Advances in autogenous breast reconstruction: the role of preoperative perforator mapping.
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Adult↗
Biomedical subjects
Koenraad Van Landuyt
Publications and source records attributed to Koenraad Van Landuyt.
The versatility of the inter-costal artery perforator (ICAP) flaps.
INTRODUCTION: Anatomy and classification of intercostal perforator flaps in addition to our experience with will be demonstrated for different indications. MATERIAL AND METHODS: The intercostal vessels form an arcade between the aorta and the internal mammary vessels. Different pedicled perforator flaps can be raised on this neurovascular bundle to cover defects on the trunk. They are classified as following: dorsal intercostal artery perforator flap (DICAP); lateral intercostal artery perforator (LICAP); and anterior intercostal artery perforator (AICAP) flap. RESULTS: Between 2001 and 2004, 20 pedicled (ICAP) flaps were harvested in 16 patients. The indications were: immediate partial breast reconstruction in eight patients who had a quadrantectomy for breast cancer; midline back and sternal defects in three patients who had radical excisions for a dermatofibrosarcoma or malignant melanoma; and autologous breast augmentation (four bilateral and one unilateral flap) in five post-bariatric-surgery patients. The average flap dimension was 18 x 8 cm(2) (range 8 x 5-24 x 12 cm(2)). There were two DICAP flaps, two (AICAP) flaps and 16 (LICAP) flaps. All but two flaps were based on one perforator. Mean harvesting time was 45min for a single flap. Bilateral breast augmentation with LICAP flap necessitated longer operative time (range 2-3h) depending whether it was combined or not with mastopoexy. Complete flaps survival was obtained. All donor sites were closed primarily. CONCLUSION: The (ICAP) flaps provide valuable options in breast surgery; and for challenging defects on the trunk without sacrifice of the underlying muscle.
Adolescent↗
The versatile DIEP flap: its use in lower extremity reconstruction.
The deep inferior epigastric perforator (DIEP) flap gained widespread popularity as a free flap in breast reconstruction. It is also a versatile and reliable supply of a large amount of skin and soft-tissue, which can be used in other types of reconstruction. We present 25 consecutive cases (28 DIEP flaps) performed in our service during the past 5 years for different indications in lower extremity aesthetic and functional reconstruction, both as pedicled or free flaps. The amount of tissue provided, its reliable vascular supply and long and adequately sized pedicles, together with its limited donor-site morbidity make it a useful alternative free flap.
Abdomen↗
Free perforator flaps in children.
BACKGROUND: Raising perforator flaps is said to be a tedious procedure. The benefits, however, are great. In adults, perforator flaps have proved their usefulness and reliability in various clinical situations. In children, donor sites for free flaps are particularly scarce because of the need for a long and reliable vascular pedicle of sufficient size. There is also the need to minimize donor-site morbidity from aesthetic, functional, and psychological perspectives. METHODS: The authors present a series of 23 consecutive free perforator flaps performed by the first author in 20 children; ages at the time of operation ranged from premature (born at 28 weeks) to 16 years (mean age, 7 years 5 months). Three children presented with upper limb defects; the remaining 17 children sustained major soft-tissue defects of the lower limb. All the lesions necessitated extensive coverage with a free flap. Flaps used in this series included nine deep inferior epigastric artery perforator flaps, seven thoracodorsal artery perforator flaps, and seven compound ("chimera") thoracodorsal artery perforator flaps. RESULTS: All flaps but one were successful. With a follow-up of up to 7 years, the results in this series compare favorably with those of perforator flaps in adults or pediatric free flaps in the literature. CONCLUSIONS: In children, as in adults, perforator flaps are a valuable alternative to the traditional muscle or myocutaneous free flap. Because of the added advantage of reducing donor-site morbidity, perforator flaps have become the authors' preferred option in reconstructive cases in children.
Adolescent↗
A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity.
Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.
Adolescent↗
Algorithm in choosing recipient vessels for perforator free flap in breast reconstruction: the role of the internal mammary perforators.
