Myocutaneous Gracilis Free Flaps in Microsurgical Breast Reconstruction: A Systematic Review Comparing Variations of the Upper Gracilis Flap

2017 ◽  
Vol 33 (09) ◽  
pp. 630-635 ◽  
Author(s):  
Vicky Kang ◽  
Emilie Robinson ◽  
Eric Barker ◽  
Anuja Antony
Keyword(s):  
Systematic Review ◽  
Breast Reconstruction ◽  
Donor Site ◽  
Free Flaps ◽  
Donor Site Morbidity ◽  
Fat Grafting ◽  
Complication Rates ◽  
Implant Placement ◽  
Pubmed Database ◽  
Low Incidence

Background The transverse upper gracilis (TUG) flap has gained increasing acceptance as a reliable option for breast reconstruction, specifically in patients without adequate abdominal tissue. Three major flap designs of the upper gracilis flap have been proposed to balance volume needs with flap vascularity. A systematic review was performed to identify outcomes of the major gracilis flaps: TUG, vertical-transverse upper gracilis (V-TUG), and longitudinal gracilis myocutaneous (LGM) flaps. This study is the first and only systematic review to date reviewing the variations of the upper gracilis flap in microsurgical breast reconstruction. Methods A systematic review of the literature was conducted using PubMed database from 1966 through 2015. Inclusion and exclusion criteria were applied. Outcomes assessed included total flap volumes, additional breast procedures to achieve intended breast volume, and complication rates. Results A total of 485 gracilis-type flaps were performed in 335 patients. V-TUG flaps provided the largest mean flap weights and did not require additional lipofilling or implant placement, whereas the majority of TUG flaps (50.6%) required additional fat grafting or implant placements. All flap types demonstrated a low incidence of donor-site morbidity. Overall flap loss rate was low; TUG flaps reported 2.3% total and 2.0% partial flap losses, while V-TUG and LGM flaps reported no flap losses. Conclusion This review found V-TUG yielded highest mean flap weights and did not require additional breast augmentation procedures as compared with the TUG. Also, the V-TUG was a safer donor-site option with fewer flap and donor-site morbidities.

scholarly journals Bilateral Breast Reconstruction With Profunda Artery Perforator Flaps and Immediate Implant Augmentation

2020 ◽  
Vol 2 (1) ◽  
Author(s):  
Carrie K Chu ◽  
Michael DeFazio ◽  
Rene D Largo ◽  
Merrick Ross
Keyword(s):  
Breast Reconstruction ◽  
Brca2 Mutation ◽  
Donor Site ◽  
Free Flaps ◽  
Fat Grafting ◽  
Silicone Implants ◽  
Level Of Evidence ◽  
Immediate Reconstruction ◽  
Immediate Implant ◽  
Artery Perforator

Abstract The smaller volume of the profunda artery perforator (PAP) flap relative to that of abdominal flaps limits the size of breast reconstruction that may be achieved. Immediate implant augmentation of abdominal free flaps has been performed, but immediate implant augmentation of PAP flaps has never been described. A 54-year-old woman with BRCA2 mutation, submuscular implants, and previous abdominoplasty presented for nipple-sparing mastectomies (NSM). Autologous tissue volume was inadequate to support reconstruction to the desired size. She wished to avoid serial expansion. Skin quality was unsuitable for direct-to-implant reconstruction. The patient underwent bilateral NSM. The previous implants were removed with capsule preservation. Bilateral PAP flaps were harvested and anastomosed to the internal mammary vessels. Moderate classic profile 170-mL smooth round silicone implants were placed into the existing capsule pockets with lateral capsulorraphy. There were no flap, implant, or infectious complications. Initial mastectomy skin and nipple ischemia completely resolved without necrosis. Donor site healing was uneventful. At 8 months, the reconstruction is supple and the implants remain well-positioned without rippling. One minor revision was performed for fat grafting and to correct lateral nipple deviation. PAP flap breast reconstruction with immediate implant augmentation is technically feasible. Advantages include improved prosthetic coverage, allowing for immediate reconstruction to a larger size with reduced concern regarding mastectomy skin necrosis and threat to the device, optimal implant camouflage, and improved substrate for secondary fat grafting if necessary. Level of Evidence: 5

scholarly journals Laparoscopic Harvesting of Omental Flaps for Breast Reconstruction—A Review of the Literature and Outcome Analysis

