins preparing the recipient pocket and vessels. The SIEA is deemed suitable if, on CTA, it is medial enough in the flap, that is, at or medial to the linear semilunaris and of good caliber (at least 1.5 mm). If it meets suitability for the primary pedicle, it is dissected out as far proximally as possible. The flap raise then continues, starting laterally and cranially. For a DIEP flap raise, the rectus fascia is opened at the level of the predetermined dominant perforator (or perforators). Either one or two perforators are included depending on their size (> 1.5 mm ¼ 1; < 1.5 mm ¼ 2). This is then dissected through the rectus as far as the main DIEA, clipping long and preserving any large side branches that may be required for the secondary pedicle—as in type 2. If the dominant perforator/s is from the lateral row, efforts are made to preserve a long medial branch, and vice versa if the dominant perforator/s is from the medial row. The superior continuity of the DIEA is also preserved, as it may be required for the secondary pedicle—as in type 1. Innervation to the rectus abdominis muscle is preserved throughout. The contralateral hemi-abdomen is then raised, starting with the SIEA/V dissection if deemed suitable. Otherwise this step is not pursued. The second side of the flap is raised in a similar fashion to the first, without the need for preservation of the branching points or superior extension. There may occasionally be the opportunity to raise this side based on a long medial perforator that can then be anastomosed onto the superior continuity (type 1 DD) or the dissected medial side branch (type 2 DD) of the primary pedicle. If length and/or caliber of the superior continuity or side branch are inadequate, an end-side anastomosis of the secondary pedicle onto the primary should be considered (type 3). In certain situations, two independent pedicles and recipients (type 4) may be favorable in terms of maximizing vascularity and also enabling good orientation and inset. The secondary pedicle length will range from 5 to 9 cm, depending on the recipient for the second side; that is, for medial branch (type 2), it can be shorter than superior continuation of DIEA (type 1).
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In certain situations, there may be little difference in caliber between each pedicle, in which case the primary pedicle can be considered to be that which is anastomosed onto the primary recipient (antegrade IMA/V). It is now possible to plan the configuration of pedicles, anastomoses, and flap inset to ensure maximum flap vascularity and optimal breast shape. Before the pedicles are ligated, steps are performed to ensure a smooth transition and minimal ischemia time, including de-epithelialization of the flap prior to pedicle ligation where required. The secondary pedicle is then divided for types 1–3. Microsurgical anastomoses are performed in situ on the abdomen either end to end (types 1 and 2) or end to side (type 3) for single artery and both veins. Performing this step in situ on the abdomen again minimizes ischemic time. This is done with a 10/0 nylon, and where possible a venous coupler is used for the veins, providing perfusion to the extended territory via the secondary pedicle before definitive primary pedicle division. Our preferred primary recipients are the internal mammary vessels, preserving the thoracodorsal pedicle for lifeboat scenarios. The IMA/V are prepared via removal of the third costal cartilage and clearing the intercostal space above and sometimes below. This provides additional recipient length, particularly crucial when the retrograde IMA/V are needed as secondary recipient (type 4). The venous coupler is used most of the time for internal mammary venous anastomoses and also for intraflap anastomoses where possible. In all cases, 100% of the abdominal pannus is used, with no zones discarded. The double flap is folded and inset into the pocket (►Fig. 1), with the de-epithelialized side facing the chest wall. The two lateral flap apices lie superiorly and are slightly offset, with a central stay suture (see ►Fig. 1). For types 1, 2, and 3 flaps, the primary pedicle is then anastomosed onto the primary recipient (IMA/V antegrade). For a type 4 flap, the primary pedicle is anastomosed onto the antegrade IMA/V first, followed by the secondary pedicle onto the retrograde IMA/V. A type 4 configuration is selected when using both SIEA flaps, or when there is no adequate distal DIEA or side branch on the primary side. In our experience of
Fig. 3 (a, b) “Stacked” for inadequacy of volume. Patient underwent a stacked flap for inadequacy of volume. This was done as an immediate reconstruction following a skin-sparing mastectomy (weight 700 g). The flap was raised as a type 2 DS. There were no complications and the only secondary procedure was a nipple reconstruction. Journal of Reconstructive Microsurgery
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two type 4 flaps, the retrograde flow through the IMV was sufficient to drain the flap. This anastomotic approach has been previously described and shown to be successful.23 Once the microanastomoses are complete, pedicle position is carefully checked, including position of the pedicle–pedicle anastomosis in types 1, 2, and 3. The breast mound is shaped and additional stay sutures used where necessary to give optimal symmetry and contour. Drains are carefully placed a distance away from the pedicle. A handheld Doppler signal is marked on the skin-paddle for postoperative monitoring. Standard postoperative free flap monitoring is performed on all patients by trained nursing staff, using clinical assessment and handheld Doppler. All patients received intra- and postoperative prophylactic subcutaneous heparin only, until fully mobile and discharged home.