INTRODUCTION: Although the internal mammary (IM) vessels are our first choice as recipient vessels for free flap breast reconstruction, attempts to reduce surgical morbidity led us to adopt an algorithm when choosing recipient vessels. MATERIALS AND METHODS: The IM vessels give direct perforators to the breast. They can be found either superficial or deep to the pectoralis major muscle. If they are of a reasonable calibre they can be considered as recipient vessels. When the perforators are not suitable, the IM vessels are used for the microanastomosis. This protocol was adopted for our patients between June 1999 and December 2002. RESULTS: Breast reconstruction with free flaps was performed on 298 patients with perforator flaps. IM and thoracodorsal (TD) vessels are used in 88% and 3% of cases, respectively. IM perforators were successfully used in 30 cases (9%). The IM perforators used were located at the level of the second and third intercostal space in nine (30%) and 21 (70%) cases, respectively. The average diameters of those perforators were 1 mm (0.5-1.3 mm) for the artery and 1.7 mm (1-3 mm) for the vein. CONCLUSIONS: The IM perforators can be used as recipient vessels for free flaps. This spares the IM vessels for eventual cardiac bypass surgery, avoiding recipient site morbidity and decreasing the postoperative discomfort.
Algorithms↗
Pedicled perforator flaps in breast reconstruction: a new concept.
INTRODUCTION: Pedicled perforator flaps have not been widely described for the breast. The aim of this study is to report our clinical experience with pedicled perforator flaps in breast reconstruction. MATERIAL AND METHODS: Between May 2000 and May 2003, pedicled perforator flaps were used in 31 patients. The indications were immediate partial breast reconstruction and thoracic reconstruction for carcinomatous mastitis or tumour recurrence. Perforators were identified by Doppler preoperatively. The Doppler-located thoracodorsal artery perforator (TDAP) or another perforator such as the intercostal artery perforator (ICAP) was looked for. If the perforators had good calibers, the flaps were then based solely on these perforators. If the perforators were tiny but pulsating, the TDAP flap was harvested as a muscle-sparing latissimus dorsi type I (MS-LD I) with a small piece of muscle (4x2 cm) included to protect the perforators. If the perforators were not-pulsating, a larger segment of the LD muscle was incorporated to include the maximum of perforators (MS-LD II flap). The nerve that innervates the rest of the LD muscle was always spared. If most of the LD was included in the flap, the flap was then classified as MS-LD III. RESULTS: The mean flap dimensions were 20x8 cm. Using this algorithm, the TDAP flap was harvested in 18 cases and the ICAP flap in three cases. In addition, there were 10 MS-LD flaps with a variable amount of muscle. In addition, one parascapular flap was dissected. A successful flap transfer was achieved in all but three patients, in whom limited partial necrosis occurred. Seroma was not encountered at the donor sites of the perforator flaps (0%) compared to four (40%) after a MS-LD flap. CONCLUSION: Our results show that pedicled perforator flaps are additional options for breast surgery and that they may be used whenever an adequate perforator can be found. This technique is safe and reliable if the algorithm described is used when choosing a flap.
Adult↗
Aesthetic and functional considerations in the reconstruction of large skin defects with free flaps.
Free flaps can be used effectively in the primary reconstruction of large defects after resection of large tumors. The ultimate goal is radical excision of tumors and achievement of primary wound healing with a single procedure and long-term local control of disease. Although this can be obtained with the use of free tissue transfer, patients often seek more aesthetic results. Therefore, refinements of reconstructive techniques with minimal functional donor site morbidity are now the gold standard in our practice.
Esthetics↗
What exactly was wrong with the Trilucent breast implants? A unifying hypothesis.