2017 ◽  
Vol 26 (2) ◽  
pp. 126-133 ◽  
Author(s):  
Hani Shash ◽  
Becher Al-halabi ◽  
Salah Aldekhayel ◽  
Tassos Dionisopoulos
Keyword(s):  
Breast Reconstruction ◽  
Donor Site ◽  
Patient Characteristics ◽  
Donor Site Morbidity ◽  
Outcome Analysis ◽  
Complication Rates ◽  
Search Terms ◽  
The Mean ◽  
Pedicle Flaps

Background: Evidence on the use of omental flaps for breast reconstruction in patients with breast cancer is lacking, and no published reviews report an outcome-based assessment of such flap. This review explores available data and evidence for change in complication rates following the shift toward laparoscopic harvesting. Methods: We searched the databases Excerpta Medica database, MEDLINE, and PubMed from inception until December 2015 using search terms “omental flaps“ and “breast reconstruction.” Data extracted were patient characteristics, technique used, and outcome measures reported and were then analyzed based on the technique of harvesting. Results: Twenty-two articles reporting 651 patients who underwent mastectomies and breast-conserving surgeries were included in this review. Most flaps, 537 (82.5%), were harvested by laparoscopy, and 626 (96.2%) of the flaps were pedicle flaps. The mean age was 47.7 years (standard deviation: 4.29), and mean follow-up was 38.1 months. There were 88 reported complications among 562 patients in 16 reports. The rate of any complication was calculated to be 15.0%, with a higher rate (29.1%) occurring with the open technique in comparison to laparoscopy (12.6%). The commonest complications were postoperative infection and breast firmness each reported in 2.22%. Most authors reported advantages of malleability and excellent aesthetic outcomes and disadvantages in terms of inability to estimate the volume of the flap and variability in size. Conclusion: Omentum use is safe and has advantages in breast reconstruction where other options are limited including a natural feeling and minimal donor site morbidity if harvested laparoscopically.

Check the Record: Remote CT Scans for Breast Flap Perforator Mapping

2018 ◽  
Vol 34 (07) ◽  
pp. 485-491 ◽  
Author(s):  
Amanda Sergesketter ◽  
Bryan Pyfer ◽  
Brett Phillips ◽  
Ruya Zhao ◽  
Scott Hollenbeck
Keyword(s):  
Breast Reconstruction ◽  
Donor Site ◽  
Free Flaps ◽  
Donor Site Morbidity ◽  
Ct Scans ◽  
Autologous Reconstruction ◽  
Positron Emission ◽  
Pet Ct ◽  
Delayed Breast Reconstruction ◽  
Average Utility

Background Perforator mapping with computed tomography angiography (CTA) prior to autologous breast reconstruction reduces donor-site morbidity and operative time, but is costly. The aim of this study was to evaluate whether pre-existing CT scans could be used for dominant perforator identification before autologous reconstruction. Methods We identified all female patients who underwent mastectomy with immediate or delayed breast reconstruction with abdominal free flaps at a single institution between 2006 and 2016. Medical records were reviewed to identify patients with pre-existing CT scans of the abdomen/pelvis. CT images were reviewed by the senior surgeon and ranked on a 1 to 3 scale to indicate utility for preoperative planning. An analysis was performed to assess financial savings and radiation avoidance associated with the use of pre-existing scans. Results Of 301 identified patients, 44.9% (n = 135) had an available pre-existing CT. A dominant perforator was identified on 92.6% of scans. A higher proportion of dominant perforators was identified using positron emission tomography (PET)/CT scans compared with CT scans with intravenous (IV) contrast and noncontrast CTs (p < 0.0001). Compared with PET/CTs and CTs with IV contrast, the average utility score for noncontrast CTs was lower (p = 0.0001). Dominant perforators were clearly identified in patients who had both a remote CT scan and a preoperative CTA. Perforator mapping using remote CT scans yielded a projected radiation reduction of 13.2 mGy per patient and yielded a projected annual U.S. health care savings of $28,459,638. Conclusion Our study suggests that pre-existing CT scans represent a viable and economical alternative for perforator mapping before abdominal-based free flap breast reconstruction.

scholarly journals Free Tissue Breast Reconstruction

2019 ◽  
Vol 33 (01) ◽  
pp. 059-066 ◽  
Author(s):  
Rami Dibbs ◽  
Jeff Trost ◽  
Valerie DeGregorio ◽  
Shayan Izaddoost
Keyword(s):  
Breast Reconstruction ◽  
Free Flap ◽  
Donor Site ◽  
Perforator Flap ◽  
Free Tissue Transfer ◽  
Donor Site Morbidity ◽  
Fat Grafting ◽  
Microsurgical Technique ◽  
Deep Inferior Epigastric Perforator ◽  
Aesthetic Breast