Results The mean age was 49 years (range, 30–67 years). Eight patients had abdominal scarring (44%), with three (16%) of these having more than one scar. None of the patients were smokers and three patients had comorbidities that included asthma, hypertension, and a previous aortic valve replacement. A total of 16 patients required a stacked flap due to inadequate volume (►Fig. 3), while the remaining 2 patients had inadequate volume and skin (►Fig. 4), based on a
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single-pedicle flap. Mean body mass index was 25 (range, 22–28). Twelve patients presented for immediate reconstruction at the time of mastectomy, for ductal carcinoma (n ¼ 6), widespread ductal carcinoma-in-situ (DCIS) (n ¼ 4), and the remaining two for an aggressive radiotherapy-induced angiosarcoma of the chest wall (►Fig. 4) and recurrent Phylloides tumor. These two cases were performed at day 3 and day 5 post radical resection, ensuring histological clearance. Out of the immediate group, one patient received neoadjuvant radiotherapy, and one required unplanned post-operative radiotherapy, with no subsequent fat necrosis or adverse effects. Six patients presented for delayed reconstruction following treated ductal carcinoma (n ¼ 4) and widespread DCIS (n ¼ 2). Three of these already had a tissue expander-based reconstruction with preserved skin envelope, having completed adjuvant radiotherapy. The other delayed cases had not received radiotherapy and had a standard transverse mastectomy scar at time of presentation. In those undergoing immediate reconstruction, the median mastectomy weight was 600 g. Type 1 DD was the most commonly used configuration (n ¼ 8, 4 immediate and 4 delayed) in this series (►Fig. 5 for an intraoperative example). Type 2 DD or DS flap (n ¼ 6) were the next most frequently used, with the majority of these being carried out in the
Fig. 4 (a–d) “Stacked” for inadequacy of volume and skin. Patient underwent a stacked flap for inadequacy of volume and skin due to an aggressive radiotherapy-induced angiosarcoma. Flap reconstruction was performed at day 3 post resection. This flap was raised as a type 2 DD. There were no complications and the only secondary procedure was a nipple reconstruction. Journal of Reconstructive Microsurgery
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Stacked Abdominal Flap for Unilateral Breast Reconstruction
Stacked Abdominal Flap for Unilateral Breast Reconstruction
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Fig. 5 (a–c) Intraoperative demonstration of the most common anastomotic and pedicle configuration—type 1 DD. Primary pedicle: R-sided deep inferior epigastric artery and veins (DIEA/V) on one large medial perforator. Secondary pedicle: L-sided DIEA/V on one large medial perforator.
immediate group. Use of the superficial vessels (S) as the secondary pedicle was as common as use of the deep vessels in this group. Here, a long side branch preserved from the primary DIEA/V pedicle facilitated anastomosis of the SIEA/V secondary pedicle in the type 2 configuration. A type 3 flap was used in two cases of immediate reconstruction, both with DIEA/V as the primary pedicle. In both cases, neither the superior continuation nor side branch from the DIEA/V was suitable; hence, an end-to-side type 3 configuration was used. A type 4 flap was used in two cases, one immediate (DS) and one delayed (SS). The total abdominal pannus was used in all cases and all flaps were inset in the folded configuration described, including the patient with a midline scar who had a type 2 DS flap (►Fig. 6). The primary pedicle was then anastomosed onto the primary recipient vessels in a timely fashion, that is, antegrade IMA/V (n ¼ 17) and a large IMA/V intercostal perforator (n ¼ 1). The secondary pedicle was anastomosed onto the secondary recipient vessels, that is, retrograde IMA/V in the two cases of type 4 flap. The thoracodorsal pedicle was not used as a recipient in any of the cases described. The mean operative time was 7 hours (range, 5.5–8 hours) and the mean hospital stay was 6 days (range, 4–8 days). There were no intraoperative revisions of anastomoses, no returns to theatre, no partial or complete flap losses, and no major complications. One patient had a 1.5 cm area of late fat necrosis detected clinically, which did not require intervention and settled spontaneously. Three patients had liposuction (100–150 mL) for minimal flap reduction at 6 months and two had a revision to the central portion of the abdominal scar. All patients had excellent postoperative abdominal wall integrity. All patients went on to have nipple reconstruction and all reported a high degree of satisfaction with their reconstruction at follow-up, although this was not formally Journal of Reconstructive Microsurgery
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assessed. Follow-up ranged from 3 to 36 months, with a mean of 20 months.
Discussion For unilateral breast reconstruction, the double-pedicled stacked approach can be a reliable option when the deficit requires use of the entire pannus.21,22,24,25 The successful vascularization of all four perfusion zones,26 even with abdominal scarring, has been previously demonstrated.12–22 The stacked flap is more challenging, but can be aided by a safe and logical approach. The classification system ensures maximal flap vascularity. Out of the 18 stacked flaps presented, there were no partial or complete flap losses and only 1 case of spontaneously resolving fat necrosis. These outcomes compare favorably to other series,21,24 although not all previous series present fat necrosis rates.24 CTA is a reliable and essential tool when used to select the dominant pedicles6—a priority for this flap. Anastomotic configuration and flap inset are lesser priorities, and follow on from this. Hamdi et al21 and DellaCroce et al24 describe preferential use of the double-DIEP pedicle (DD) and mainly use type 2 and 3 configurations, based on our classification. Here, pedicle choice was based on achieving maximum pedicle length, rather than maximum pedicle diameter and, therefore, flap perfusion. However, both these studies demonstrate favorable outcomes. Abdominal scarring was seen in 44% in this series (n ¼ 8), compared with 31 and 27% in other series.21,24 Vascular architecture has been shown to be universally altered by scarring, excluding the use of certain pedicles.6,7 It is, therefore, important to consider this when planning pedicle arrangements. ►Fig. 6 demonstrates a CTA of a patient with midline scarring and its effect on the vascularity of abdominal flap.
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Fig. 6 (a–c) Computed tomography angiography showing the vascularity of the abdominal flap with a midline vertical scar. This patient went on to have a successful type 2 DS flap, with no postoperative fat necrosis or complications.