Trilucent soybean oil-filled breast implants were initially announced as the ultimate prostheses for breast augmentation. However, after an increasing number of reports of local complications and hazardous metabolites attributable to lipid oxidation, first the United Kingdom Medical Devices Agency and later the Belgian National Ministry of Health urged all plastic surgeons to contact their patients and advise them to have the implants removed and, if desired, replaced with another type of prosthesis. In our plastic surgery department, 13 patients received bilateral implants with triglyceride-filled prostheses between February and July of 1996, for primary breast augmentation or replacement of previously implanted prostheses. For 12 of those 13 patients, the prostheses have been explanted, because of unilateral breast enlargement attributable to a ruptured prosthesis for five patients and following the recommendation of the Belgian National Ministry of Health for the other seven patients. Before explantation, all patients underwent standard clinical examinations, with assessments of breast shape, volume, and firmness. Blood analyses were performed, with a special focus on liver enzymes, as were urinalyses. Magnetic resonance imaging scans were obtained before explantation; for two patients, the scans revealed a fluid level separating two liquid layers in an intact prosthesis. This is the first report of such a finding. The removed implants were examined for any damage or shell deterioration and for changes in color and viscosity, the weights and volumes were measured and compared with the initial values for the implanted prostheses, and complete biochemical analyses of the accumulated fluid in cases of ruptured prostheses and of the filler material in cases of intact prostheses were performed. This small but well-documented series illustrates the multitude of problems associated with triglyceride-filled implants, including bleeding of the triglyceride filler; shell deterioration, as indicated by a loss of texture and extreme fragility of the implant (with rupture or delamination with a simple finger touch); an increase in osmotic pressure exerted by the degraded filler material; progressive weakening of the outer silicone shell, with influx of plasma proteins of up to 750 kDa, eventually resulting in rupture of the prosthesis; a lack of oxidative stability and the formation of toxic oxidation products; a lack of biocompatibility, with the formation of insoluble organic soap-like material; and a pronounced inflammatory reaction. It is concluded that the sequential and/or simultaneous occurrence of (1) implant bleeding, (2) lipid infiltration of the silicone elastomer, and (3) inflammation attributable to oxidation products provides an overall explanation or unifying hypothesis for the wide variety of adverse events related to soybean oil-filled implants.
Biocompatible Materials↗
Bilateral autogenous breast reconstruction using perforator free flaps: a single center's experience.
The authors present a single center's experience in bilateral breast reconstruction using perforator free flaps. The aim of this study was to show their indications, surgical technique, and results. A series of 53 patients underwent this procedure between February of 1996 and October of 2002. The surgical procedures were performed on patients with bilateral breast cancer (11 patients), patients with unilateral breast cancer and contralateral prophylactic mastectomy (22 patients), patients who had undergone bilateral prophylactic mastectomy (18 patients), a patient with Poland's syndrome, and a patient whose aesthetic breast augmentation had failed. Primary and secondary bilateral breast reconstructions were done in 18 and four patients, respectively. Eighteen patients who had earlier undergone breast reconstruction with implants had a tertiary breast reconstruction. Combined reconstruction (primary with secondary and primary with tertiary reconstruction) was done in 13 patients. Ninety-eight deep inferior epigastric perforator flaps and eight superior gluteal artery perforator flaps were used. The average operative time was 10 hours (range, 8 to 14.5 hours) for the simultaneous bilateral reconstruction. Total flap necrosis occurred in two cases (one deep inferior epigastric perforator flap and one superior gluteal artery perforator flap). Partial flap necrosis was not encountered, and fat necrosis was found in one deep inferior epigastric perforator flap (1 percent). Two pulmonary infections, one deep vein thrombosis, and one cardiac arrhythmia occurred as postoperative complications. The mean hospital stay was 9 days (range, 6 to 20 days). Abdominal bulging was reported in one patient. There were no recurrent disease or cancer manifestations, with an average follow-up of 3.5 years. This series clearly shows that perforator flaps are reliable and useful tools for bilateral breast reconstruction. This technique decreases the donor-site morbidity and offers an excellent aesthetic and long-term outcome and high patient satisfaction.
Adult↗
Autologous breast augmentation by pedicled perforator flaps.
A technique is described for autologous breast augmentation based on perforator flaps of the lateral chest wall. Raising these flaps as perforator flaps implies minimal donor site morbidity; however, the price to pay is a scar underneath the armpit extending from the lateral end of the inframammary fold onto the back. This scar can be relatively well hidden underneath the arm and in the brassiere. Indications depend on the aversion of the patient against prostheses and the extent of available tissue versus the desired augmentation. As typical indications, we would consider the occasional developmental asymmetry, autologous augmentation after contralateral breast reconstruction, or contour surgery in the bariatric patient.
Adult↗
Evaluation of nipple-areola complex sensitivity after the latero-central glandular pedicle technique in breast reduction.