AbstractFree tissue transfer serves as a modern workhorse for breast reconstruction. Advancements in microsurgical technique have allowed for the development of free flap procedures that produce an aesthetic breast while minimizing donor site morbidity. Here, the authors review the use of different free flap procedures for breast reconstruction with a focus on the preferred and most commonly used flap, the deep inferior epigastric perforator flap. Each flap has its advantages and drawbacks, and certain patient risk factors increase postoperative complications. Other techniques of breast reconstruction including pedicled flaps and adjunctive fat grafting are also briefly discussed.

scholarly journals Bilateral Simultaneous Breast Reconstruction with DIEP- and TMG Flaps: Head to Head Comparison, Risk and Complication Analysis

2020 ◽  
Vol 9 (7) ◽  
pp. 2031
Author(s):  
Laurenz Weitgasser ◽  
Karl Schwaiger ◽  
Fabian Medved ◽  
Felix Hamler ◽  
Gottfried Wechselberger ◽  
...  
Keyword(s):  
Breast Reconstruction ◽  
Operative Time ◽  
Donor Site ◽  
Patient Characteristics ◽  
Study Groups ◽  
Donor Site Morbidity ◽  
Fat Grafting ◽  
Deep Inferior Epigastric Perforator ◽  
Group 2 ◽  
Group 1

Background: A two center retrospective cohort study of simultaneous bilateral breast reconstructions using double deep inferior epigastric perforator (DIEP) flaps and double transverse myocutaneous/upper gracilis (TMG) flaps was conducted. The aim of this study was to compare surgical procedures, complications, and overall outcome. Patients and Methods: Two study groups, either receiving a simultaneous bilateral breast reconstruction, with double DIEP flaps (n = 152) in group 1, or double TMG flaps (n = 86) in group 2, were compared. A detailed risk and complication analysis was performed. Patient characteristics, operative time and the need for further operations were evaluated. Results: Double DIEP patients had donor site complications in 23.7% and double TMG patients in 16.3% (p = 0.9075, RR 1.45). Flap loss rates of 3.5% (double TMG) and 2.6% (double DIEP) were recorded (p = 0.7071, RR 1.33). The need for postoperative lipofilling was significantly higher in double TMG patients (65.1% vs. 38.2 %, p = 0.0047, RR 1.71). Conclusion: Complication analysis favors the double DIEP procedure. Donor site morbidity was lower and less severe in the double TMG group. Later fat grafting was more frequently needed after double TMG reconstructions. Further studies, preferably of prospective nature, are needed to evaluate the benefit of bilateral simultaneous breast reconstructions.

scholarly journals Investigation Into the Optimal Number of Intercostal Nerve Transfers for Musculocutaneous Nerve Reinnervation: A Systematic Review

Hand ◽  
2017 ◽  
Vol 13 (6) ◽  
pp. 621-626 ◽  
Author(s):  
Hyuma A. Leland ◽  
Beina Azadgoli ◽  
Daniel J. Gould ◽  
Mitchel Seruya
Keyword(s):  
Systematic Review ◽  
Brachial Plexus ◽  
Donor Site ◽  
Elbow Flexion ◽  
Donor Site Morbidity ◽  
Intercostal Nerve ◽  
Optimal Number ◽  
Musculocutaneous Nerve ◽  
Nerve Transfers ◽  
Meta Analyses

Background: The purpose of this study was to systematically review outcomes following intercostal nerve (ICN) transfer for restoration of elbow flexion, with a focus on identifying the optimal number of nerve transfers. Methods: A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to identify studies describing ICN transfers to the musculocutaneous nerve (MCN) for traumatic brachial plexus injuries in patients 16 years or older. Demographics were recorded, including age, time to operation, and level of brachial plexus injury. Muscle strength was scored based upon the British Medical Research Council scale. Results: Twelve studies met inclusion criteria for a total of 196 patients. Either 2 (n = 113), 3 (n = 69), or 4 (n = 11) ICNs were transferred to the MCN in each patient. The groups were similar with regard to patient demographics. Elbow flexion ≥M3 was achieved in 71.3% (95% confidence interval [CI], 61.1%-79.7%) of patients with 2 ICNs, 67.7% (95% CI, 55.3%-78.0%) of patients with 3 ICNs, and 77.0% (95% CI, 44.9%-93.2%) of patients with 4 ICNs ( P = .79). Elbow flexion ≥M4 was achieved in 51.1% (95% CI, 37.4%-64.6%) of patients with 2 ICNs, 42.1% (95% CI, 29.5%-55.9%) of patients with 3 ICNs, and 48.4% (95% CI, 19.2%-78.8%) of patients with 4 ICNs ( P = .66). Conclusions: Previous reports have described 2.5 times increased morbidity with each additional ICN harvest. Based on the equivalent strength of elbow flexion irrespective of the number of nerves transferred, 2 ICNs are recommended to the MCN to avoid further donor-site morbidity.