Use of the thoracodorsal artery (TDA) recipient should be preserved for lifeboat situations, corresponding to similar work.21,24 Use of the TDA can carry a higher risk of flap compromise. Often, to ensure vessel caliber is adequately matched, it is necessary to dissect the recipient deep into the axilla. Other authors have described this approach.19 IMA/V is the primary recipient in this series and ensured successful flap perfusion in all cases. Use of the retrograde IMA/V as a secondary recipient has been previously described23 and is preferred for a type 4 configuration. Of note, only prophylactic subcutaneous intra- and postoperative heparin was used, with no extended use of additional agents, for example, aspirin. No thrombotic complications were seen (early or late). This can possibly be explained by considering the delay phenomenon, whereby the distal flap becomes independent of its secondary anastomosis by day 5, once choke vessels have opened up between the two flaps. Folding as opposed to dividing of the double flap allowed good stability and shape (see ►Fig. 1). This is contrary to previous studies that have divided the flap19,24 based on concerns about developing a zone of hypoperfusion.24 We report no cases of fat necrosis within the folded zone, even with midline scars, and the entirety of the pannus was used in all cases. An aesthetically pleasing breast shape can be achieved using the inset technique described. This approach is flexible and can be tailored to the defect needs, demonstrated clearly by the two cases of reconstruction post radical chest wall resection.
Despite this approach being relatively novel and challenging, fat necrosis rates and complications are very low and excellent overall flap outcomes have been achieved. Larger prospective clinical studies need to verify the validity of this approach.
Conclusion The stacked approach is more technically demanding than a standard single-pedicle flap, but facilitated by preoperative mapping and a system such as this, excellent outcomes with minimal complications can be achieved, as we have shown. Our inclusive classification demonstrates the options available when using this flap. As women seeking unilateral breast reconstruction increasingly request a life-long autologous solution, so our skills must improve to provide the ideal solution.
Acknowledgments Thanks to Dr. Levent Efe, CMI, for schematic illustrations. All patients featuring in this article have given fully informed consent for use of images.
Ethical Approval Gained from the Local Quality Assurance Sub-committee of the Human Research and Ethics Committee (Reference: QA 031/13). Journal of Reconstructive Microsurgery
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Stacked Abdominal Flap for Unilateral Breast Reconstruction
Stacked Abdominal Flap for Unilateral Breast Reconstruction Funding None.
13 Semple JL. Retrograde microvascular augmentation (turbocharg-
Conflict of Interest None declared.
14
15
References 1 Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site
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morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 1997;50(5):322–330 Futter CM, Webster MH, Hagen S, Mitchell SL. A retrospective comparison of abdominal muscle strength following breast reconstruction with a free TRAM or DIEP flap. Br J Plast Surg 2000;53(7): 578–583 Nahabedian MY, Dooley W, Singh N, Manson PN. Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation. Plast Reconstr Surg 2002;109(1):91–101 Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal experience. Br J Plast Surg 1999;52(2):104–111 Katz RD, Manahan MA, Rad AN, Flores JI, Singh NK, Rosson GD. Classification schema for anatomic variations of the inferior epigastric vasculature evaluated by abdominal CT angiograms for breast reconstruction. Microsurgery 2010;30(8):593–602 Rozen WM, Ashton MW, Stella DL, Phillips TJ, Grinsell D, Taylor GI. The accuracy of computed tomographic angiography for mapping the perforators of the deep inferior epigastric artery: a blinded, prospective cohort study. Plast Reconstr Surg 2008;122(4): 1003–1009 Rozen WM, Garcia-Tutor E, Alonso-Burgos A, Corlett RJ, Taylor GI, Ashton MW. The effect of anterior abdominal wall scars on the vascular anatomy of the abdominal wall: a cadaveric and clinical study with clinical implications. Clin Anat 2009;22(7):815–822 Rozen WM, Ashton MW, Grinsell D. The branching pattern of the deep inferior epigastric artery revisited in-vivo: a new classification based on CT angiography. Clin Anat 2010;23(1):87–92 Arnez ZM, Scamp T. The bipedicled free TRAM flap. Br J Plast Surg 1992;45(3):214–218 Simon AM, Bouwense CL, McMillan S, Lamb S, Hammond DC. Comparison of unipedicled and bipedicled TRAM flap breast reconstructions: assessment of physical function and patient satisfaction. Plast Reconstr Surg 2004;113(1):136–140 Jensen JA. Is double pedicle TRAM flap reconstruction of a single breast within the standard of care? Plast Reconstr Surg 1997; 100(6):1592–1593 Pennington DG, Nettle WJ, Lam P. Microvascular augmentation of the blood supply of the contralateral side of the free transverse rectus abdominis musculocutaneous flap. Ann Plast Surg 1993; 31(2):123–126, discussion 126–127
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18
19
20
21
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23
24
25
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ing) of a single-pedicle TRAM flap through a deep inferior epigastric arterial and venous loop. Plast Reconstr Surg 1994;93(1): 109–117 Blondeel PN, Boeckx WD. Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery. Br J Plast Surg 1994; 47(7):495–501 Lam TC, Sellars GD. Free perforator crossover TRAM flap for breast reconstruction. Ann Plast Surg 2003;50(2):126–131 Tseng CY, Lang PO, Cipriani NA, Song DH. Pedicle preservation technique for arterial and venous turbocharging of free DIEP and muscle-sparing TRAM flaps. Plast Reconstr Surg 2007;120(4): 851–854 Agarwal JP, Gottlieb LJ. Double pedicle deep inferior epigastric perforator/muscle-sparing TRAM flaps for unilateral breast reconstruction. Ann Plast Surg 2007;58(4):359–363 Schoeller T, Wechselberger G, Roger J, Hussl H, Huemer GM. Management of infraumbilical vertical scars in DIEP-flaps by crossover anastomosis. J Plast Reconstr Aesthet Surg 2007;60(5): 524–528 Ali RS, Garrido A, Ramakrishnan V. Stacked free hemi-DIEP flaps: a method of autologous breast reconstruction in a patient with midline abdominal scarring. Br J Plast Surg 2002;55(4): 351–353 Kronowitz SJ, Robb GL, Youssef A, et al. Optimizing autologous breast reconstruction in thin patients. Plast Reconstr Surg 2003; 112(7):1768–1778 Hamdi M, Khuthaila DK, Van Landuyt K, Roche N, Monstrey S. Double-pedicle abdominal perforator free flaps for unilateral breast reconstruction: new horizons in microsurgical tissue transfer to the breast. J Plast Reconstr Aesthet Surg 2007;60(8): 904–912, discussion 913–914 Rabey NG, Erel E, Malata CM. Double-pedicled abdominal free flap using an entirely new microvascular combination of DIEP and SIEA vascular pedicles for unilateral breast reconstruction: a novel addition to the Hamdi classification. Plast Reconstr Surg 2012; 130(5):767e–769e Chan RK, Przylecki W, Guo L, Caterson SA. Case report. The use of both antegrade and retrograde internal mammary vessels in a folded, stacked deep inferior epigastric artery perforator flap. Eplasty 2010;10:e32 DellaCroce FJ, Sullivan SK, Trahan C. Stacked deep inferior epigastric perforator flap breast reconstruction: a review of 110 flaps in 55 cases over 3 years. Plast Reconstr Surg 2011;127(3): 1093–1099 Beahm EK, Walton RL. The efficacy of bilateral lower abdominal free flaps for unilateral breast reconstruction. Plast Reconstr Surg 2007;120(1):41–54 Holm C, Mayr M, Höfter E, Ninkovic M. Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg 2006;117(1): 37–43
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Stacked Abdominal Flap for Unilateral Breast Reconstruction Alexandra Murray, MBChB, MD, FRCS(Plast)1,2,3 Jason Wasiak, MPH4 Warren Matthew Rozen, MBBS, BMedSc, MD, PhD1,2,3 Scott Ferris, MBBS, FRACS(Plast)1,2,3 Damien Grinsell, MBBS, FRACS(Plast)1,2,3
Australia 2 Plastic Surgery Department, St Vincent’s Private, East Melbourne, Victoria, Australia 3 Plastic Surgery Department, Western Hospital, Gordon Street, Footscray, Victoria, Australia 4 Victorian Adult Burns Service and School of Public Health and Preventive Medicine, Monash University, The Alfred Hospital, Commercial Road, Melbourne, Victoria, Australia
Address for correspondence Alexandra M. Murray, MBChB, MD, FRCS (Plast), Unit 6, 14, Victoria Ave, Claremont, WA 6010, Australia (e-mail: [email protected]).
J Reconstr Microsurg 2015;31:179–186.
Abstract
Keywords
► ► ► ► ►
breast stacked DIEP reconstruction classification
Background The abdominal flap can be used in a stacked, double-pedicle configuration for unilateral breast reconstruction. Aided by preoperative mapping, this is a good option when a single-pedicle flap is deemed unsuitable. We present reliable outcomes using the stacked flap and a logical classification system for its use. Methods From 2008 to 2013, 18 patients underwent a stacked abdominal flap for unilateral breast reconstruction. Flaps utilized deep inferior epigastric (D) and superficial inferior epigastric (S) pedicle combinations. Preoperative computed tomography angiogram was performed on all patients. Medical records were reviewed for complications and clinical data, and a thorough clinical evaluation was performed on all patients at follow-up. Flaps were all double-pedicled, with the secondary pedicle anastomosed onto the primary pedicle (type 1 to 3) or onto a second recipient vessel (type 4). Flaps were then classified into groups, based on pedicle dominance and intraflap anastomosis. Results Twelve reconstructions were immediate and six delayed. Mean operative time was 7 hours, the most frequently used configuration being a type 1 DD, that is, secondary pedicle (D) anastomosed end-to-end onto the superior continuation of the primary pedicle (D). Average hospital stay was 6 days. There were no flap losses and minimal complications, and mean follow-up was 20 months. Conclusion Use of this flap poses a greater challenge to the microsurgical breast reconstruction. We demonstrate its reliable use in women deemed unsuitable for a single-pedicle flap. Our structured system clarifies vascular options, and preoperative perforator mapping tools are essential to the success of this technique.
The deep inferior epigastric artery perforator (DIEP) flap is now universally felt to be the most ideal breast reconstruction, with minimal donor site morbidity and aesthetic excellence.1–4
The abdominal flap’s reliability has been increased by preoperative perforator mapping.5 Computed tomography angiography (CTA) has recently been shown to have 99.6% positive predictive value for mapping perforators.6 Moreover,
received March 3, 2014 accepted after revision August 6, 2014 published online September 26, 2014
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1390165. ISSN 0743-684X.
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1 Plastic Surgery Department, St Vincent’s Hospital, Fitzroy, Victoria,
Stacked Abdominal Flap for Unilateral Breast Reconstruction
Murray et al.
Materials and Methods
Fig. 1 Flap raise and inset schematic to demonstrate flap raise and the folded inset with preferential use of internal mammary artery and vein/s recipients.
CTA and cadaveric studies have more clearly defined branching patterns of the deep inferior epigastric artery and veins (DIEA/V) and the effects of abdominal wall scarring on vascularity.5,7,8 The flap we describe has been termed “stacked,” “doublepedicled,” or “bipedicled” and involves raising the entire abdominal pannus on two pedicles, creating a breast mound using a layered or folded configuration. Arnez et al described the successful use of a “bipedicled” free transverse rectus abdominis myocutaneous (TRAM) flap, anastomosed onto both the thoracodorsal and serratus collateral branches.9 However, donor morbidity associated with raising both recti was shown to be unacceptable.10,11 The “stacked” or “doublepedicle” idea continued to evolve, with various crossover anastomoses described, reporting successful vascularization of the entire abdominal pannus for unilateral breast reconstruction.12–19 Specific attention has since been given to maximize the flap in thinner patients20 and provide a classification for pedicle arrangements.21,22 However, no study has been fully inclusive of all vascular options for this flap. All advancements in microsurgical reconstruction require a logical approach. We, therefore, propose a comprehensive classification system for the use of this flap—more inclusive than previously described—and present its successful use in our clinical outcome series of 18 cases.