INTRODUCTION: Previous anatomical and clinical studies have shown that nipple-areola sensitivity decreased significantly after conventional superior and inferior pedicle technique for 3-6 months postoperatively. We found it necessary to modify our techniques in breast reduction to achieve a better outcome regarding breast sensation. Since 1999, we have been using a new technique of breast reduction with a latero-central glandular pedicle. The pedicle for the nipple-areola is based on a horizontal septum and it is designed to incorporate the anterior ramus of the lateral branch of the fourth inter-costal nerve and perforator vessels. Using this technique, a prospective study was conducted in order to quantitatively assess the nipple-areola sensitivity. MATERIAL AND METHODS: The sensitivity of the nipple-areola complex (NAC) was evaluated in 20 consecutive patients undergoing breast reduction with the septum-based lateral pedicle technique. The sensitivity was assessed preoperatively, 2 weeks and 3 months postoperatively by the same examiner. The nipple and four cardinal points of the areola were tested. Pressure thresholds were measured with Semmes-Weinstein monofilaments, temperature sensitivity with hot (40 degrees C) and cold (4 degrees C) metal probes and vibratory thresholds with the Biothesiometer. Average sensation of the areola was calculated by means of the four areas tested. RESULTS: Average values of different patterns of sensitivity decreased significantly on the tested areola 2 weeks postoperatively. Three months postoperatively, pressure and vibration values were statistically comparable in averages to preoperative values (nipple: 46.2+/-3.8 versus 34.6+/-2.2 g/mm2 and 6.4+/-1.2 versus 3.7+/-1 micron; areola: 57.4+/-5.7 versus 49+/-6.8 g/mm2 and 6.7+/-1.2 versus 3.1+/-0.6 micron). Concerning the ability to recognise temperature, 27.5 and 20% of patients could not distinguish between cold and hot 3 months after surgery, on the nipple and the areola, respectively. Numbness was found only on two NAC despite the significant decrease of sensitivity after 2 weeks. This may be attributed to postoperative oedema or neuropraxia. CONCLUSION: Our results showed that using the latero-central glandular pedicle technique preserves the sensitivity of the NAC.
Adolescent↗
Creation of a neovagina with use of a pudendal thigh fasciocutaneous flap and restoration of uterovaginal continuity.
OBJECTIVE: To create a neovagina and an endocervival canal in two patients with vaginal aplasia and a functioning uterus. DESIGN: Technique and instrumentations. SETTING: University hospital. PATIENT(S): A 31-year-old woman with vaginal aplasia and a double noncommunicating uterus (classified as Mayer-Rokitansky-Kuster-Hauser syndrome) and a 19-year-old woman with partial vaginal aplasia and a functional uterus. INTERVENTION(S): Creation of a neovagina by using the bilateral pudendal thigh fasciocutaneous flap procedure and laparotomy to establish uterovaginal continuity. MAIN OUTCOME MEASURE(S): Clinical follow-up evaluation of restoration of outflow of menstrual blood and coital satisfaction. RESULT(S): Uterovaginal continuity was established in both patients, resulting in normal menstruation. Granulomatous polyps occurred in one patient, and stenosis at the site of anastomosis occurred in the other patient; these conditions were successfully managed. Unimpeded menstrual flow continued after 1 year of follow-up in one patient and 3 years of follow-up in the other patient. CONCLUSION(S): Bilateral fasciocutaneous pudendal thigh flaps permit vaginal reconstruction and a uterovaginal connection in patients with vaginal agenesis and a functional uterus. The main advantages of this technique are that postoperative dilatation is not necessary, sensation is maintained, and the resulting scar is inconspicuous. The main disadvantage is the presence of some sebaceous vaginal secretion and hair in the vaginal lining; the latter can be managed by preoperative and postoperative laser depilation.
Adult↗
Perforator flap terminology: update 2002.
The first terminology consensus on perforator flaps, reached in 2001, was reviewed and further simplified following the Sixth International Course on Perforator Flaps.
Humans↗
Soft tissue reconstruction with the superior gluteal artery perforator flap.
The development of the perforator flap technique revolutionized the practice of soft tissue transfer. The main goal of this technique is muscle sparing at the donor site for function and strength. Meanwhile, this concept is being widely applied for reconstruction of tissues throughout the entire body. Perforator flaps are the ultimate upgrade of the well-known myocutaneous flaps. Theoretically, any myocutaneous flap can be harvested as a perforator flap if skin resurfacing is needed. Although the DIEP flap, the anterolateral thigh flap, and the TAP flap are probably more frequently used for breast, trunk, and upper and lower limb reconstruction, as well as head and neck reconstruction, the SGAP flap takes its own position in the large group of perforator flaps and has its own specific indications.
Buttocks↗