scholarly journals Suprafascial Free Flaps: Classification and Comprehensive Review of the Literature

2021 ◽  
Vol 6 ◽  
pp. 247275122110205
Author(s):  
Sebastian Rios ◽  
María Isabel Falguera-Uceda ◽  
Alicia Dean ◽  
Susana Heredero
Keyword(s):  
Survival Rate ◽  
Preoperative Planning ◽  
Donor Site ◽  
Free Flaps ◽  
Donor Site Morbidity ◽  
Anterolateral Thigh Flap ◽  
Cochrane Library ◽  
Review Of The Literature ◽  
Comprehensive Review ◽  
Search Terms

Study Design: Suprafascial free flaps have become common place in reconstructive surgery units. Nomenclature related to these flaps has not been uniform throughout the scientific literature, especially in regard to planes of dissection. This study is designed as a comprehensive review of the literature. Objectives: Our study highlights which flaps are used most frequently, their main indications, their survival rate, and how they have evolved in the last few decades as innovations have been introduced. Methods: A review of the literature was performed using keywords and Medical Subject Headings search terms. PubMed, Embase, and Cochrane Library were searched using the appropriate search terms. Data collected from each study included flap type, dissection plane, preoperative planning, area of reconstruction, as well as complications, donor-site morbidity and survival rate. Results: Seven hundred and fifty-five studies were found based on the search criteria. After full-text screening for inclusion and exclusion criteria 34 studies were included. A total of 1332 patients were comprised in these studies. The most common types of flaps used were superficial circumflex iliac perforator flap (SCIP), anterolateral thigh flap (ALT), and radial forearm flap. The most common areas of reconstruction were head & neck and limbs. There was no significant difference in survival rates between flaps that were raised in different planes of dissection. Conclusions: Based on the author’s review of the literature, suprafascial flaps are reliable, they have low donor site morbidity, and there is a wide selection available for harvest. The use of new technologies for preoperative planning, such as CT-Angiography and UHF ultrasound, have contributed to have more predictable results. We propose a standardized classification for these flaps, in order to create a uniform nomenclature for future reference.

scholarly journals Autologous Unilateral Breast Reconstruction with Venous Supercharged IMAP-Flaps: A Step by Step Guide of the Split Breast Technique

2020 ◽  
Vol 9 (9) ◽  
pp. 3030
Author(s):  
Kathrin Bachleitner ◽  
Laurenz Weitgasser ◽  
Amro Amr ◽  
Thomas Schoeller
Keyword(s):  
Breast Cancer ◽  
Surgical Technique ◽  
Breast Reconstruction ◽  
Donor Site ◽  
Operating Time ◽  
Cancer Recurrence ◽  
Free Tissue Transfer ◽  
Donor Site Morbidity ◽  
Aesthetic Result ◽  
Secondary Operations

Various techniques for breast reconstruction ranging from reconstruction with implants to free tissue transfer, with the disadvantage of either carrying a foreign body or dealing with donor site morbidity, have been described. In patients who had a unilateral mastectomy and offer a contralateral mamma hypertrophy a breast reconstruction can be performed with the excess tissue from the hypertrophic side using the split breast technique. Here a local internal mammary artery perforator (IMAP) flap of the hypertrophic breast can be used for reconstruction avoiding the downsides of implants or a microsurgical reconstruction and simultaneously reducing the enlarged donor breast in order to achieve symmetry. Methods: Between April 2010 and February 2019 the split breast technique was performed in five patients after mastectomy due to breast cancer. Operating time, length of stay, complications and the need for secondary operations were analyzed and the surgical technique including flap supercharging were described in detail. Results: All five IMAP-flaps survived and an aesthetically pleasant result could be achieved using the split breast technique. An average of two secondary corrections to achieve better symmetry were necessary after each breast reconstruction. Complications included venous flap congestion, partial flap necrosis and asymmetry. No breast cancer recurrence was recorded. An overall approval of the surgical technique among patients was observed. Conclusions: The use of the contralateral breast for unilateral total breast reconstruction represents an additional highly useful technique for selected patients, is safe and reliable results can be achieved. Although this technique is carried out as a single-stage procedure, including breast reduction and reconstruction at the same time, secondary operations may be necessary to achieve superior symmetry and a satisfying aesthetic result. Survival of the IMAP-flaps can be improved by venous supercharging of the flaps onto the thoracoepigastric vein.

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