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This is a retrospective review of 18 patients who requested autologous unilateral breast reconstruction using an abdominal flap between 2008 and 2013. Out of all abdominal flaps, only patients with a relative contraindication to a single-pedicle flap were included. Therefore, in all cases, the flaps were required to extend beyond a single pedicle’s vascular territory to ensure adequate volume or skin replacement. Preoperative perforator mapping was performed on all patients using multidetector CTA. The same specialist (W.M.R.) reported all CTAs and all procedures were carried out as a two-team approach by the two senior authors (D.G. and S.F.). Clinical review of medical charts was done to include patient demographics and indications, surgical techniques used, operative times, and postoperative complications. Any evidence of fat necrosis or abdominal wall morbidity had been recorded at follow-up and further investigated if indicated. Once data was collated, flaps were subdivided based on pedicle dominance and anatomy and the intraflap anastomotic pattern used between the two pedicles. This allowed us to develop the classification system, which has been schematically illustrated for ease of understanding ( ►Figs. 1 and 2). The vascular options are summarized in ►Table 1. This study has received ethical approval from the local research and ethics committee and all patients who feature in this article have given fully informed consent, including for publication of images.
Classification System Definition of Pedicles and Recipient Vessels Primary pedicle: It provides the largest diameter and most centrally situated vascular supply to the flap, whether it is from the deep DIEA/V (D) or superficial inferior epigastric artery and veins (SIEA/V) (S) system. Secondary pedicle: Contralateral to the primary pedicle, this is the second largest diameter vascular supply to the flap, allowing the entire abdominal flap to be utilized, and can be from the deep DIEA/V (D) or superficial SIEA/V (S) system. Selection of both of these pedicles is based on preoperative CTA mapping and on-table assessment.
Double-Pedicle Options DIEA/V (primary pedicle); DIEA/V (secondary pedicle) ¼ DD DIEA/V (primary pedicle); SIEA/V (secondary pedicle) ¼ DS SIEA/V (primary pedicle); DIEA/V (secondary pedicle) ¼ SD SIEA/V (primary pedicle); SIEA/V (secondary pedicle) ¼ SS ►Fig. 1 demonstrates the approach to flap raise, folding, and inset. A type 4 SS is depicted in the figure.
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Fig. 2 Schematic illustration of the four types of anastomotic: type 1, type 2, type 3, and type 4.
Intraflap Anastomotic Configurations Type 1: Secondary pedicle anastomosed end to end onto superior continuity of primary pedicle; primary pedicle anastomosed onto primary recipient (►Fig. 2a). Type 2: Secondary pedicle anastomosed end to end onto side branch of primary pedicle; primary pedicle anastomosed onto primary recipient (►Fig. 2b). Table 1 Pattern of intraflap anastomosis and pedicles for each type Type
Pattern of intraflap anastomosis
Pedicle combinations
1
End to end
DD, DS
Secondary ! superior continuation of primary 2
End to end
DD, DS
Secondary ! side branch of primary 3
End to side None
Surgical Technique Flap Planning
DD, DS, SD, SS
Secondary ! primary (direct) 4
Type 3: Secondary pedicle anastomosed end to side onto primary pedicle; primary pedicle anastomosed onto primary recipient (►Fig. 2c). Type 4: Both primary and secondary pedicles anastomosed independently onto primary and secondary recipient vessels (►Fig. 2d). Primary recipients: The internal mammary artery and vein/s (IMA/V) antegrade or large intercostal perforator. The thoracodorsal pedicle is reserved for lifeboat scenarios. Secondary recipients: The IMA/V retrograde. This recipient is only used in type 4 anastomotic configurations, that is, when pedicles are independently anastomosed to two recipients (►Fig. 2d). The thoracodorsal pedicle is reserved for lifeboat scenarios.
DD, DS, SD, SS
Pedicles independent (two recipients) Note: For definitions of DD, DS, SD, and SS, see text.
Patients are only selected for the “stacked approach” if a single-pedicled flap cannot meet the defect requirements. CTA perforator mapping is performed on all, with pedicle choice preplanned where possible.
Operative Technique The flaps are raised completely sparing rectus abdominis musculature and fascia. Dissection of the flap usually begins Journal of Reconstructive Microsurgery
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Stacked Abdominal Flap for Unilateral Breast Reconstruction
Stacked Abdominal Flap for Unilateral Breast Reconstruction with the primary hemi-abdomen. The second team begins preparing the recipient pocket and vessels. The SIEA is deemed suitable if, on CTA, it is medial enough in the flap, that is, at or medial to the linear semilunaris and of good caliber (at least 1.5 mm). If it meets suitability for the primary pedicle, it is dissected out as far proximally as possible. The flap raise then continues, starting laterally and cranially. For a DIEP flap raise, the rectus fascia is opened at the level of the predetermined dominant perforator (or perforators). Either one or two perforators are included depending on their size (> 1.5 mm ¼ 1; < 1.5 mm ¼ 2). This is then dissected through the rectus as far as the main DIEA, clipping long and preserving any large side branches that may be required for the secondary pedicle—as in type 2. If the dominant perforator/s is from the lateral row, efforts are made to preserve a long medial branch, and vice versa if the dominant perforator/s is from the medial row. The superior continuity of the DIEA is also preserved, as it may be required for the secondary pedicle—as in type 1. Innervation to the rectus abdominis muscle is preserved throughout. The contralateral hemi-abdomen is then raised, starting with the SIEA/V dissection if deemed suitable. Otherwise this step is not pursued. The second side of the flap is raised in a similar fashion to the first, without the need for preservation of the branching points or superior extension. There may occasionally be the opportunity to raise this side based on a long medial perforator that can then be anastomosed onto the superior continuity (type 1 DD) or the dissected medial side branch (type 2 DD) of the primary pedicle. If length and/or caliber of the superior continuity or side branch are inadequate, an end-side anastomosis of the secondary pedicle onto the primary should be considered (type 3). In certain situations, two independent pedicles and recipients (type 4) may be favorable in terms of maximizing vascularity and also enabling good orientation and inset. The secondary pedicle length will range from 5 to 9 cm, depending on the recipient for the second side; that is, for medial branch (type 2), it can be shorter than superior continuation of DIEA (type 1).
Murray et al.
In certain situations, there may be little difference in caliber between each pedicle, in which case the primary pedicle can be considered to be that which is anastomosed onto the primary recipient (antegrade IMA/V). It is now possible to plan the configuration of pedicles, anastomoses, and flap inset to ensure maximum flap vascularity and optimal breast shape. Before the pedicles are ligated, steps are performed to ensure a smooth transition and minimal ischemia time, including de-epithelialization of the flap prior to pedicle ligation where required. The secondary pedicle is then divided for types 1–3. Microsurgical anastomoses are performed in situ on the abdomen either end to end (types 1 and 2) or end to side (type 3) for single artery and both veins. Performing this step in situ on the abdomen again minimizes ischemic time. This is done with a 10/0 nylon, and where possible a venous coupler is used for the veins, providing perfusion to the extended territory via the secondary pedicle before definitive primary pedicle division. Our preferred primary recipients are the internal mammary vessels, preserving the thoracodorsal pedicle for lifeboat scenarios. The IMA/V are prepared via removal of the third costal cartilage and clearing the intercostal space above and sometimes below. This provides additional recipient length, particularly crucial when the retrograde IMA/V are needed as secondary recipient (type 4). The venous coupler is used most of the time for internal mammary venous anastomoses and also for intraflap anastomoses where possible. In all cases, 100% of the abdominal pannus is used, with no zones discarded. The double flap is folded and inset into the pocket (►Fig. 1), with the de-epithelialized side facing the chest wall. The two lateral flap apices lie superiorly and are slightly offset, with a central stay suture (see ►Fig. 1). For types 1, 2, and 3 flaps, the primary pedicle is then anastomosed onto the primary recipient (IMA/V antegrade). For a type 4 flap, the primary pedicle is anastomosed onto the antegrade IMA/V first, followed by the secondary pedicle onto the retrograde IMA/V. A type 4 configuration is selected when using both SIEA flaps, or when there is no adequate distal DIEA or side branch on the primary side. In our experience of
Fig. 3 (a, b) “Stacked” for inadequacy of volume. Patient underwent a stacked flap for inadequacy of volume. This was done as an immediate reconstruction following a skin-sparing mastectomy (weight 700 g). The flap was raised as a type 2 DS. There were no complications and the only secondary procedure was a nipple reconstruction. Journal of Reconstructive Microsurgery
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two type 4 flaps, the retrograde flow through the IMV was sufficient to drain the flap. This anastomotic approach has been previously described and shown to be successful.23 Once the microanastomoses are complete, pedicle position is carefully checked, including position of the pedicle–pedicle anastomosis in types 1, 2, and 3. The breast mound is shaped and additional stay sutures used where necessary to give optimal symmetry and contour. Drains are carefully placed a distance away from the pedicle. A handheld Doppler signal is marked on the skin-paddle for postoperative monitoring. Standard postoperative free flap monitoring is performed on all patients by trained nursing staff, using clinical assessment and handheld Doppler. All patients received intra- and postoperative prophylactic subcutaneous heparin only, until fully mobile and discharged home.
Results The mean age was 49 years (range, 30–67 years). Eight patients had abdominal scarring (44%), with three (16%) of these having more than one scar. None of the patients were smokers and three patients had comorbidities that included asthma, hypertension, and a previous aortic valve replacement. A total of 16 patients required a stacked flap due to inadequate volume (►Fig. 3), while the remaining 2 patients had inadequate volume and skin (►Fig. 4), based on a
Murray et al.
single-pedicle flap. Mean body mass index was 25 (range, 22–28). Twelve patients presented for immediate reconstruction at the time of mastectomy, for ductal carcinoma (n ¼ 6), widespread ductal carcinoma-in-situ (DCIS) (n ¼ 4), and the remaining two for an aggressive radiotherapy-induced angiosarcoma of the chest wall (►Fig. 4) and recurrent Phylloides tumor. These two cases were performed at day 3 and day 5 post radical resection, ensuring histological clearance. Out of the immediate group, one patient received neoadjuvant radiotherapy, and one required unplanned post-operative radiotherapy, with no subsequent fat necrosis or adverse effects. Six patients presented for delayed reconstruction following treated ductal carcinoma (n ¼ 4) and widespread DCIS (n ¼ 2). Three of these already had a tissue expander-based reconstruction with preserved skin envelope, having completed adjuvant radiotherapy. The other delayed cases had not received radiotherapy and had a standard transverse mastectomy scar at time of presentation. In those undergoing immediate reconstruction, the median mastectomy weight was 600 g. Type 1 DD was the most commonly used configuration (n ¼ 8, 4 immediate and 4 delayed) in this series (►Fig. 5 for an intraoperative example). Type 2 DD or DS flap (n ¼ 6) were the next most frequently used, with the majority of these being carried out in the
Fig. 4 (a–d) “Stacked” for inadequacy of volume and skin. Patient underwent a stacked flap for inadequacy of volume and skin due to an aggressive radiotherapy-induced angiosarcoma. Flap reconstruction was performed at day 3 post resection. This flap was raised as a type 2 DD. There were no complications and the only secondary procedure was a nipple reconstruction. Journal of Reconstructive Microsurgery
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Stacked Abdominal Flap for Unilateral Breast Reconstruction
Stacked Abdominal Flap for Unilateral Breast Reconstruction
Murray et al.
Fig. 5 (a–c) Intraoperative demonstration of the most common anastomotic and pedicle configuration—type 1 DD. Primary pedicle: R-sided deep inferior epigastric artery and veins (DIEA/V) on one large medial perforator. Secondary pedicle: L-sided DIEA/V on one large medial perforator.
immediate group. Use of the superficial vessels (S) as the secondary pedicle was as common as use of the deep vessels in this group. Here, a long side branch preserved from the primary DIEA/V pedicle facilitated anastomosis of the SIEA/V secondary pedicle in the type 2 configuration. A type 3 flap was used in two cases of immediate reconstruction, both with DIEA/V as the primary pedicle. In both cases, neither the superior continuation nor side branch from the DIEA/V was suitable; hence, an end-to-side type 3 configuration was used. A type 4 flap was used in two cases, one immediate (DS) and one delayed (SS). The total abdominal pannus was used in all cases and all flaps were inset in the folded configuration described, including the patient with a midline scar who had a type 2 DS flap (►Fig. 6). The primary pedicle was then anastomosed onto the primary recipient vessels in a timely fashion, that is, antegrade IMA/V (n ¼ 17) and a large IMA/V intercostal perforator (n ¼ 1). The secondary pedicle was anastomosed onto the secondary recipient vessels, that is, retrograde IMA/V in the two cases of type 4 flap. The thoracodorsal pedicle was not used as a recipient in any of the cases described. The mean operative time was 7 hours (range, 5.5–8 hours) and the mean hospital stay was 6 days (range, 4–8 days). There were no intraoperative revisions of anastomoses, no returns to theatre, no partial or complete flap losses, and no major complications. One patient had a 1.5 cm area of late fat necrosis detected clinically, which did not require intervention and settled spontaneously. Three patients had liposuction (100–150 mL) for minimal flap reduction at 6 months and two had a revision to the central portion of the abdominal scar. All patients had excellent postoperative abdominal wall integrity. All patients went on to have nipple reconstruction and all reported a high degree of satisfaction with their reconstruction at follow-up, although this was not formally Journal of Reconstructive Microsurgery
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assessed. Follow-up ranged from 3 to 36 months, with a mean of 20 months.
Discussion For unilateral breast reconstruction, the double-pedicled stacked approach can be a reliable option when the deficit requires use of the entire pannus.21,22,24,25 The successful vascularization of all four perfusion zones,26 even with abdominal scarring, has been previously demonstrated.12–22 The stacked flap is more challenging, but can be aided by a safe and logical approach. The classification system ensures maximal flap vascularity. Out of the 18 stacked flaps presented, there were no partial or complete flap losses and only 1 case of spontaneously resolving fat necrosis. These outcomes compare favorably to other series,21,24 although not all previous series present fat necrosis rates.24 CTA is a reliable and essential tool when used to select the dominant pedicles6—a priority for this flap. Anastomotic configuration and flap inset are lesser priorities, and follow on from this. Hamdi et al21 and DellaCroce et al24 describe preferential use of the double-DIEP pedicle (DD) and mainly use type 2 and 3 configurations, based on our classification. Here, pedicle choice was based on achieving maximum pedicle length, rather than maximum pedicle diameter and, therefore, flap perfusion. However, both these studies demonstrate favorable outcomes. Abdominal scarring was seen in 44% in this series (n ¼ 8), compared with 31 and 27% in other series.21,24 Vascular architecture has been shown to be universally altered by scarring, excluding the use of certain pedicles.6,7 It is, therefore, important to consider this when planning pedicle arrangements. ►Fig. 6 demonstrates a CTA of a patient with midline scarring and its effect on the vascularity of abdominal flap.
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Fig. 6 (a–c) Computed tomography angiography showing the vascularity of the abdominal flap with a midline vertical scar. This patient went on to have a successful type 2 DS flap, with no postoperative fat necrosis or complications.
Use of the thoracodorsal artery (TDA) recipient should be preserved for lifeboat situations, corresponding to similar work.21,24 Use of the TDA can carry a higher risk of flap compromise. Often, to ensure vessel caliber is adequately matched, it is necessary to dissect the recipient deep into the axilla. Other authors have described this approach.19 IMA/V is the primary recipient in this series and ensured successful flap perfusion in all cases. Use of the retrograde IMA/V as a secondary recipient has been previously described23 and is preferred for a type 4 configuration. Of note, only prophylactic subcutaneous intra- and postoperative heparin was used, with no extended use of additional agents, for example, aspirin. No thrombotic complications were seen (early or late). This can possibly be explained by considering the delay phenomenon, whereby the distal flap becomes independent of its secondary anastomosis by day 5, once choke vessels have opened up between the two flaps. Folding as opposed to dividing of the double flap allowed good stability and shape (see ►Fig. 1). This is contrary to previous studies that have divided the flap19,24 based on concerns about developing a zone of hypoperfusion.24 We report no cases of fat necrosis within the folded zone, even with midline scars, and the entirety of the pannus was used in all cases. An aesthetically pleasing breast shape can be achieved using the inset technique described. This approach is flexible and can be tailored to the defect needs, demonstrated clearly by the two cases of reconstruction post radical chest wall resection.
Despite this approach being relatively novel and challenging, fat necrosis rates and complications are very low and excellent overall flap outcomes have been achieved. Larger prospective clinical studies need to verify the validity of this approach.
Conclusion The stacked approach is more technically demanding than a standard single-pedicle flap, but facilitated by preoperative mapping and a system such as this, excellent outcomes with minimal complications can be achieved, as we have shown. Our inclusive classification demonstrates the options available when using this flap. As women seeking unilateral breast reconstruction increasingly request a life-long autologous solution, so our skills must improve to provide the ideal solution.
Acknowledgments Thanks to Dr. Levent Efe, CMI, for schematic illustrations. All patients featuring in this article have given fully informed consent for use of images.
Ethical Approval Gained from the Local Quality Assurance Sub-committee of the Human Research and Ethics Committee (Reference: QA 031/13). Journal of Reconstructive Microsurgery
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Stacked Abdominal Flap for Unilateral Breast Reconstruction
Stacked Abdominal Flap for Unilateral Breast Reconstruction Funding None.
13 Semple JL. Retrograde microvascular augmentation (turbocharg-
Conflict of Interest None declared.
14
15
References 1 Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site
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4 5
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9 10
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morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 1997;50(5):322–330 Futter CM, Webster MH, Hagen S, Mitchell SL. A retrospective comparison of abdominal muscle strength following breast reconstruction with a free TRAM or DIEP flap. Br J Plast Surg 2000;53(7): 578–583 Nahabedian MY, Dooley W, Singh N, Manson PN. Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation. Plast Reconstr Surg 2002;109(1):91–101 Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal experience. Br J Plast Surg 1999;52(2):104–111 Katz RD, Manahan MA, Rad AN, Flores JI, Singh NK, Rosson GD. Classification schema for anatomic variations of the inferior epigastric vasculature evaluated by abdominal CT angiograms for breast reconstruction. Microsurgery 2010;30(8):593–602 Rozen WM, Ashton MW, Stella DL, Phillips TJ, Grinsell D, Taylor GI. The accuracy of computed tomographic angiography for mapping the perforators of the deep inferior epigastric artery: a blinded, prospective cohort study. Plast Reconstr Surg 2008;122(4): 1003–1009 Rozen WM, Garcia-Tutor E, Alonso-Burgos A, Corlett RJ, Taylor GI, Ashton MW. The effect of anterior abdominal wall scars on the vascular anatomy of the abdominal wall: a cadaveric and clinical study with clinical implications. Clin Anat 2009;22(7):815–822 Rozen WM, Ashton MW, Grinsell D. The branching pattern of the deep inferior epigastric artery revisited in-vivo: a new classification based on CT angiography. Clin Anat 2010;23(1):87–92 Arnez ZM, Scamp T. The bipedicled free TRAM flap. Br J Plast Surg 1992;45(3):214–218 Simon AM, Bouwense CL, McMillan S, Lamb S, Hammond DC. Comparison of unipedicled and bipedicled TRAM flap breast reconstructions: assessment of physical function and patient satisfaction. Plast Reconstr Surg 2004;113(1):136–140 Jensen JA. Is double pedicle TRAM flap reconstruction of a single breast within the standard of care? Plast Reconstr Surg 1997; 100(6):1592–1593 Pennington DG, Nettle WJ, Lam P. Microvascular augmentation of the blood supply of the contralateral side of the free transverse rectus abdominis musculocutaneous flap. Ann Plast Surg 1993; 31(2):123–126, discussion 126–127
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18
19
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21
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23
24
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ing) of a single-pedicle TRAM flap through a deep inferior epigastric arterial and venous loop. Plast Reconstr Surg 1994;93(1): 109–117 Blondeel PN, Boeckx WD. Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery. Br J Plast Surg 1994; 47(7):495–501 Lam TC, Sellars GD. Free perforator crossover TRAM flap for breast reconstruction. Ann Plast Surg 2003;50(2):126–131 Tseng CY, Lang PO, Cipriani NA, Song DH. Pedicle preservation technique for arterial and venous turbocharging of free DIEP and muscle-sparing TRAM flaps. Plast Reconstr Surg 2007;120(4): 851–854 Agarwal JP, Gottlieb LJ. Double pedicle deep inferior epigastric perforator/muscle-sparing TRAM flaps for unilateral breast reconstruction. Ann Plast Surg 2007;58(4):359–363 Schoeller T, Wechselberger G, Roger J, Hussl H, Huemer GM. Management of infraumbilical vertical scars in DIEP-flaps by crossover anastomosis. J Plast Reconstr Aesthet Surg 2007;60(5): 524–528 Ali RS, Garrido A, Ramakrishnan V. Stacked free hemi-DIEP flaps: a method of autologous breast reconstruction in a patient with midline abdominal scarring. Br J Plast Surg 2002;55(4): 351–353 Kronowitz SJ, Robb GL, Youssef A, et al. Optimizing autologous breast reconstruction in thin patients. Plast Reconstr Surg 2003; 112(7):1768–1778 Hamdi M, Khuthaila DK, Van Landuyt K, Roche N, Monstrey S. Double-pedicle abdominal perforator free flaps for unilateral breast reconstruction: new horizons in microsurgical tissue transfer to the breast. J Plast Reconstr Aesthet Surg 2007;60(8): 904–912, discussion 913–914 Rabey NG, Erel E, Malata CM. Double-pedicled abdominal free flap using an entirely new microvascular combination of DIEP and SIEA vascular pedicles for unilateral breast reconstruction: a novel addition to the Hamdi classification. Plast Reconstr Surg 2012; 130(5):767e–769e Chan RK, Przylecki W, Guo L, Caterson SA. Case report. The use of both antegrade and retrograde internal mammary vessels in a folded, stacked deep inferior epigastric artery perforator flap. Eplasty 2010;10:e32 DellaCroce FJ, Sullivan SK, Trahan C. Stacked deep inferior epigastric perforator flap breast reconstruction: a review of 110 flaps in 55 cases over 3 years. Plast Reconstr Surg 2011;127(3): 1093–1099 Beahm EK, Walton RL. The efficacy of bilateral lower abdominal free flaps for unilateral breast reconstruction. Plast Reconstr Surg 2007;120(1):41–54 Holm C, Mayr M, Höfter E, Ninkovic M. Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg 2006;117(1): 37–43
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